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Oxford Handbook of
Rheumatology
Fourth Edition

Gavin Clunie
Consultant Rheumatologist and Metabolic Bone Physician,
Addenbrooke’s Hospital, Cambridge, UK

Nick Wilkinson
Consultant Paediatric and Adolescent Rheumatologist,
Evelina London Children’s Hospital, London, UK

Elena Nikiphorou
Consultant Rheumatologist, Whittington Hospital;
Clinical Researcher, Academic Rheumatology Department,
King’s College London, UK

Deepak Jadon
Consultant Rheumatologist and Director of the
Rheumatology Research Unit,
Addenbrooke’s Hospital, Cambridge, UK

1
1
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First Edition published in 2002
Second Edition published in 2006
Third Edition published in 2011
Fourth Edition published in 2018
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 v

Foreword

I am pleased to introduce you to the 4th edition of the Oxford Handbook

of Rheumatology. This edition has increased in size, but continues to be just
as accessible. It presents the reader with a pragmatic approach to making
a differential diagnosis. The approach to thinking about how to make sense
of the history and clinical findings is clear. The common rheumatological
conditions are covered well, and the new edition incorporates relevant sec-
tions on paediatric and adolescent rheumatology.
From the days of Sir William Osler, the art of listening to and observing
the patient has been a key focus of what defines a good doctor. Medicine
has advanced considerably since his day, but the core values of a physician
have not changed.
The focus on good clinical history taking and examination technique is a
reminder of the core skill set that we use as physicians. When all else fails,
go back to the basic principles, and back to the patient. This book shows us
how important that skill set is.
Professor Jane Dacre MD, PRCP
President
Royal College of Physicians
London, UK
vi

Preface

Rheumatic musculoskeletal conditions are common both in general and

hospital practice. Musculoskeletal symptoms are a primary feature of many
multisystem illnesses, not only in the autoimmune joint and connective tis-
sue diseases, but also metabolic, endocrine, neoplastic, and infectious con-
ditions. Symptoms are also common in the context of injury, age-​related
change, and psychological distress. Many conditions in rheumatology are a
major source of morbidity and mortality.
We have kept the format of the previous edition for this version but
importantly have updated the text to include paediatric and adolescent
rheumatology.
Part I remains as a guide to evaluation of rheumatic and musculoskeletal
disease from the point of referral and reflects the way clinical problems/​
symptoms present to the clinician in real life. We have considered how this
happens for adults, and new in this version, for children and adolescents,
affected by rheumatological and musculoskeletal disease. The reader will
find detail on musculoskeletal anatomy and functional anatomy in this part
of the book.
Part II remains as the section of the book where the reader can find
disease-​specific information (e.g. spondyloarthritis, vasculitis, back pain, and
so on). We have included paediatric sections in each chapter where there
is relevance for disease occurring in children and adolescents, noting the
difference in disease and its management in children and adolescents com-
pared with adults.
Part III remains as medicine management and contains chapters on drugs
used in rheumatology practice, glucocorticoid injection therapy, and rheu-
matological emergencies.
We have tried to avoid duplication but cross reference between chap-
ters. We hope this book is helpful and informative for all doctors, physio-
therapists, and specialist nursing practitioners who are faced with managing
people and patients with undiagnosed musculoskeletal symptoms or estab-
lished rheumatic musculoskeletal diseases.
 vii

Acknowledgements

The authors would like to acknowledge the work of the co-​founder author-​
editor of the textbook Dr Alan Hakim for his contribution, whom together
with Dr Clunie, devised and wrote the book from the first edition and co-​
author-​editor Dr Inam Haq (who joined for the 2nd and 3rd editions), in
helping to establish the Oxford Handbook of Rheumatology as the market
leader small textbook for rheumatology.
 ix

Contents

Contributors xi
Symbols and abbreviations xii

Part I The presentation of rheumatic disease

1 Evaluating rheumatological and
musculoskeletal symptoms    3
2 Musculoskeletal assessment and patterns
of disease: making a working diagnosis   25
3 Regional musculoskeletal symptoms:
making a working diagnosis   71
4 The spectrum of disorders associated with adult
rheumatic and musculoskeletal diseases 205

Part II T
 he clinical features and management
of rheumatic diseases
5 Rheumatoid arthritis 243
6 Osteoarthritis 265
7 Crystal-​induced musculoskeletal disease 277
8 The spondyloarthritides including
psoriatic arthritis 293
9 Juvenile idiopathic arthritis 321
10 Systemic lupus erythematosus 343
11 Antiphospholipid syndrome 375
12 Sjögren’s syndrome 389
13 Systemic sclerosis and related disorders 401
14 Idiopathic inflammatory myopathies including
polymyositis and dermatomyositis 425
x CONTENTS

15 Primary vasculitides 447

16 Metabolic bone diseases 483
17 Infection and rheumatic disease 525
18 Rare autoinflammatory and miscellaneous diseases 541
19 Hereditary disorders of connective tissue 577
20 Common upper limb musculoskeletal lesions 595
21 Spinal disorders and back pain 605
22 Chronic pain syndromes 623

