In some cases there are symptoms of diminished elasticity and loss of functional power. I may remind the reader of "rheumatic torticollis" due to myositis in the scaleni and sterno-cleido-mastoid on one side; of the lame or abnormal walk when there is myositis in the leg muscles; of the way in which the patient tries' to avoid all movement of the lumbar region when he suffers from "lumbago"; of the impossibility of hard mechanical work with myositis in the arm muscles (this last example often causes changes which must be referred to under the complex symptoms of "writer's cramp").*

Myositis, especially the kind in question, of rheumatic origin, of which the cause is unknown, often leads to a mistaken diagnosis; it is frequently mistaken for other diseases, and other diseases are not seldom mistaken for myositis. Beginners are often led astray in palpation by infiltration in the skin and subcutaneous tissue, by normal conditions such as lobulation of the subcutaneous fatty tissues, by differences of consistency due to the underlying parts (e.g., in omohyoid near the shoulder joint), or to the formation of the muscle itself. Swellings caused by myositis are seldom so definitely separated from the surrounding tissues as new growths of any kind whatever; nevertheless, I have seen new formation, especially gummata, mistaken for myositis by well-known physicians.

* Myositis and neuritis give rise to the symptoms of writer's cramp. But since in many of these cases, to which I shall refer later, there are no perceptible changes in the arms, they must be included in the group of functional neuroses, the pathology of which is unknown.

The pain caused by myositis is often of very variable nature; sometimes it resembles closely the pain of "pure" neuralgia and other neuroses; often it is similar to the pain present in chlorosis, anaemia, gout, poisoning (especially lead poisoning), or trichinosis, and other diseases caused by local processes. How often is pleurisy mistaken for intercostal "rheumatism"; and how often, again, is myositis of the pectoral muscles diagnosed as pleurisy ! We can very easily be led astray by the symptom of pain on pressure. Remarkable mistakes may arise in this way; for example, I have known appendicitis to be mistaken for myositis when there has been pain in the anterior abdominal wall, for it is not easy to diagnose this from processes in the abdominal cavity. I also remember examining a patient who suffered from infiltration in the upper portion of the rectus abdominis, and until I had completed the examination I naturally suspected ulcer of the stomach. One must not impute to myositis all the symptoms which were formerly ascribed to it, nor must one accept without criticism too many new views which arise in this as in all other diseases. Rheumatic torticollis, according to Lanceraux, is caused by neuralgia in the cervical plexus; Robin and Londe give as its cause inflammation in the ligaments and articulations of the cervical region; Erbin also is of the same opinion. Nowadays there is a fairly general opinion that "rheumatic" torticollis does not exist. Both Robin and Erbin believe lumbago to be other than myositic in origin, and they suggest that it is in many cases caused by disease of the ligaments and joints, or it may be entirely neuralgic. I do not wish to enter into details as to the frequency of muscular and articular forms of lumbago, but I affirm that both rheumatic and traumatic myositis (over-strain of muscle) may give rise to it. One must bear in mind that syphilitic muscular affections must not be mistaken for rheumatic. Syphilis is found in the muscles in two different forms, either as diffuse muscle inflammation or as gummata. The syphilitic diffuse myositis (which most frequently occurs in the muscles of the calf and upper arms) can only be distinguished from rheumatic myositis by the result of treatment, in that the former does not yield to massage as does the latter. Gummata in muscle are more circumscribed and the swelling is more definite than that of rheumatic myositis, and more resembles the consistency of the traumatic form. Mistakes often occur, however, in cases of rheumatic myositis. Another problem which often occurs in medical practice is to distinguish the false angina (pseudo-angina) pectoris from the true, which depends upon changes in the coronary arteries and cardiac muscles. "Nervous" people often complain of attacks of sudden acute pain in the region of the heart; the attack may occur either by night or day, the patient suffers extreme agony, and the attack can only be distinguished from the real angina when by examination it is found that there are no morbid changes in the heart and blood vessels, and it may be years before such changes do occur. On examining these cases one often finds myositis in the pectoral or other muscles of the chest, and one has a right to assume a causal connection between these two conditions, since the attacks often cease when the myositis is cured by treatment.

In connection with these phenomena I will mention briefly one or two conditions which, though not fully understood, are of special interest to the physician-masseur. Brissaud in his study of metameric zones teaches that the body, from an anatomical, physiological, and pathological point of view, is divided into certain zones or segments, each of which has its own nerve centre in the spinal cord and in the corresponding spinal ganglion, from which centre, by means of reflexes from the segments or metameric visceral parts, a neuro-trophic influence can be carried to the peripheral parts. Head, who has further enlarged this theory, believes that every internal visceral complaint produces certain external inflammatory and other reflex effects, especially hyperesthesia of the skin, and, according to James Mackenzie, causes hyperalgesia in the subcutaneous tissue and in the muscles of the corresponding segment. It is to be hoped that in the future we shall more thoroughly understand many subjects which are not yet clear; we shall thus gain knowledge of the connection between peripheral and visceral conditions; for example, we shall discover the origin of subcutaneous and muscular infiltration, of the mysterious forms of local ocdema, etc., which we now find puzzling. I pass on to mention a remarkable and interesting theory of the French-Swedish medical gymnast, Dr. Gustaf Krikortz.* He has drawn several conclusions from Brissaud's theory of metamerism, and holds that many, perhaps most, of the palpable changes in the skin and subcutaneous tissue and muscles are due to irritation of the corresponding metameric centres in the spinal cord produced by visceral lesions. Krikortz believes that the condition known and recognised as myositis in trapezius may be connected with tubercle in the apex of the lung, that myositis of the pectoral muscles may result from organic heart disease (arterio-sclerosis in the aorta or in the coronary arteries, acute dilatation of the heart, etc.), that infiltration in rectus abdominis may be caused by gastric ulcer, that cellulitis in the abdominal wall may be caused by disease of the uterus or its adnexa. All these suggestions are at present only theories, but theories worth considering, and of special interest for the masseur.