INFLAMMATIONS OF MUSCLES (MYOSITIS) We distinguish local and general, purulent and nonpurulent in flammations of muscles.
Local purulent myositis results either from trauma or from in flammation of neighboring organs, or from some general infection. Multiple purulent myostitis is a rare complication of universal sepsis, scarlatina and other infections. Nonpurulent inflammation of indi vidual muscles may result from rheumatism, scarlatina, gonorrhcea, typhoid fever, etc., or from injury. It is possible that syphilis (Hoch singer) and tuberculosis also lead to inflammation of individual muscles without abscess formation.
These different forms of myositis are all part of other diseases and have received due attention in the appropriate places.
Polymyositis or non-purulent inflammation of the entire muscular system is an independent disease and often quite difficult to recognize. It occurs either as a primary affection without any recognizable cause or as a sequel of some parasitic infection, particularly trichinosis. In primary polyinyositis the intestinal symptoms are at first so pronounced as to suggest that the causative organism first effects an entrance through the intestinal tract.
Lorenz has subdivided primary polymyositis into the following groups: dermatomyositis, hamorrhagic myositis, myositis with ery thema multiforme, and fibrous myositis. Certain other less pronounced forms of polymyositis might be added. These different varieties of multiple myositis, however, do not represent so many different clinical types, the classification being based on individual symptoms, which may characterize the clinical picture of myositis as a whole either clinically or pathologically. Myositis following a polyneuritis is desig nated neuromyositis. Primary progressive ossifying my-ositis is a special disease which will be discussed separately.
The characteristic features of polymyositis are briefly as follows: The prodromal stage, lasting several days, is marked by general malaise with fever, anorexia, vomiting, pain in the limbs and headache; the fever gradually rises; the patient's subjective state rapidly becomes worse; and albuminuria sometimes makes its appearance. (Edema then develops in the eyelids and in the face and, as a rule, spreads rapidly to the surface of the entire body. At the same time the muscles of the face become rigid, boardlike and very painful. The fever con tinuing, sometimes inereasing by abrupt rises, the myositis spreads to the other portions of the body, particularly the extremities; the hands and feet being as a rule less severely damaged than any other portions. The muscles feel swollen, bard and doughy, and are extremely painful. The deep reflexes arc usually diminished; the skin reflexes, as a rule, persist.
The patients are quite unable to move. The general condition is greatly impaired by the pyrexia, which suggests that of typhoid fever, by the pain, and by the difficulty of taking nourishment. The course
may be quite rapid and death may result in a short time from involve ment of the muscles of respiration, the heart and muscles of deglutition. In favorable eases the oedema, fever and gradually also the muscu lar swelling subside, and the patient recovers within a few weeks or months. Sometimes the course is subacute or even chronic and inter rupted by exacerbations.
The pathology consists in acute inflammation of the musele paren chyma and of the interstitial tissue. When the inflammatory cutaneous cedema is pronounced, the term dermatomyositis is used (Unverricht). Iitemorrhagic polymyositis is accompanied by a hxmorrhagic exudate and other themorrhages into the skin and mucous membranes. The heart is usually attacked in this form, and the prospect of a favorable outcome is very slender. When the inflammatory process exhibits a more chronic [diameter from the beginning and is attended by prolifera tion of connective tissue in the muscle, the disease is called fibrous myosins.
Polymyositis usually runs a less violent course in children than in adults. The cases collected by Schuller all ended in recovery [Janicke, Schultze, Koster, Cassirer, Oppenheim (the last case is doubtful)]. The ease from my own clinic, which was described by Schuller, when at its height bore a great similarity to a form of cerebral infantile palsy designated "cerebral rigidity." In this case the course was mild, but in other re.spects like the above-described typical clinical picture.
Cases of myositis are susceptible only to purely symptomatic treatment.
Trichinous polymyositis, the cause of which is the entrance of the embryonal para sites into the intestine and their migration by way of the lymph or blood channels into the muscular capillaries, with the production of irritative symptoms is quite similar to primary myositis. Accordingly, trichinosis myositis differs from the primary form only by its cause, and the clinical picture in the 1.11-0 diseases may be clinically so nearly identical that the differential diagnosis must be based on etiologic and other extraneous factors. The occurrence of similar cases in the same locality or in the same family, the prominence of the primary intestinal symp toms, the presence of the parasites in the feces, eosinophilia and possibly the demon stration by means of the X-ray of numerous calcified trichina capsules in the thinner muscles ,Gocht, Schuller) are points in favor of trichinosis. The course of trichinosis is also milder in the child than in the adult, recovery frequently resulting by- calcification of the incapsulated parasites. Other para sites (echinococcus, cysticercus, sporozoa) may produce similar diseases of the muscles.