Part III Medicine management and emergencies

23 Drugs used in rheumatology practice 645
24 Glucocorticoid injection therapy 689
25 Rheumatological emergencies 707

Index 729

Contributors
Dr Emma Davies
Specialist Registrar in
Rheumatology, Royal National
Hospital for Rheumatic Diseases,
Bath, UK
Dr Catherine Fairris
Specialist Registrar in
Rheumatology, Royal National
Hospital for Rheumatic Diseases,
Bath, UK
Dr Shabina Habibi
Senior Clinical Research Fellow,
Royal National Hospital for
Rheumatic Diseases, Bath, UK
Dr Philip Hamann
PhD Research Fellow &
Specialist Registrar in
Rheumatology, Royal National
Hospital for Rheumatic Diseases,
Bath, UK
Dr Dobrina Hull
Specialist Registrar in
Rheumatology, Guys and
St Thomas’ Hospital NHS
Foundation Trust, London, UK
Dr Eiphyu Htut
Specialist Registrar in
Rheumatology, Addenbrooke’s
Hospital, Cambridge University
Hospitals NHS Foundation Trust,
Cambridge, UK
Dr Anthony Isaacs
Specialist Registrar in
Rheumatology, The Whittington
Hospital NHS Trust,
London, UK
xi
Dr Ritu Malayia
Specialist Registrar in
Rheumatology, Guys and
St Thomas’ Hospital NHS
Foundation Trust, London, UK
Dr Seraina Palmer
Fellow in Paediatric
Rheumatology, Kinderspital,
Zürich, Switzerland
Dr Elizabeth Reilly
Specialist Registrar in
Rheumatology, Royal National
Hospital for Rheumatic Diseases,
Bath, UK
Dr Maliha Sheikh
Specialist Registrar in
Rheumatology, Addenbrooke’s
Hospital, Cambridge University
Hospitals NHS Foundation Trust,
Cambridge, UK
Dr Giulia Varnier
Fellow in Paediatric
Rheumatology, Evelina London
Children’s Hospital, Guys and
St Thomas’ Hospital NHS
Foundation Trust, London, UK
Dr Natasha Weisz
Specialist Registrar in
Rheumatology, The Whittington
Hospital NHS Trust, London, UK
Dr Cee Yi Yong
Specialist Registrar in
Rheumatology, Norfolk and
Norwich University Hospitals
NHS Foundation Trust,
Norwich, UK
xii

Symbols and abbreviations

E cross-​reference
α alpha
β beta
i increased
d decreased
n normal
> greater than
< less than
7 approximately
∴ therefore
AAV ANCA-​associated vasculitis
ABA abatacept
AC adhesive capsulitis
ACA anticentromere antibody
ACE angiotensin-​converting enzyme
AChA acrodermatitis chronicum atrophicans
AC( J) acromioclavicular (joint)
ACL anticardiolipin
ACPA anticitrullinated peptide antibody(-​ies)
ACR American College of Rheumatology
AD autosomal dominant
ADM abductor digiti minimi
AFF atypical femoral fracture
AICTD autoimmune connective tissue disease
AIS autoinflammatory syndrome
AKI acute kidney injury
ALNT anterolateral neospinothalamic tract
ALP alkaline phosphatase
ALT alanine transaminase
AMA amyloid A
AML amyloid L
ANA antinuclear antibody
ANCA antineutrophil cytoplasmic antibody
Anti-​β2GP1 β2 glycoprotein-​1
anti-​
AOSD adult-​onset Still’s disease
AP anteroposterior
 SYMBOLS AND ABBREVIATIONS xiii

APB abductor pollicis brevis

APL abductor pollicis longus
APL antiphospholipid
APRIL a proliferation inducing-​ligand
APS antiphospholipid (antibody) syndrome
APTT activated partial thromboplastin time
AR autosomal recessive
ARA American Rheumatism Association
ARB angiotensin II receptor blocker
ARDS adult respiratory distress syndrome
ARTEMIS Abatacept Treatment in Polymyositis and
Dermatomyositis trial
AS ankylosing spondylitis
ASAS Assessment of Spondyloarthritis International Society
AST aspartate transaminase
ASOT antistreptolysin O titre
ASU avocado/​soybean unsaponifiable
ATN acute tubular necrosis
axSpA axial spondyloarthritis
AZA azathioprine
β2GP1 β2 glycoprotein-​1
BAFF B-​cell activating factor (see also BLyS)
BAL bronchoalveolar lavage
BCP basic calcium phosphate (crystals)
BD Behçet’s disease
bDMARD biologic disease-​modifying antirheumatic drug
BILAG British Isles Lupus Assessment Group
BLyS B-​lymphocyte stimulator (see also BAFF)
BMC bone mineral content
BMD bone mineral density
BMI body mass index
BSR British Society of Rheumatology
BVAS Birmingham Vasculitis Activity Score
C cervical (e.g. C6 is the sixth cervical vertebra)
CA coracoacromial
CADM clinically amyopathic dermatomyositis
CAMPS CARD14-​mediated psoriasis
CANDLE chronic atypical neutrophilic dermatosis with lipodystrophy
and elevated temperature
cAPS catastrophic antiphospholipid syndrome
CAPS cryopyrin-​associated periodic fever syndromes
xiv SYMBOLS AND ABBREVIATIONS

CARD caspase activation and recruitment domain

CBT cognitive and behavioural therapy
CCP cyclic citrullinated peptide
CDAI Clinical Disease Activity Index
CHB congenital heart block
CHCC Chapel Hill Consensus Conference
CINCA chronic, infantile, neurological, cutaneous, and articular
syndrome
CK creatine kinase
CKD chronic kidney disease
CMC(J) carpometacarpal (joint)
CMP comprehensive metabolic panel
CMV cytomegalovirus
CNO chronic non-​bacterial osteomyelitis
CNS central nervous system
COMP cartilage oligomeric matrix protein
COX cyclooxygenase
CPP calcium pyrophosphate
CPPD calcium pyrophosphate deposition
CREST calcinosis, Raynaud’s, (o)esophageal dysmotility,
sclerodactyly, telangiectasia (syndrome)
CRMO chronic recurrent multifocal osteomyelitis
CRP C-​reactive protein
CRPS complex regional pain syndrome
CS congenital scoliosis
CSF cerebrospinal fluid
CT computed tomography
CTX collagen X-​link
cTnC cardiac troponin C
cTnT cardiac troponin T
CTS carpal tunnel syndrome
CWP chronic widespread pain
CXR chest radiograph
CYC cyclophosphamide
DAS Disease Activity Score
dcSScl diffuse cutaneous systemic sclerosis
DIC diffuse intravascular coagulation
DILE drug-​induced lupus erythematosus
DIP(J) distal interphalangeal (joint)
DIRA deficiency of IL-​1 receptor agonist
DISH diffuse idiopathic skeletal hyperostosis
 SYMBOLS AND ABBREVIATIONS xv

