l-!-(:"';-!i!iit!u^ii;i!i!!l^ 1ZC LIBRARY NEW YORK STATE VETERINARY COLLEGE ITHACA, NEW YORK Cornell University Library RC 71.A54 1914 A text-book of medical diagnosis, 3 1924 000 282 966 ■<\ Cornell University Library The original of tiiis book is in tine Cornell University Library. There are no known copyright restrictions in the United States on the use of the text. http://www.archive.org/details/cu31924000282966 A TEXT-BOOK of MEDICAL DIAGNOSIS By JAMES M. ANDERS, M. D., Ph.D., LL. D. PROFESSOR OF THE THEORY AND PRACTICE OF MEDICINE AND OF CLINICAL MEDICINE, MEDICO-CHIRURGICAL COLLEGE OF PHILADELPHIA; OPFICIER DE l' INSTRUCTION PUBLIQUE, ETC., ETC. and L. NAPOLEON BOSTON, A. M„ M. D. PROFESSOR OF PHYSICAL DIAGNOSIS, MEDICO-CHIRURGICAL COLLEGE; PHYSICIAN TO THE PHILADELPHIA GENERAL HOSPITAL ; PATHOLOGIST TO THE FRANKFORD HOSPITAL SECOND EDITION, THOROUGHLY REVISED, WITH 500 ILLUSTRATIONS, SOME OF THEM IN COLORS PHILADELPHIA AND LONDON W. B. SAUNDERS COMPANY 1914 Z. Copyright, 191T, by W. B. Saunders Company. Reprinted January^ 1912. Revised, reprinted, and recopyrighted June, 1914 Copyright, 1914, by W. B. Saunders Company 7 / PRrNTED tN AMERICA PRESS OF W. u. SAUNDERS COMPANY PHILADELPHIA PREFACE TO THE SECOND EDITION. The revision of this edition has been in progress for the past two years. The most efficient manner in which the authors can express their grati- tude for favor shown to this .work is by keeping it a fair exponent of its subject. Every effort has been made to bring the present volume abreast with our clinical and laboratory methods of diagnosis. It is earnestly hoped by the authors that all practical advances in diagnosis have been given consideration. While our aim has been to make a thorough revision of this work, special mention may be made of the more important additions : Movements of the two halves of the chest; electrocardiograms; extrasystole; auricular fibrillation; sinus irregularity; succussion sounds audible over the abdo- men; abdominal tension with original methods of determination; albumin- ous sputum; cobra-venom reaction in syphilis; the tick in transmitting relapsing fever; Rumpell-Leed phenomena in scarlet fever; inclusion bodies of Dohle in scarlet fever; sweating and its significance; Trichinella spiralis in the blood; MacEwen's sign and Brudzendski's sign of epidemic meningitis; Prendergast's reaction for typhoid fever; fatty emboli; pupil- lary reaction; drug eruptions; nitrogen content of the blood; respiratory movements in [hiccough; colloidal nitrogen of the urine, and initial erup- tions in measles. Clinical tables have been added on the following subjects: Bloody sputum; dyspnea; hemorrhage from the mouth; abdominal enlargement; vomiting; ascites; splenic enlargement; hematuria, and bacteriuria. Among the subjects that have been rewritten are Stokes-Adams disease; blood-pressure; ulceration of the duodenum; Addison's disease, and an- terior poliomyelitis. We are especially indebted to Dr. Francis Ashley Faught for assistance in connection with the chapter on blood-pressure, and to the pubfishers, W. B. Saunders Co., for special courtesies, and, most of all, for their untir- ing devotions to the interest of this book; features which can only be appreciated by those responsible in the capacity of its authorship. James M. Andebs. L. Napoleon Boston. Philadelphia, Pa., June, 1914. 