In the third degree we find ruptures of the muscular tissue and extensive effusions of blood or even purulent collections. The mus cle is very soft and friable, its color is yellowish, grayish, or brown ish, and the fibres are separated. But alongside of this destructive process proceeds one of repair which is very interesting to observe. There is a true regeneration of the muscular tissue starting from the nuclei of the muscles and also from those of the internal perimysium.
There are three points of particular importance in the pathologi cal anatomy of this form of myositis, viz., the work of regeneration, of which I have just spoken, and the granular and waxy degenera tions. We know that granular degeneration is characterized by a deposit of fine granules in the substance of the primary fibres. The vitreous degeneration, which is called waxy by Zenker, consists in a tumefaction of the primary fibre, the muscular elements of which have become transformed in mass into a substance having a shining aspect.
In typhoid fever we meet especially with waxy degeneration, and in small-pox with granular degeneration.
Etiology.—As regards the pathogenesis of these inflammations, the increased temperature due to the fever was formerly looked upon as a factor of the greatest importance. While not denying wholly the influence of this cause, I believe that there is another factor of much greater importance. Here again we have to consider the ac tion of microbes. In a lecture on typhoid fever recently published, Achard has expressed himself as follows : " These forms of myositis associated with typhoid fever are produced by micro-organisms, and in our case we were able to detect Eberth's bacillus together with the staphylococcus albus in the fluid withdrawn by aspiration." It can therefore not be doubted that the micro-organisms are the essential factors in the production of the muscular'inflammations occurring in the course of acute infectious diseases.
The symptomatology of these forms of myositis is often obscure, and in many cases there is nothing to lead us to suspect the condition which is revealed at the autopsy. Nevertheless the fatigue and feel ing of lassitude, which are among the first symptoms of an infectious fever, must certainly be due to inflammation of the muscular tissue. This depression, a feeling as though the limbs were broken, and vague pains referred to the muscles are present more especially in typhoid fever, small-pox, and influenza. I do not, however, believe that we ought to refer the intense rachialgia which accompanies the onset of small-pox to a myositis affecting the dorsal and lumbar mus cles. That is rather, in my opinion, a phenomenon referable to the spinal nerve centres, the rapidity of its appearance and its immediate intensity arguing against the supposition that it is of muscular origin.
But in addition to these indefinite symptoms, which may easily be confounded with those of the original malady, we find others more precise. Small-pox and especially typhoid fever furnish us with ex amples of this kind. We find certain muscles or groups of muscles more painful than others, and it is especially the recti abclominis, the pectorals, the adductors, and the muscles of the extremities that are chiefly affected. Their contraction causes pain, and palpation
enables us to map out the inflammatory induration of which they are the seat.
The most frequent complication of myositis is muscular hemor rhage, which is not infrequently observed in typhoid fever. It is this fact, indeed, which has drawn the attention of clinicians to the muscular lesions occurring in the course of this affection ; and for a considerable time the only recognized form of symptomatic myositis was that complicating typhoid fever. The innscular hemorrhage takes place during the third or fourth week of the disease, and is the result of the rupture of the muscular fibres which occurs during con traction. It is for this reason that the hemorrhage is most commonly observed in the rectus abdominis muscle, which is the one that enters into action whenever the patient turns in bed or attempts to sit up.
When hemorrhage has taken place we find a painful tumefaction at the site of the lesion, which is indurated, somewhat elastic, and occasionally fluctuating. In the course of a few days an ecchymosis appears under the skin; this may gradually become absorbed, pre senting all the colors indicative of this process, or may become the seat of suppuration. In the latter case the skin becomes. red and hot, there may be some fever, and all the signs point to the presence of pus, which should immediately be evacuated.
In the category of muscular inflammations which we are now con sidering I would range that described by Gaucher and Marage under the name of the myositis of measles. The case reported by these authors was that of a child seven years of age who presented symp toms of a chronic myositis in the right calf and torticollis affecting the sterno-cleido-mastoid muscle of the left side, consequent upon an attack of measles.
The forms of secondary myositis which we have just been study ing exert a very feeble influence upon the progress of the disease which gives rise to them. Nevertheless if suppuration occurs we have a complication that may be of serious import by reason of the de pressed condition of the organism already weakened through the action of the primary disease, and which may retard recovery even if it leads to nothing more grave.
Treatment.—There is almost nothing to acid here to what I have said in the corresponding section under the heading of primary myo sins. At the beginning we may combat the inflammation of the mus cles by means of mild revulsives. If a rupture has occurred and been followed by hemorrhage, imm6bilization of the part or light com pression will usually bring about resorption of the effused blood; only occasionally will it be necessary to make an incision into the muscle. If pus forms we must evacuate it and treat the wound anti septically. In the chronic sclerosing form we must have recourse to inunctions with Neapolitan ointment, electricity, and methodical massage.