DITRA deficiency of interleukin 36 receptor antagonist

DLCO diffusion capacity for carbon monoxide
DOMS delayed-​onset muscular strain
DM dermatomyositis
DMARD disease-​modifying antirheumatic drug
DVT deep vein thrombosis
DXA dual-​energy X-​ray absorptiometry
EA enteropathic arthritis
EANM European Association of Nuclear Medicine
EBV Epstein–​Barr virus
ECG electrocardiogram
ECM erythema chronicum migrans
ECRB extensor carpi radialis brevis
ECRL extensor carpi radialis longus
ECU extensor carpi ulnaris
ED extensor digitorum
EDL extensor digitorum longus
EDM extensor digiti minimi
EDS Ehlers–​Danlos syndrome
EED erythema elevatum dictinum
EHL extensor hallucis longus
EI extensor indicis
EGPA eosinophilic granulomatosis and polyangiitis
ELISA enzyme-​linked immunosorbent assay
ELMS Eaton–​Lambert myasthenic syndrome
EM erythema migrans
EMG electromyography
EN erythema nodosum
ENA extractable nuclear antigen
ENT ear, nose, and throat
EPB extensor pollicis brevis
EPL extensor pollicis longus
ERA enthesitis-​related arthritis
ESR erythrocyte sedimentation rate
ESSG European Spondyloarthropathy Study Group
EULAR European League Against Rheumatism
F female
FBC full blood count
FCAS familial cold autoinflammatory syndrome
FCR flexor carpi radialis
xvi SYMBOLS AND ABBREVIATIONS

FCU flexor carpi ulnaris

FD fibrous dysplasia
FDA Food and Drug Administration
18
F-​FDG fluorine-​18 fluorodeoxyglucose
FDL flexor digitorum longus
FDP flexor digitorum profundus
FDS flexor digitorum superficialis
FENa fractional excretion of sodium
FFS Five-​Factor Score
FGF fibroblast growth factor
FHB flexor hallucis brevis
FHH familial hypocalciuric hypercalcaemia
FJ facet joint
FLS Fracture Liaison Service
FM fibromyalgia
FMF familial Mediterranean fever
FPL flexor pollicis longus
FR flexor retinaculum
FVSG French Vasculitis Study Group
GALS gait, arms, legs, spine (examination)
GARA gut-​associated reactive arthritis
GBS Guillain–​Barré syndrome
GC glucocorticoid
GCA giant cell arteritis
GFR glomerular filtration rate
GH( J) glenohumeral (joint)
GI gastrointestinal
GIO glucocorticoid-​induced osteoporosis
GLA gamma linoleic acid
GOA generalized osteoarthritis
GORD gastro-​oesophageal reflux disease
HA hydroxyapatite
HAQ Health Assessment Questionnaire
HCQ hydroxychloroquine
HDCT hereditary disorder of connective tissue
h-​EDS hypermobility (type) Ehlers–​Danlos syndrome
HELLP haemolysis, elevated liver enzymes, and low platelets
HIDS hyper IgD syndrome
HIV human immunodeficiency virus
HLA human leucocyte antigen
 SYMBOLS AND ABBREVIATIONS xvii

HMG-​COA 3-​hydroxy-​3-​methyl-​glutaryl-​coenzyme A
HPOA hypertrophic pulmonary osteoarthropathy
HPT hyperparathyroidism
HRT hormone replacement therapy
HSCT haematopoietic stem cell transplantation
HSP Henoch–​Schönlein purpura
HUS haemolytic uraemic syndrome
HTLV human T-​cell leukaemia virus
IA intra-​articular
IBD inflammatory bowel disease
IBM inclusion-​body myositis
ICD implantable cardioverter defibrillator
IFN interferon
IgG4-​RD immunoglobulin G4-​related disease
IGRA interferon gamma release assay
IIM idiopathic inflammatory myopathy
IL interleukin
ILAR International League of Associations for Rheumatology
ILD interstitial lung disease
IM intramuscular(ly)
IMM idiopathic inflammatory myopathy
INR international normalized ratio
IP interphalangeal
ISCD International Society of Clinical Densitometry
ISG International Study Group
ISN International Society for Nephrology
ITB iliotibial band
IV intravenous(ly)
IVDU intravenous drug user
IVIg intravenous immunoglobulin
JAK Janus kinase
JAS juvenile ankylosing spondylitis
JCA juvenile chronic arthritis
JDM juvenile dermatomyositis
JIA juvenile idiopathic arthritis
JIIM juvenile idiopathic inflammatory arthritis
JIO juvenile idiopathic osteoporosis
JPM juvenile polymyositis
JPsA juvenile psoriatic arthritis
JRA juvenile rheumatoid arthritis
xviii SYMBOLS AND ABBREVIATIONS

JSLE juvenile systemic lupus erythematosus

JSpA juvenile spondyloarthritis
KD Kawasaki disease
KUB kidney ureter bladder
L lumbar (e.g. L5 is the fifth lumbar vertebra)
LA lupus anticoagulant
LCL lateral collateral ligament
lcSScl limited cutaneous systemic sclerosis
LDA low-​dose aspirin (75–​150 mg/​day)
LDH lactate dehydrogenase
LE lupus erythematosus
LEF leflunomide
LFTs liver function tests
LGL large granular lymphocyte
LH luteinizing hormone
LHE lateral humeral epicondylitis
LIP lymphocytic interstitial pneumonitis
LLLT low-​level laser therapy
LMWH low-​molecular-​weight heparin
M male
MAA myositis-​associated autoantibodies
MAGIC mouth and genital ulcers with inflamed cartilage
MAS macrophage activation syndrome
MCL medial collateral ligament
MCP(J) metacarpophalangeal (joint)
MCTD mixed connective tissue disease
MDI Myositis Disease Index
MDP methylene diphosphonate
MDT multidisciplinary team
MEN mycophenolate mofetil
MEVK mevalonate kinase
MFS Marfan syndrome
MG myasthenia gravis
MHC major histocompatibility complex
MKD mevalonate kinase deficiency
MMF mycophenolate mofetil
MMPI Minnesota Multiphasic Personality Inventory
MMT manual muscle test
mNY modified New York
MPA microscopic polyangiitis
 SYMBOLS AND ABBREVIATIONS xix

