As the muscular lesions take their.course the general condition of the patient remains stationary. There is always considerable fever to 104° F.), the tongue is dry, there is dyspncea, the appetite is lost, there are abundant sweats, and in certain cases a vesicular eruption has been observed. These vesicles contain first a clear transparent fluid which gradually becomes milky, and then the vesicle dries up and a sort of epidermic desquamatiou follows. When the disease is going to take a fatal course, which is not infrequent, all these symptoms become aggravated: diarrhoea sets in, the teeth are covered with sordes, the patient is agitated, delirious, and finally falls into a condition of extreme exhaustion, and dies.
In certain favorable cases the general condition is never very grave; the symptoms are then referable chiefly to the stomach ; the tongue is white, there is a bad taste in the mouth, but the tempera ture is usually not so elevated as in the class of cases previously described.
Infectious myositis, when occurring in its most grave form, may carry off the patient in five or six days; in less rapid cases death may ensue from the ninth to the sixteenth clay. In favorable cases the symptoms gradually amend, the pains become less severe, the tem perature falls, and the patient enters into the stage of convalescence. But this convalescence, like that of all infectious diseases, is always long and tedious, and for months the patient suffers from muscular pains and general weakness.
A remarkable fact in this variety of infectious myositis is the ra pidity with which the pus is formed. In the very acute cases death may take place before we are able to discover the presence of pus or to adopt measures for its evacuation, and yet at the autopsy we may find entire masses of muscular tissue transformed into abscesses. Pus has been found within three or four days of the onset of the dis ease. Suppuration is not, however, necessarily attended with fatal results, and patients have been known to recover after the evacuation of very large abscesses. When the course of the disease is more be nign it may terminate by resolution; in this case the muscles gen erally remain more or less rigid for a considerable period of time, impeding in great part the movements of the affected limbs.
Primary Acute Infections Polymyositis.—This disease, which has been studied by Unverricht, Marchand, Hepp, Larger, and Gouget, presents a clinical picture differing very markedly from that which we have just drawn. In this form suppuration never occurs, and fur thermore the disease, instead of being localized in any muscle or group of muscles, involves almost the entire muscular system. But
that is not all, and we shall see by a study of the symptoms and of the course of the disease that we have here to do with an indepen dent morbid entity.
The prodromic period of acute infectious polymyositis may be very long. For weeks or months the patient may complain of fa tigue and unusual lassitude, but in general this period lasts only from three to five weeks. The first manifestations of the disease are oedema, pain, and redness. The cedema, at first of slight extent and painless, is commonly localized on the extremities or the face. The redness, more or less pronounced, appears on the face, extremities, or abdomen. The erythema is seen, on examination, to be due to the presence of little spots, not elevated above the surface, more or less confluent, and disappearing on pressure. The pains gradually increase in severity, and the patient, who at first feels only an unu sual fatigue and some gastric disturbance, is soon forced by the pain to take to his bed. It is at this time that the grave symptoms de clare themselves. Occasionally they may be at their height by the end of from eight to twelve days, but usually their full development does not take place until, as we have seen, the expiration of from three to five weeks. At this time the patient often has a succession of chills and the temperature rises to, or exceeds, 104° F. The (edema becomes hard, and the pains grow so violent that the patient instinctively restricts all motion, and lies stiff and as if strapped to his bed. The muscles seem to be in a state of contraction, holding the limbs in semiflexion; they do not react to electrical stimula tion. The tendon reflexes are abolished (Hepp).
Perspiration is most commonly very abundant; the urine is dark in color and sometimes contains albumin; the tongue is dry; the thirst is intense; constipation is the rule. The pulse is small, the liver and spleen are enlarged, and very frequently lobar pneu monia is present. The latter is generally one of the later com plications.
All the muscles are more or less affected; those of the thorax and of the pharynx lose their functional power, and the patient succumbs to exhaustion or to suffocation and asphyxia, a result to which the pneumonia often contributes.
In certain cases, unfortunately rare, after the disease has existed for a considerable period it may begin to recede, and the patients then enter upon a period of convalescence, which is always of long duration.