XX. DISEASES AND INJURIES OF MUSCLES, TENDONS, AND BURSÆ.

Myalgia, or muscular rheumatism, is a painful disorder of the voluntary muscles and of the fibrous and periosteal areas where they are attached. The term "muscular rheumatism" is not strictly correct. It is possible that in some cases the muscular structure is inflamed, but it is certain that in many cases the pain is distinctly neuralgic. Muscular rheumatism may be due to cold and wet, to overexertion and strain, to acute infectious disorders, to syphilis, to chronic intoxications (lead, mercury, and alcohol), and to disturbances of the circulation. Gouty and rheumatic persons are especially predisposed, men being more liable to the disease than women. The disease is usually acute, but it may be chronic.

Symptoms.-Muscular rheumatism is apt to come on suddenly. The pain, which may be very acute and lancinating or may be dull and aching, is in some cases constantly present; in other cases it is awakened only by muscular contraction. The pain is frequently relieved by pressure, though there is often some soreness. The skin above the muscle is sometimes tender to light pressure. The disease usually lasts for a few days, but it tends to recur. There is little, if any, fever.

Lumbago is myalgia of the muscles of the loins. Rheu matic torticollis is myalgia of the muscles of the neck. Usually one side of the neck is attacked. The chin is turned from the affected side and the neck is stiff. Pleurodynia is myalgia of the intercostal muscles. The pain is very severe, is aggravated by deep respiration, by coughing, and by yawning, there may be tenderness, and the patient tries to limit chest-movement. In intercostal neuralgia the pain is limited, is not constant, but occurs in distinct paroxysms, and is linked with the presence of the tender spots of Valleix. Pleurodynia lacks the physical signs of pleurisy. Myalgia must not be confused with the pains of locomotor ataxia. Cephalodynia is myalgia of the muscles of the scalp. The muscles of the shoulder, upper dorsal region, abdomen, and extremities may also be attacked by myalgia.

Treatment. Remove any obvious cause. Treat any existing diathesis, such as gout or rheumatism. Rest is of the first importance. For lumbago, put the person to bed. For pleurodynia, strap the side of the chest. A hypodermatic injection of morphin and atropin into the affected muscles at

once allays the pain, and a deep injection of water is often curative. The introduction of four or five aseptic needles into the muscles, and their retention for a few minutes, sometimes act most favorably. Ironing the skin above the painful muscles is a useful domestic remedy. Vigorous rubbing of the area with a piece of ice allays the pain. Hot poultices do good. If the pain is widely diffused, alters its seat, or is very obstinate, order hot baths or Turkish baths and administer diuretics. In chronic cases employ blisters or counterirritation by the cautery, give iodid of potassium and nux vomica, and have the patient take a Turkish bath every week. The constant electric current finds advocates. In an ordinary severe case order a hot bath, put the patient to bed with a hot-water bag over the part, and administer 10 grains of Dover's powder; the next morning order to be taken four times daily a capsule containing 5 grains of salol and 3 grains of phenacetin, until the pain disappears. Citrate of potassium, citrate of lithium, chlorid of ammonium, or the salicylate of colchicin may be ordered.

Infective myositis is a widespread inflammation of the voluntary muscles, due to an unknown infective cause. It is a disorder accompanied by pain and stiffness, by cutaneous edema, and by various paresthesia. Myositis resembles trichinosis, and is distinguished from it only by spearing out a bit of muscle and examining it microscopically. Occasionally diffuse suppuration occurs. Ordinary myositis arises from injuries, from syphilis, or from rheumatism, and it presents the usual inflammatory symptoms. Contraction and adhesions may follow.

Treatment. Infective myositis is treated by anodynes, stimulants, nutritious food, hot applications, and rest. If pus forms, it should be evacuated. Rheumatic myositis calls for the administration of the salicylates, the alkalies, or salol. Syphilitic myositis is treated with mercury and iodid of potassium. The remedies employed for myalgia are used in traumatic myositis.

Hypertrophy of the muscles may arise from their increased use. In pseudohypertrophic paralysis the bulk of the muscle is greatly augmented, but it contains less musclestructure and more fat or connective tissue.

Atrophy of the muscles arises from want of use, from injury, from continuous pressure, from interference with the blood-supply, from disease of the nerves or their centers, or from lead-poisoning.

Degeneration of Muscles.-The muscles may undergo

granular degeneration, waxy degeneration, fatty degeneration, and calcareous degeneration, and may become pigmented.

Local Ossification and Myositis Ossificans.—It is not unusual for a small portion of bone to form in the periosteal insertion of a muscle which is subjected to frequent strain. In persons who ride many hours a day there not infrequently develops the "rider's bone," which is an area of ossification in the adductor muscles of the thigh. Myositis ossificans, a widespread ossification of the muscles, is a rare disorder the cause of which is unknown, and which if not congenital begins at least in early life.

Tumors of the Muscles.-Primary tumors of the muscles are rare. Among those which may occur are sarcoma, fibroma, lipoma, osteoma, angioma, myxoma, and enchondroma. Most cases of supposed primary sarcoma of muscle are in reality cases of syphiloma (Esmarch).

Syphilis may cause inflammation. Gummata may form, or gummatous infiltration may take place.