MPO myeloperoxidase
MR magnetic resonance
MRA magnetic resonance angiography
MRI magnetic resonance imaging
MSA myositis-​specific autoantibodies
MSK musculoskeletal
MSU monosodium urate
MTP(J) metatarsophalangeal (joint)
MTX methotrexate
MUA manipulation under anaesthesia
MVA mevalonic aciduria
MVK mevalonate kinase
MWS Muckle–​Wells syndrome
MYOACT myositis disease activity index
MYODAM myositis damage index
NAI non-​accidental injury
NCS nerve conduction study
NICE National Institute for Health and Care Excellence (UK)
NLE neonatal lupus erythematosus
NLRs NOD-​like receptors
NMS neuromuscular scoliosis
NO nitrous oxide
NOAC novel oral anticoagulant
NOD nucleotide-​binding oligomerization domain
NOMID neonatal-​onset multisystem inflammatory disease
NSAID non-​steroidal anti-​inflammatory drug
NSF nephrogenic systemic fibrosis
OA osteoarthritis
OI osteogenesis imperfecta
OMIN Online Mendelian Inheritance in Man
ONFH osteonecrosis of the femoral head
OO osteoid osteoma
OT occupational therapist
PAH pulmonary artery hypertension
PAMPS pathogen-​associated molecular patterns
PAN polyarteritis nodosum
PAPA pyogenic arthritis, pyoderma gangrenosum, and acne
PBC primary biliary cirrhosis
PCR polymerase chain reaction
PDB Paget’s disease of bone
xx SYMBOLS AND ABBREVIATIONS

PDE5 phosphodiesterase type 5

PE pulmonary embolism
PET positron emission tomography
PFAPA periodic fever, aphthous stomatitis, pharyngitis, adenitis
syndrome
PHP pseudohypoparathyroidism
PIN posterior interosseous nerve
PIP(J) proximal interphalangeal (joint)
PL palmaris longus
PM polymyositis
PML progressive multifocal leucoencephalopathy
PMN polymorphonuclear neutrophil
PMR polymyalgia rheumatica
PoTS postural orthostatic tachycardia syndrome
PRR pattern-​recognition receptor
Ps psoriasis
PsA psoriatic arthritis
PSA prostatic-​specific antigen
PTH parathyroid hormone
PUO pyrexia of unknown origin
PV plasma viscosity
PVNS pigmented villonodular synovitis
RA rheumatoid arthritis
RAID rare autoinflammatory disease
RAPS rivaroxaban for antiphospholipid antibody syndrome
RCT randomized controlled trial
RD Raynaud’s disease
ReA reactive arthritis
RF rheumatoid factor
RhF rheumatic fever
RNA ribonucleic acid
RNP ribonuclear protein
ROD renal osteodystrophy
RP relapsing polychondritis
RPS Renal Pathology Society
RSD reflex sympathetic dystrophy (algo/​osteodystrophy)
RSI repetitive strain injury
RS3PE remitting seronegative symmetrical synovitis with
pitting oedema
RTA renal tubular acidosis
 SYMBOLS AND ABBREVIATIONS xxi

RTX rituximab
sACE serum angiotensin converting enzyme
SAI subacromial impingement
SAA serum amyloid A
SADAI Simplified Disease Activity Index
SAPHO synovitis, acne, palmoplantar pustulosis, hyperostosis,
aseptic osteomyelitis (syndrome)
SARA sexually acquired reactive arthritis
SC subcutaneous
SC(J) sternoclavicular (joint)
Scl systemic scleroderma
SCS spinal cord stimulation
SD standard deviation
sDMARD synthetic disease-​modifying antirheumatic drug
SERM selective oestrogen receptor modulator
SHPT secondary hyperparathyroidism
SI( J) sacroiliac (joint)
SIP Sickness Impact Profile
SLE systemic lupus erythematosus
SLEDAI Systemic Lupus Erythematosus Disease Activity Index
SLICC Systemic Lupus International Collaborating criteria
SNRI serotonin-​norepinephrine re-​uptake inhibitors
SoJIA systemic-​onset juvenile idiopathic arthritis
SpA spondyloarthritis
SRC scleroderma renal crisis
SRP signal recognition peptide
SS Sjögren’s syndrome
SScl systemic sclerosis
SSRI selective serotonin reuptake inhibitor
SSZ sulfasalazine
STIR short tau inversion recovery
SUA serum uric acid
SUFE slipped upper femoral epiphysis
T thoracic (e.g. T5 is the fifth thoracic vertebra)
TA Takayasu arteritis
TB tuberculosis
TCZ tocilizumab
TENS transcutaneous electrical nerve stimulation
TFT thyroid function test
TGF transferring growth factor
xxii SYMBOLS AND ABBREVIATIONS

TIA transient ischaemic attack

TLRs Toll-​like receptors
TM( J) temporomandibular (joint)
TNFα tumour necrosis factor (alpha)
tPA tissue plasminogen activator
TPMT thiopurine S-​methyltransferase
TRAPS tumour necrosis factor-​associated periodic syndrome
TSH thyroid-​stimulating hormone
TTP thrombotic thrombocytopenic purpura
U&E urea and electrolytes (in UK test includes creatinine)
UC ulcerative colitis
uPCR urine protein:creatinine ratio
US ultrasound
UV ultraviolet
VAS visual analogue scale
VDI Vasculitis Damage Index
vs versus
WBC white blood cell
WHO World Health Organization
WRD work-​related disorder
XLHR X-​linked hypophosphataemic rickets
Part I

The presentation
of rheumatic
disease
 Chapter 1 3

Evaluating rheumatological
and musculoskeletal
symptoms

Introduction 4
Musculoskeletal pain in adults 6
Elicited pain on examination in adults 10
Other presenting symptoms in adults 12
The adult gait, arms, legs, spine (GALS) screening
examination 14
Pain assessment in children and adolescents 20
Limp and gait concerns in children and adolescents 22
Pyrexia, fatigue and unexplained acute-phase response
in children and adolescents 23
The paediatric GALS screen 24
4 Chapter 1 Evaluating MSK symptoms

Introduction
Adults and children can present with musculoskeletal (MSK), inflamma-
tory, and autoimmune diseases in varied ways. Symptoms can be simple
and focal, such as regional pain, or general and non-​specific, often in the
context of a generalized process such as fever or fatigue. The following are
important points in assessing the time, type, and nature of presentation:
• Why someone has presented at a particular time.
• What is the impact of symptoms, emotionally and functionally.
• The individual’s perceptions, fears, or cultural references that might
modify (amplify or suppress) expression of the symptoms.
• What fears, beliefs, and factors might present a barrier to effective
medical engagement.
• The same pathological processes might present variably at different
ages: broadly speaking, the young, adults, and the elderly.
In this chapter, the assessment of symptoms has been separated into two
parts. First, the assessment of symptoms in adults and second, the patterns
of disease presentation in children and adolescents.
Introduction 5
6 Chapter 1 Evaluating MSK symptoms