1 PREFACE. The present volume is offered to the medical public at the repeated solicitations of both practitioners and imdergraduate students. The special purposes of the authors have been primarily to furnish an improved method of determining the clinical features of disease, so that all of the more im- portant sjTnptomatic phenomena in a given case may be collected with ease and certainty, and to emphasize the importance of coroUating symptoms with the structural changes on which they are dependent and their organismal etiology. It is confidently believed that a knowledge of the laws of disease thus gained, combined with personal experience, will prove the best guide to accurate diagnosis, and obviate the danger of being sidetracked by non- essential evidence. This method, which brings the entire organism imder consideration, of investigating disease, as outlined in the introductory chapter of this work (vide infra), will render the question of individualization of cases, a prime requisite, free from serious difficulty. Moreover, it wiU provide a sure and proper basis for rational treatment. The method herein advocated will forcibly encourage painstaking, thor- ough, and scientifically accurate investigation of disease, and it will more than compensate for the indifferent and embarrassing results of mere super- ficial observations of cases, which, be it remembered, can never carry an observer to eminence as a diagnostician. Additionally, the authors have aimed to present, consistently with a single volume text-book, the full modem resources of the art and science of medicine as related to medical diagnostics. The new features, which it is hoped will commend themselves to pro- fessional favor, are the brief pathologic definitions of special diseases, the illustrative cases selected from those actually observed in the hospital and private practice of the authors, and the numerous diagnostic tables, designed to aid the student and practitioner in contrasting the distinguishing signs and symptoms of diseases which bear a close clinical resemblance to one another. Here should also be mentioned the sub-headings, Summary of Diagnostic Features and Laboratory Diagnosis, which occur in connection with the individual complaints described. The text is profusely illustrated with photographs and colored plates, with a view to facilitating the reader's grasp of the technic of the more refined methods of diagnosis. Our best thanks are hereby extended to Dr. John M. Swan for kind aid rendered in connection with the task of proof-reading, to Dr. T. H. Weisen- burg for preparing the section on diseases of the nervous system, and to Dr. George E. Pfahler, who furnished the subject-matter relating to Rontgen- ology. Finally, our thanks are due the publishers for much courtesy and kindly interest manifested while the volume was passing through the press. James M. Anders, L. Napoleon Boston. Philadelphia, Pa. CONTENTS. PASB Introduction 17 General and Special Considerations 17 Investigation of Individual Cases 23 Physical Examination 27 Bedside Observations 29 DISEASES OF THE RESPIRATORY SYSTEM. DISEASES OF THE NOSE AND THROAT. Laboratory Examinations 32 Diseases of the Nose 33 Acute Rhinitis 33 Chronic Rhinitis (Chronic Nasal Catarrh) 33 DISEASES OF THE LARYNX. Acute Catarrhal Laryngitis (Acute Endolaryngitis) 34 Spasmodic Laryngitis (Laryngismus Stridulus; False Croup) 34 Tuberculous Laryngitis 35 SyphUitic Laryngitis 36 Eidematous Laryngitis 36 Chronic Laryngitis 36 Tumors of the Larynx 37 DISEASES OF THE BRONCHI, LUNGS, AND PLEURA. Methods of Examination 37 Data Obtained by Inquiry 37 Physical Examination of the Chest 40 Inspection of the Chest 45 Palpation of the Chest 52 Percussion of the Chest 55 Auscultation of the Chest 63 Ri,les (Rhonchi; Rattles) 69 The X-Ray Evidence of Diseases of the Bronchi, Lungs, Pleura, and Diaphragm . . 