Trichinosis or trichiniasis is a disease due to the embryos of the trichina spiralis. The disease originates from eating insufficiently cooked meat which contains the trichinæ. These nematodes are carried into the intestine, there to develop and multiply. In from seven to nine days a horde of embryos develop in the bowel, and leave the alimentary canal by passing through the peritoneum or by means of the blood, and finally reach the connective tissue of the muscles. From the connective tissue the embryos migrate into the primitive muscle-fibers, where they dwell and enlarge. Myositis develops, and in the course of five or six weeks the parasites become encapsuled and develop no further. The cyst-walls may calcify and the worms may become calcified, or may live for years. Because infected meat is eaten the disease does not inevitably develop, and a few embryos lodged in muscle may cause no symptoms.

Symptoms. The symptoms of trichinosis often appear in a day or two after eating infected meat. The symptoms of acute gastro-intestinal catarrh or of cholera morbus are common, but in some cases no gastro-intestinal manifestations usher in the disease. In from seven to fourteen days after the infected meat is eaten the migration of the parasites develops obvious symptoms. A chill may be noted; there is usually fever; muscular pain, tenderness, swelling, and stiffness are complained of. This condition may be widespread. Involve

ment of the muscles of mastication interferes with chewing; of the larynx, with audition and respiration; of the intercostals and diaphragm, with respiration. Skin-edema and itching are marked. In some cases delirium exists. The writer saw in the Philadelphia Hospital one fatal case which was mistaken for erysipelas because of the high fever, the delirium, and the edematous redness of the face and neck. Dyspnea is frequent. Mild cases get well in a week or two; severe cases may last many weeks. The mortality varies in different epidemics from 1 to 30 per cent. (Osler). The diagnosis is made by spearing out a piece of muscle, which is then examined for trichinæ under a microscope; or the worm may be detected in the feces by means of a pocketlens.

Treatment.-To treat trichinosis employ purgatives (senna and calomel) early in the case, and give glycerin, and also santonin or filix mas. When muscular invasion has taken place, sedatives, hypnotics, nourishing diet, and stimulants are indicated.

Wounds and Contusions of the Muscles.-Wounds of muscles may be either open or subcutaneous. In a longitudinal wound the edges lie close together, and hence drainage must be provided for by the surgeon. In a transverse wound the edges separate widely, and catgut stitches must be inserted, Contusions of muscles, like contusions of other tissues, vary in extent and in severity. There are pain (which is increased by attempts to use the muscle), loss of function, swelling beneath the deep fascia, and discoloration, which may appear at once because of superficial damage from the initial injury, or which may appear in dependent parts after many days by gravitation of the blood and the blood-stained serum. As a result of contusion, suppuration, inflammation, or atrophy may arise.

Treatment. The indications in wounds and contusions of muscles are to obtain rest by means of splints and to secure relaxation. Limitation of swelling is secured by bandaging. Inflammation is combated first by cold and leadwater and laudanum; later by iodin, blue ointment, ichthyol, and intermittent heat. To prevent loss of function employ, as soon as the acute symptoms subside, massage, passive motion, and stimulating liniments, and, later in the case, electricity (galvanism if the reactions of degeneration exist, faradism if they are absent).

Strains and Ruptures.-A strain is a stretching of a muscle with a small amount of rupture. The muscle is

swollen, tender, stiff, weak, and sore, and attempts at motion produce sharp pain. Strains are common in the deltoid, the hamstring muscles, the back, the calf, the biceps, and the great pectoral. Strain of the psoas muscle causes pain on flexing the thigh, and is associated with tenderness in the iliac fossa. Strain of the right psoas may be mistaken for appendicitis, but it lacks the intense local tenderness, the abdominal rigidity, and the constitutional symptoms. "Lawn-tennis arm" is a strain of the pronator radii teres muscle. "Rider's leg" is a strain of the adductor muscles of the thigh. A strain may be the only injury, or may be associated with some other condition (fracture of bone, dislocation, sprain, contusion, etc.).

The muscle is often rigid, is tender, and pains greatly when an attempt is made to use it. The skin over it, especially over its point of insertion, is usually tender.

A strain of the back is a very common accident which is often associated with sprains of the vertebral ligaments. There is great pain when the patient voluntarily straightens up. If the vertebral ligaments are not sprained, the patient can be straightened by passive motion without pain. The skin is tender in certain areas. The muscles are often rigid. There may be unilateral rigidity. In a back injury make a careful examination to be sure there is no damage to vertebræ or cord.

Treatment. Relaxation by suitable position; rest by the use of splints or by putting the patient to bed; bandages for compression; hot fomentations or hot lead-water and laudanum; ichthyol. As soon as acute symptoms subside employ frictions and massage. If there is much pain after a strain, administer Dover's powder, or even morphin.

Rupture of a muscle is announced by a sudden and violent pain and by loss of function arising during powerful muscular contraction or strong traction on a muscle. The rupture may be announced by a clearly audible snap (A. Pearce Gould). A distinct gap is felt between the ends; great pain develops on movement; there are tenderness, loss of power, and swelling. Strains and rupture may be followed by atrophy, as are contusions. Among the muscles which occasionally rupture we may mention the quadriceps, biceps, triceps, deltoid, etc.

Treatment. In limited rupture treat as a severe strain. In treating extensive rupture of an important muscle, when the ends are widely separated, incise with every aseptic care, unite the divided ends by sutures of chromic catgut, and