Musculoskeletal pain in adults

Introduction
The most common presenting symptom to the rheumatologist is unex-
plained or ineffectively treated MSK pain.
• Pain is defined by its subjective description, which may vary depending
on its physical (or biological) cause, the patient’s understanding of it,
its impact on function, and the emotional and behavioural response it
invokes.
• Pain is particularly prone to be ‘coloured’ by cultural, linguistic, and
religious differences. Therefore, pain is not merely an unpleasant
sensation to many; it is, in effect, an ‘emotional change’.
• Pain experience is different for every individual.
Localization of pain
Adults usually localize pain accurately, although there are some situations
worth noting in rheumatic disease where pain can be poorly localized
(Table 1.1):
• Adults may not clearly differentiate between periarticular and articular
pain, referring to bursitis, tendonitis, and other forms of soft tissue
injury as ‘joint pain’. Therefore, it is important to confirm the precise
location of the pain on physical examination.
• Pain may be well localized but caused by a distant lesion, e.g. interscapular
pain caused by mechanical problems in the cervical spine, or right
shoulder pain caused by acute cholecystitis.
• Pain caused by neurological abnormalities, ischaemic pain, and pain
referred from viscera is harder for the patient to visualize or express,
and the history may be given with varied interpretations.
• Bone pain is generally constant despite movement or change in
posture—​unlike muscular, synovial, ligament, or tendon pain—​and often
disturbs sleep. Fracture, tumour, and metabolic bone disease are all
possible causes. Such constant, local, sleep-​disturbing pain should always
be investigated.

Table 1.1 Clinical pointers in conditions in adults where pain is poorly

localized
Diagnosis
Periarticular shoulder pain
Carpal tunnel syndrome
Insertional gluteus medius
tendonitis/​enthesitis
Hip synovitis
Clinical pointer
Referred to deltoid insertion—​not specific for
lesion but typical in rotator cuff lesions
Nocturnal paraesthesias and/​or pain, often
diffuse—​patients often report symptoms in all
fingers but detailed assessment then is needed
to disclose 5th finger sparing
Nocturnal pain lying on affected side
Groin/​outer thigh pain radiating to the knee
Another random document with
no related content on Scribd:
 Darwin tells us that the flower of an orchid originally consisted
of fifteen different parts, three petals, three sepals, six stamens, and
three pistils. He shows traces of all these parts in the modern orchid.
 FLOWER DESCRIPTIONS

“A fresh footpath, a fresh flower, a fresh delight”

Richard Jefferies
 I
WHITE

Blood-root.
Sanguinaria Canadensis. Poppy Family.

Rootstock.—Thick, charged with a crimson juice. Scape.—Naked, one-

flowered. Leaves.—Rounded, deeply lobed. Flower.—White, terminal. Calyx.—Of
two sepals falling early. Corolla.—Of eight to twelve snow-white petals. Stamens.—
About twenty-four. Pistil.—One, short.
In early April the firm tip of the curled-up leaf of the blood-root
pushes through the earth and brown leaves, bearing within its
carefully shielded burden—the young erect flower-bud. When the
perils of the way are passed and a safe height is reached this pale,
deeply lobed leaf resigns its precious charge and gradually unfolds
itself; meanwhile the bud slowly swells into a blossom.
Surely no flower of all the year can vie with this in spotless
beauty. Its very transitoriness enhances its charm. The snowy petals
fall from about their golden centre before one has had time to grow
satiated with their perfection. Unless the rocky hill-sides and wood-
borders are jealously watched it may escape us altogether. One or
two warm sunny days will hasten it to maturity, and a few more
hours of wind and storm shatter its loveliness.
Care should be taken in picking the flower—if it must be picked
—as the red liquid which oozes blood-like from the wounded stem
makes a lasting stain. This crimson juice was prized by the Indians
for decorating their faces and tomahawks.

Shad-bush. June-berry. Service-berry.

Amelanchier oblongifolia. Rose Family.

A tall shrub or small tree found in low ground. Leaves.—Oblong, acutely

pointed, finely toothed, mostly rounded at base. Flowers.—White, growing in
racemes. Calyx.—Five-cleft. Corolla.—Of five rather long petals. Stamens.—
Numerous, short. Pistils.—With five styles. Fruit.—Round, red, berry-like, sweet
and edible, ripening in June.
 PLATE I

BLOOD-ROOT.—S. Canadensis.

Down in the boggy meadow in early March we can almost fancy

that from beneath the solemn purple cowls of the skunk-cabbage
brotherhood comes the joyful chorus—
For lo, the winter is past!—

but we chilly mortals still find the wind so frosty and the woods so
unpromising that we return shivering to the fireside and refuse to
take up the glad strain till the feathery clusters of the shad-bush
droop from the pasture thicket. Then only are we ready to admit that
The flowers appear upon the earth,
The time of the singing of birds is come.

Even then, search the woods as we may, we shall hardly find

thus early in April another shrub in blossom, unless it be the spice-
bush, whose tiny honey-yellow flowers escape all but the careful
observer. The shad-bush has been thus named because of its
flowering at the season when shad “run;” June-berry, because the
shrub’s crimson fruit surprises us by gleaming from the copses at the
very beginning of summer; service-berry, because of the use made by
the Indians of this fruit, which they gathered in great quantities, and,
after much crushing and pounding, utilized in a sort of cake.

Wood Anemone. Wind-flower.

Anemone nemorosa. Crowfoot Family.

Stem.—Slender. Leaves.—Divided into delicate leaflets. Flower.—Solitary,

white, pink, or purplish. Calyx.—Of from four to seven petal-like sepals. Corolla.—
None. Stamens and Pistils.—Numerous.

—Within the woods,

Whose young and half transparent leaves scarce cast
A shade, gay circles of anemones
Danced on their stalks;

writes Bryant, bringing vividly before us the feathery foliage of the

spring woods, and the tremulous beauty of the slender-stemmed
anemones. Whittier, too, tells how these
—wind flowers sway
Against the throbbing heart of May.
 PLATE II

RUE ANEMONE.—A. thalictroides.

WOOD ANEMONE.—A. nemorosa.

