Diseases of Muscles and Tendons

Congenital absence of muscles is sometimes met with, usually in association with other deformities. The pectoralis major, for example, may be absent on one or on both sides, without, however, causing any disability, as other muscles enlarge and take on its functions. Atrophy of Muscle.Simple atrophy, in which the muscle elements are merely diminished in size without undergoing any structural alteration, is commonly met with as a result of disuse, as when a patient is confined to bed for a long period. In cases of joint disease, the muscles acting on the joint become atrophied more rapidly than is accounted for by disuse alone, and this is attributed to an interference with the trophic innervation of the muscles reflected from centres in the spinal medulla. It is more marked in the extensor than in the flexor groups of muscles. Those affected become soft and flaccid, exhibit tremors on attempted movement, and their excitability to the faradic current is diminished. Neuropathic atrophy is associated with lesions of the nervous system. It is most pronounced in lesions of the motor nervetrunks, probably because vaso-motor and trophic fibres are involved as well as those that are purely motor in function. It is attended with definite structural alterations, the muscle elements first undergoing fatty degeneration, and then being absorbed, and replaced to a large extent by ordinary connective tissue and fat. At a certain stage the muscles exhibit the reaction of degeneration. In the common form of paralysis resulting from poliomyelitis, many fibres undergo fatty degeneration and are replaced by fat, while at the same time there is a regeneration of muscle fibres. Fibrositis or Muscular Rheumatism.This clinical term is applied to a group of affections of which lumbago is the bestknown example. The group includes lumbago, stiff-neck, and pleurodyniaconditions which have this in common, that sudden and severe pain is excited by movement of the affected part. The lesion consists in inflammatory hyperplasia of the connective tissue; the new tissue differs from normal fibrous tissue in its tendency to contract, in being swollen, painful and tender on pressure, and in the fact that it can be massaged away (Stockman). It would appear to involve mainly the fibrous tissue of muscles, although it may extend from this to aponeuroses, ligaments, periosteum, and the sheaths of nerves. The term fibrositis was applied to it by Gowers in 1904. In lumbagolumbo-sacral fibrositisthe pain is usually located over the sacrum, the sacro-iliac joint, or the aponeurosis of the lumbar muscles on one or both sides. The amount of tenderness varies, and so long as the patient is still he is free from pain. The slightest attempt to alter his position, however, is attended by pain, which may be so severe as to render him helpless for the moment. The pain is most marked on rising from the stooping or sitting posture, and may extend down the back of the hip, especially if, as is commonly the case, lumbago and gluteal fibrosis coexist. Once a patient has suffered from lumbago, it is liable to recur, and an attack may be determined by errors of diet, changes of weather, exposure to cold or unwonted exertion. It is met with chiefly in male adults, and is most apt to occur in those who are gouty or are the subjects of oxaluric dyspepsia. Gluteal fibrositis usually follows exposure to wet, and affects the gluteal muscles, particularly the medius, and their aponeurotic coverings. When the condition has lasted for some time, indurated strands or nodules can be detected on palpating the relaxed muscles. The patient complains of persistent aching and stiffness over the buttock, and sometimes extending down the lateral aspect of the thigh. The pain is aggravated by such movements as bring the affected muscles into action. It is not referred to the line of the sciatic nerve, nor is there tenderness on pressing over the nerve, or sensations of tingling or numbness in the leg or foot. If untreated, the morbid process may implicate the sheath of the sciatic nerve and cause genuine sciatic neuralgia (Llewellyn and Jones). A similar condition may implicate the fascia lata of the thigh, or the calf muscles and their aponeurosescrural fibrositis. In painful stiff-neck, or rheumatic torticollis, the pain is located in one side of the neck, and is excited by some inadvertent movement. The head is held stiffly on one side as in wry-neck, the patient contracting the sterno-mastoid. There may be tenderness over the vertebral spines or in the lines of the cervical nerves, and the sterno-mastoid may undergo atrophy. This affection is more often met with in children. In pleurodyniaintercostal fibrositisthe pain is in the line of the intercostal nerves, and is excited by movement of the chest, as in coughing, or by any bodily exertion. There is often marked tenderness. A similar affection is met with in the shoulder and armbrachial fibrositisespecially on waking from sleep. There is acute pain on attempting to abduct the arm, and there may be localised tenderness in the region of the axillary nerve. Treatment.The general treatment is concerned with the diet, attention to the stomach, bowels, and kidneys and with the correction of any gouty tendencies that may be present. Remedies such as salicylates are given for the relief of pain, and for this purpose drugs of the aspirin type are to be preferred, and these may be followed by large doses of iodide of potassium. Great benefit is derived from massage, and from the induction of hypermia by means of heat. Cupping or needling, or, in exceptional cases, hypodermic injections of antipyrin or morphin, may be called for. To prevent relapses of lumbago, the patient must take systematic exercises of all kinds, especially such as bring out the movements of the vertebral column and hip-joints.