73 Diseases which Increase the Transparency of the Lung 73 Diseases which Decrease the Transparency of the Lung 74 The Diaphragm 75 The Pleura 76 The Sputum 77 Collection 77 Characteristics of the Sputum in Disease 77 Microscopic Study of the Sputum 80 Chemic Study of the Sputimi 87 DISEASES OF THE BRONCHI. Acute Bronchitis 87 Infectious Bronchitis 90 Chronic Bronchitis 91 Fibrinous Bronchitis (Plastic Bronchitis; Croupous Bronchitis; Mucous Bron- chitis) 94 Asthma (Bronchial Asthma) 96 Bronchiectasis 100 bronchial Stenosis 103 5 6 CONTENTS. DISEASES OF THE LUNGS. p^gj. Congestion of the Lungs 104 Pulmonary Edema 105 Bronchopneumonia (Capillary Bronchitis; Catarrhal Pnexmionia) 107 Lobar Pneumonia (Croupous or Fibrinous Pneumonia: Pneumonitis; Lvmg Fever). 113 Chronic Interstitial Pneumonia (Fibroid Induration; Cirrhosis of the Lung) 113 Pneumonokoniosis (Anthracosis; Chahcosis; Siderosis) 115 Pulmonary Tuberciilosis 116 Pneumorrhagia (Pulmonary Apoplexy) 116 Pulmonary EmboUsm (Hemorrhagic Infarction; Embohsm of the Lungs) 117 Puhnonary Gangrene 118 Pulmonary Atelectasis (Collapse of the Lung; Compression of the Lung) 120 Abscess of the Lungs (Suppurative Pneumonitis) 121 New-growths of the Lungs 123 Carcinoma of the Lungs 123 Sarcoma of the Lungs 124 Pulmonary Emphysema 124 Interlobular Emphysema 125 Vesicular Emphysema (Compensatory Emphysema) 125 Hypertrophic Emphysema 125 Senile Empliysema 129 Fungoid Disease, of the Lungs 130 Pulmonary Actinomycosis 130 Aspergillosis of the Lungs (Pseudotuberculosis) 130 Pulmonary Blastomycosis 130 Streptothricosis 130 Parasitic Diseases of the Lungs 130 Echinococcic Disease of the Lungs 130 Amebic Abscess 130 Endemic Hemoptysis 130 DISEASES OF THE PLEURA. Movements of the Two Halves of the Chest 131 Hydrothorax (Dropsy of the Pleura) 131 Pleurisy (Pleuritis) 136 Acute Plastic Pleurisy (Dry Fibrinous Pleurisy) 137 Primary Plastic Pleurisy 138 Secondary Plastic Pleurisy 138 Serofibrinous Pleurisy (Pleurisy with Effusion; Subacute Pleurisy) 141 Special Clinical Forms of Pleurisy 154 Chronic Pleurisy (Adhesive Pleurisy) 156 Dry Chronic (Adhesive) Pleurisy (Thickened Pleura) 156 Empyema (Purulent Pleuritis) 158 Pneumothorax (Seropneumothorax; Pyopneumothorax) 161 DISEASES OF THE CIRCULATORY SYSTEM. DISEASES OF THE PERICARDIUM, HEART, AND BLOOD-VESSELS. Methods of Examination 168 Data to be Obtained by Questioning the Patient 168 Inquiry with Reference to Present Conditions 169 Symptoms Suggestive of Cardiac Disease 172 Topography of the Heart 175 Variations in Health 176 Landmarks 177 Topographic Relation of the Heart to the Lungs 177 Position of Cardiac Valves 178 The Precordium 179 Inspection of the Heart 179 Examination of the Precordium 180 Palpation 186 Pulse 186 Heart-block 190 CONTENTS. 7 ^, , PAGE Blood-pressure , . 200 The Sphygmograph 211 Electrocardiogram ... 217 Mensuration of Chest in Cardiac Disease 223 Percussion 223 Auscultation 223 Normal Heart-soimds 224 Heart-sounds of Pathologic Significance 227 Z-ray Evidence in Diseases of the Pericardium, Heart, and Blood-vessels 229 The Pericardium 229 The Heart 230 The Mediastinum 234 Aneurism 235 DISEASES OF THE PERICARDIUM. Pericarditis 237 Acute Plastic Pericarditis 238 Subacute or Serofibrinous Pericarditis 240 Purulent Pericarditis (Empyema of the Pericardium) 245 Aspirating the Pericardiimi 245 Hemorrhagic Pericarditis : 248 Adhesive Pericarditis (Chronic Pericarditis) 248 Pericarditis Callosa 249 Hydropericardium (Dropsy of the Pericardium) 250 Hemopericardium 250 Pneumopericardium (Air or Gas in the Pericardium; Pyopneumopericardium) .... 