And in the writings of the ancients as well we could find many

allusions to the same flower were we justified in believing that the
blossom christened the “wind-shaken,” by some poet flower-lover of
early Greece, was identical with our modern anemone.
Pliny tells us that the anemone of the classics was so entitled
because it opened at the wind’s bidding. The Greek tradition claims
that it sprang from the passionate tears shed by Venus over the body
of the slain Adonis. At one time it was believed that the wind which
had passed over a field of anemones was poisoned and that disease
followed in its wake. Perhaps because of this superstition the flower
was adopted as the emblem of sickness by the Persians. Surely our
delicate blossom is far removed from any suggestion of disease or
unwholesomeness, seeming instead to hold the very essence of
spring and purity in its quivering cup.

Rue Anemone.
Anemonella thalictroides. Crowfoot Family.

Stem.—Six to twelve inches high. Leaves.—Divided into rounded leaflets.

Flowers.—White or pinkish, clustered. Calyx.—Of five to ten petal-like sepals.
Corolla.—None. Stamens.—Numerous. Pistils.—Four to fifteen.
The rue anemone seems to linger especially about the spreading
roots of old trees. It blossoms with the wood anemone, from which it
differs in bearing its flowers in clusters.

Star-flower.
Trientalis Americana. Primrose Family.

Stem.—Smooth, erect. Leaves.—Thin, pointed, whorled at the summit of the

stem. Flowers.—White, delicate, star-shaped. Calyx.—Generally seven-parted.
Corolla.—Generally seven-parted, flat, spreading. Stamens.—Four or five. Pistil.
—One.
Finding this delicate flower in the May woods, one is at once
reminded of the anemone. The whole effect of plant, leaf, and snow-
white blossom is starry and pointed. The frosted tapering petals
distinguish it from the rounded blossoms of the wild strawberry,
near which it often grows.
 PLATE III

STAR-FLOWER.—T. Americana.

Maianthemum Canadense.

——— ———
Maianthemum Canadense. Lily Family.

Stem.—Three to six inches high, with two or three leaves. Leaves.—Lance-

shaped to oval, heart-shaped at base. Flowers.—White or straw-color, growing in a
raceme. Perianth.—Four-parted. Stamens.—Four. Pistil.—One, with a two-lobed
stigma. Fruit.—A red berry.
 It seems unfair that this familiar and pretty little plant should be
without any homely English name. Its botanical title signifies
“Canada Mayflower,” but while it undoubtedly grows in Canada and
flowers in May, the name is not a happy one, for it abounds as far
south as North Carolina, and is not the first blossom to be entitled
“Mayflower.”
In late summer the red berries are often found in close
proximity to the fruit of the shin-leaf and pipsissewa.

Gold Thread.
Coptis trifolia. Crowfoot Family.

Scape.—Slender, three to five inches high. Leaves.—Evergreen, shining,

divided into three leaflets. Flowers.—Small, white, solitary. Calyx.—Of five to
seven petal-like sepals which fall early. Corolla.—Of five to seven club-shaped
petals. Stamens.—Fifteen to twenty-five. Pistils.—Three to seven. Root.—Of long,
bright yellow fibres.
This little plant abundantly carpets the northern bogs and
extends southward over the mountains, its tiny flowers appearing in
May. Its bright yellow thread-like roots give it its common name.

Pyxie. Flowering-moss.
Pyxidanthera barbulata. Order Diapensiaceæ.

Stems.—Prostrate and creeping, branching. Leaves.—Narrowly lance-shaped,

awl-pointed. Flowers.—White or pink, small, numerous. Calyx.—Of five sepals.
Corolla.—Five-lobed. Stamens.—Five. Pistil.—One, with a three-lobed stigma.
In early spring we may look for the white flowers of this moss-
like plant in the sandy pine-woods of New Jersey and southward. At
Lakewood they appear even before those of the trailing arbutus
which grows in the same localities. The generic name is from two
Greek words which signify a small box and anther, and refers to the
anthers, which open as if by a lid.

Crinkle-root. Toothwort. Pepper-root.

Dentaria diphylla. Mustard Family (p. 17).
 Rootstock.—Five to ten inches long, wrinkled, crisp, of a pleasant, pungent
taste. Stem.—Leafless below, bearing two leaves above. Leaves.—Divided into
three-toothed leaflets. Flowers.—White, in a terminal cluster. Pod.—Flat and
lance-shaped.
The crinkle-root has been valued—not so much on account of its
pretty flowers which may be found in the rich May woods—but for its
crisp edible root which has lent savor to many a simple luncheon in
the cool shadows of the forest.

Spring-cress.
Cardamine rhomboidea. Mustard Family (p. 17).

Rootstock.—Slender, bearing small tubers. Stem.—From a tuberous base,

upright, slender. Root-leaves.—Round and often heart-shaped. Stem-leaves.—The
lower rounded, the upper almost lance-shaped. Flowers.—White, large. Pod.—Flat,
lance-shaped, pointed with a slender style tipped with a conspicuous stigma;
smaller than that of the crinkle-root.
The spring-cress grows abundantly in the wet meadows and
about the borders of springs. Its large white flowers appear as early
as April, lasting until June.

Whitlow-grass.
Draba verna. Mustard Family (p. 17).

Scapes.—One to three inches high. Leaves.—All from the root, oblong or

lance-shaped. Flowers.—White, with two-cleft petals. Pod.—Flat, varying from oval
to oblong, lance-shaped.
This little plant may be found flowering along the roadsides and
in sandy places during April and May. It has come to us from
Europe.

Shepherd’s Purse.
Capsella Bursa-pastoris. Mustard Family (p. 17).

Stem.—Low, branching. Root-leaves.—Clustered, incised or toothed. Stem-

leaves.—Arrow-shaped, set close to the stem. Flowers.—White, small, in general
structure resembling other members of the Mustard family. Pod.—Triangular,
heart-shaped.
This is one of the commonest of our wayside weeds, working its
way everywhere with such persistency and appropriating other
people’s property so shamelessly, that it has won for itself the
nickname of pickpocket. Its popular title arose from the shape of its
little seed-pods.

May-apple. Mandrake.
Podophyllum peltatum. Barberry Family.

Flowering stem.—Two-leaved, one-flowered. Flowerless stems.—Terminated

by one large, rounded, much-lobed leaf. Leaves (of flowering stems).—One-sided,
five to nine-lobed, the lobes oblong, the leaf-stalks fastened to their lower side near
the inner edge. Flower.—White, large, nodding from the fork made by the two
leaves. Calyx.—Of six early falling sepals. Corolla.—Of six to nine rounded petals.
Stamens.—Twice as many as the petals. Pistil.—One, with a large, thick stigma set
close to the ovary. Fruit.—A large, fleshy, egg-shaped berry, sweet and edible.
“The umbrellas are out!” cry the children, when the great green
leaves of the May-apple first unfold themselves in spring. These
curious-looking leaves at once betray the hiding-place of the pretty
but unpleasantly odoriferous flower which nods beneath them. They
lie thickly along the woods and meadows in many parts of the
country, arresting one’s attention by the railways. The fruit, which
ripens in July, has been given the name of “wild lemon,” in some
places on account of its shape. It was valued by the Indians for
medicinal purposes, and its mawkish flavor still seems to find favor
with the children, notwithstanding its frequently unpleasant after-
effects. The leaves and roots are poisonous if taken internally, and
are said to have been used as a pot-herb, with fatal results. They yield
an extract which has been utilized in medicine.

Twin-leaf. Rheumatism-root.
Jeffersonia diphylla. Barberry Family.

A low plant. Leaves.—From the root, long-stalked, parted into two rounded
leaflets. Scape.—One-flowered. Flower.—White, one inch broad. Sepals.—Four,
falling early. Petals.—Eight; flat, oblong. Stamens.—Eight. Pistil.—One, with a two-
lobed stigma.
The twin-leaf is often found growing with the blood-root in the
woods of April or May. It abounds somewhat west and southward.

Harbinger-of-Spring.
Erigenia bulbosa. Parsley Family (p. 15).

Stem.—Three to nine inches high, from a deep round tuber. Leaves.—One or

two, divided into linear-oblong leaf-segments. Flowers.—White, small, few, in a
leafy-bracted compound umbel.

PLATE IV

MAY-APPLE.—P. peltatum.
 The pretty little harbinger-of-spring should be easily identified
by those who are fortunate enough to find it, for it is one of the
smallest members of the Parsley family. It is only common in certain
localities, being found in abundance in the neighborhood of
Washington, where its flowers appear as early as March.

Early Everlasting. Plantain-leaved Everlasting.

Antennaria plantaginifolia. Composite Family (p. 13).

Stems.—Downy or woolly, three to eighteen inches high. Leaves.—Silky,

woolly when young; those from the root, oval, three-nerved; those on the flowering
stems, small, lance-shaped. Flower-heads.—Crowded, clustered, small, yellowish-
white, composed entirely of tubular flowers.
In early spring the hill-sides are whitened with this, the earliest
of the everlastings.

Spring Beauty.
Claytonia Virginica. Purslane Family.

Stem.—From a small tuber, often somewhat reclining. Leaves.—Two;

opposite, long and narrow. Flowers.—White, with pink veins, or pink with deeper-
colored veins, growing in a loose cluster. Calyx.—Of two sepals. Corolla.—Of five
petals. Stamens.—Five. Pistil.—One, with style three-cleft at apex.

So bashful when I spied her,

So pretty, so ashamed!
So hidden in her leaflets
Lest anybody find:

So breathless when I passed her,

So helpless when I turned
And bore her struggling, blushing,
Her simple haunts beyond!

For whom I robbed the dingle,

For whom betrayed the dell,
Many will doubtless ask me,
But I shall never tell!
 Yet we are all free to guess—and what flower—at least in the
early year, before it has gained that touch of confidence which it
acquires later—is so bashful, so pretty, so flushed with rosy shame,
so eager to defend its modesty by closing its blushing petals when
carried off by the despoiler—as the spring beauty? To be sure, she is
not “hidden in her leaflets,” although often seeking concealment
beneath the leaves of other plants—but why not assume that Miss
Dickinson has availed herself of something of the license so freely
granted to poets—especially, it seems to me—to poets of nature?
Perhaps of this class few are more accurate than she, and although
we wonder at the sudden blindness which leads her to claim that
—Nature rarer uses yellow
Than another hue—

when it seems as though it needed but little knowledge of flowers to

recognize that yellow, probably, occurs more frequently among them
than any other color, and also at the representation of this same
nature as
—Spending scarlet like a woman—

when in reality she is so chary of this splendid hue; still we cannot

but appreciate that this poet was in close and peculiar sympathy with
flowers, and was wont to paint them with more than customary
fidelity.
 PLATE V

SPRING BEAUTY.—C. Virginica.

We look for the spring beauty in April and May, and often find it
in the same moist places—on a brook’s edge or skirting the wet
woods—as the yellow adder’s tongue. It is sometimes mistaken for an
anemone, but its rose-veined corolla and linear leaves easily identify
it. Parts of the carriage-drive in the Central Park are bordered with
great patches of the dainty blossoms. One is always glad to discover
these children of the country within our city limits, where they can be
known and loved by those other children who are so unfortunate as
to be denied the knowledge of them in their usual haunts. If the day
chances to be cloudy these flowers close and are only induced to
open again by an abundance of sunlight. This habit of closing in the
shade is common to many flowers, and should be remembered by
those who bring home their treasures from the woods and fields,
only to discard the majority as hopelessly wilted. If any such
exhausted blossoms are placed in the sunlight, with their stems in
fresh water, they will probably regain their vigor. Should this
treatment fail, an application of very hot—almost boiling—water
should be tried. This heroic measure often meets with success.
 Dutchman’s Breeches. White-hearts.
Dicentra Cucullaria. Fumitory Family.

Scape.—Slender. Leaves.—Thrice-compound. Flowers.—White and yellow,

growing in a raceme. Calyx.—Of two small, scale-like sepals. Corolla.—Closed and
flattened; of four somewhat cohering white petals tipped with yellow; the two outer
—large, with spreading tips and deep spurs; the two inner—small, with spoon-
shaped tips uniting over the anthers and stigma. Stamens.—Six. Pistil.—One.

PLATE VI

DUTCHMAN’S BREECHES.—D.
Cucullaria.

There is something singularly fragile and spring-like in the

appearance of this plant as its heart-shaped blossoms nod from the
rocky ledges where they thrive best. One would suppose that the
firmly closed petals guarded against any intrusion on the part of
insect-visitors and indicated the flower’s capacity for self-
fertilization; but it is found that when insects are excluded by means
of gauze no seeds are set, which goes to prove that the pollen from
another flower is a necessary factor in the continuance of this
species. The generic name, Dicentra, is from the Greek and signifies
two-spurred. The flower, when seen, explains its two English titles.
It is accessible to every New Yorker, for in early April it whitens
many of the shaded ledges in the upper part of the Central Park.

Squirrel Corn.
Dicentra Canadensis. Fumitory Family.

The squirrel corn closely resembles the dutchman’s breeches. Its

greenish or pinkish flowers are heart-shaped, with short, rounded
spurs. They have the fragrance of hyacinths, and are found
blossoming in early spring in the rich woods of the North.

Foam-flower. False Mitre-wort.

Tiarella cordifolia. Saxifrage Family.

Stem.—Five to twelve inches high, leafless, or rarely with one or two leaves.
Leaves.—From the rootstock or runners, heart-shaped, sharply lobed. Flowers.—
White, in a full raceme. Calyx.—Bell-shaped, five-parted. Corolla.—Of five petals
on claws. Stamens.—Ten, long and slender. Pistil.—One, with two styles.
Over the hills and in the rocky woods of April and May the
graceful white racemes of the foam-flower arrest our attention. This
is a near relative of the Mitella or true mitre-wort. Its generic name
is a diminutive from the Greek for turban, and is said to refer to the
shape of the pistil.

Early Saxifrage.
Saxifraga Virginiensis. Saxifrage Family.

Scape.—Four to nine inches high. Leaves.—Clustered at the root, somewhat

wedge-shaped, narrowed into a broad leaf-stalk. Flowers.—White, small, clustered.
Calyx.—Five-cleft. Corolla.—Of five petals. Stamens.—Ten. Pistil.—One, with two
styles.

PLATE VII

FOAM-FLOWER.—T. cordifolia.

In April we notice that the seams in the rocky cliffs and hill-sides
begin to whiten with the blossoms of the early saxifrage. Steinbrech
—stonebreak—the Germans appropriately entitle this little plant,
which bursts into bloom from the minute clefts in the rocks and
which has been supposed to cause their disintegration by its growth.
The generic and common names are from saxum—a rock, and
frango—to break.
 Mitre-wort. Bishop’s Cap.
Mitella diphylla. Saxifrage Family.

Stem.—Six to twelve inches high, hairy, bearing two opposite leaves. Leaves.—
Heart-shaped, lobed and toothed, those of the stem opposite and nearly sessile.
Flowers.—White, small, in a slender raceme. Calyx.—Short, five-cleft. Corolla.—Of
five slender petals which are deeply incised. Stamens.—Ten, short. Pistil.—One,
with two styles.
The mitre-wort resembles the foam-flower in foliage, but bears
its delicate crystal-like flowers in a more slender raceme. It also is
found in the rich woods, blossoming somewhat later.

Indian Poke. False Hellebore.

Veratrum viride. Lily Family.

Root.—Poisonous, coarse and fibrous. Stem.—Stout, two to seven feet high,

very leafy to the top. Leaves.—Broadly oval, pointed, clasping. Flowers.—Dull
greenish, inconspicuous, clustered. Perianth.—Of six spreading sepals. Stamens.—
Six. Pistil.—One, with three styles.
When we go to the swampy woods in March or April we notice
an array of green, solid-looking spears which have just appeared
above the ground. If we handle one of these we are impressed with
its firmness and rigidity. When the increasing warmth and sunshine
have tempted the veiny, many-plaited leaves of the false hellebore to
unfold themselves it is difficult to realize that they composed that
sturdy tool which so effectively tunnelled its way upward to the
earth’s surface. The tall stems and large bright leaves of this plant are
very noticeable in the early year, forming conspicuous masses of
foliage while the trees and shrubs are still almost leafless. The dingy
flowers which appear later rarely attract attention.

Carrion-flower. Cat-brier.
Smilax herbacea. Lily Family.

Stem.—Climbing, three to fifteen feet high. Leaves.—Ovate, or rounded heart-

shaped, or abruptly cut off at base, shining. Flowers.—Greenish or yellowish,
small, clustered, unisexual. Perianth.—Six-parted. Stamens.—six. Pistil.—One,
with three spreading stigmas. (Stamens and pistils occurring on different plants.)
Fruit.—A bluish-black berry.
One whiff of the foul breath of the carrion flower suffices for its
identification. Thoreau likens its odor to that of “a dead rat in the
wall.” It seems unfortunate that this strikingly handsome plant
which clambers so ornamentally over the luxuriant thickets which
border our lanes and streams, should be so handicapped each June.
Happily with the disappearance of the blossoms, it takes its place as
one of the most attractive of our climbers.
The common green-brier, S. rotundifolia, is a near relation
which is easily distinguished by its prickly stem.
The dark berries and deeply tinted leaves of this genus add
greatly to the glorious autumnal display along our roadsides and in
the woods and meadows.

Larger White Trillium.

Trillium grandiflorum. Lily Family.

Stem.—Stout, from a tuber-like rootstock. Leaves.—Ovate, three in a whorl, a

short distance below the flower. Flower.—Single, terminal, large, white, turning
pink or marked with green. Calyx.—Of three green, spreading sepals. Corolla.—Of
three long pointed petals. Stamens.—Six. Pistil.—One, with three spreading
stigmas. Fruit.—A large ovate, somewhat angled, red berry.
This very beautiful and decorative flower must be sought far
from the highway in the cool rich woods of April and May. Mr.
Ellwanger speaks of the “chaste pure triangles of the white wood
lily,” and says that it often attains a height of nearly two feet.
T. cernuum has no English title. Its smaller white or pinkish
blossom is borne on a stalk which is so much curved as to sometimes
quite conceal the flower beneath the leaves. It may be sought in the
moist places in the woods.
The painted trillium, T. erythrocarpum, is also less large and
showy than the great white trillium, but it is quite as pleasing. Its
white petals are painted at their base with red stripes. This species is
very plentiful in the Adirondack and Catskill Mountains.