250 DISEASES OF THE ENDOCARDIUM. Endocarditis 251 Simple Acute Endocarditis 251 Ulcerative Endocarditis (Malignant Endocarditis; Infectious Endocarditis) . . . 254 Recurrent Malignant Endocarditis 261 Cerebral Type of MaUgnant Endocarditis 262 Chronic Endocarditis 262 VALVULAR DISEASE. Aortic Regurgitation (Aortic Incompetency; Aortic Insufficiency) 265 Aortic Stenosis 272 Mitral Regurgitation (Mitral Insufficiency; Mitral Incompetency) 276 Mitral Stenosis 283 Tricuspid Regur^tation 286 Tricuspid Stenosis 290 Pulmonary Incompetency 291 Pulmonary Stenosis 291 Combined Forms of Cardiac Disease 292 Complications of Valvular Disease 292 Cardiac Thrombosis 293 DISEASES OF THE MYOCARDIUM. Hypertrophy of the Heart 293 Hypertrophy of the Left Ventricle 293 Hyjjertrophy of the Right Ventricle 294 Auricular Hypertrophy 295 Myocarditis 296 Acute Myocarditis 296 Chronic Myocarditis 297 Fatty Heart 299 Dilatation of the Heart 299 Acute Primary Dilatation 300 Cardiac Aneurism 302 Cardiac Rupture 302 Angina Pectoris (Stenocardia; Breast-pang) 202 Congenital Affections of the Heart 306 8 CONTENTS. DISEASES OF THE BLOOD-VESSELS, MEDIASTINUM, AND THYMUS GLAND. PAGE Diseases of the Arteries 308 Acute Aortitis 308 Arterial Sclerosis (Arteriosclerosis; Arteriocapillary Fibrosis; Endarteritis Chronica Deformans; Atheroma) 308 Aneurism 310 Aneurism of the Thoracic Aorta (Thoracic Aneurism; AneurismaAortse) . . 312 Aneurism of the Abdominal Aorta 320 Aneurism of the Puhnonary Artery 321 Arteriovenous Aneurism 321 Diseases of the Mediastinum 322 Inflammations 322 Mediastinal Abscess 322 Tumors of the Mediastinum 323 Mediastinal Hemorrhage 325 Disease of the Thymus Gland 325 THE BLOOD. Laboratory Examination of the Blood 325 Cleaning of Slides and Cover-glasses Preparatory to Making a Microscopic Study of the Blood 325 Collection of Blood 326 Study of Fresh Blood 326 Estimation of Coagulation by Wright's Coagulometer 327 Specific Gravity of the Blood 329 Hemoglobin 329 Spectroscopic Study of the Blood 330 Von Fleischl's Hemoglobinometer 332 Sahh Hemometer 334 Blotting-paper test for Hemoglobin 334 Counting of the Blood-corpuscles 334 Alkalinity of the Peripheral Blood 338 The Freezing-point of Blood 341 Study of Fixed and Stained Blood 342 SUdes and Cover-glasses 342 Staining 342 Serum-diagnosis 343 The "Widal Reaction 344 Wassermann Reaction for Syphilis 345 Noguchi Reaction for SjrphiUs 346 Opsonins and the Opsonic Index 348 Diseases of the Blood 351 Anemia 351 Polycythemia 353 Secondary Anemia 354 Leukocytes 358 Progressive Pernicious Anemia (Idiopathic Anemia) 361 Leukemia 365 Myeloid Leukemia 366 Lymphatic Leukemia 372 Chlorosis 373 Pseudoleukemia (Hodgkin's Disease; General Lymphadenoma) 376 Ansemia Infantum 380 Splenic Anemia 381 Hemophiha 382 Purpura 384 Scorbutus (Scurvy) 386 Parasitology of the Blood 390 DISEASES OF THE DIGESTIVE SYSTEM. DISEASES OF THE LIPS, TONGUE, AND MOUTH. Herpes Labialis 392 Labial Eczema 392 CONTENTS. 9 Epithelial Desquamation of the Tongue (Geographic Tongue) 392 Acute Glossitis (Glossitis Acuta) 393 Chronic Glossitis 393 Tongue-swallowing 394 Ulcers of Prenum 394 Acute Catarrhal Stomatitis (Stomatitis Erythematosa) 394 Herpetic Stomatitis (Follicular, Vesicular, Aphthous Stomatitis) 395 Fetid Stomatitis (Ulcerative Stomatitis; Riggs' Disease) 396 Ulcerative Stomatitis with Angina 398 Gonorrheal Stomatitis 398 Diphtheric Stomatitis 399 Gangrenous Stomatitis (Noma) 399 Ptyalism (Sahvation) 400 Mineral (Mercurial) Stomatitis (Sahvation; Ptyalism) 401 Drug Eruption 401 Acute Pharyngitis (Pharyngitis Acuta Simplex) 401 Chronic Phaxyngitis 403 Angina Ludovici 403 Retropharyngeal Abscess 403 THE ESOPHAGUS. Methods of Examination 404 X-ray Evidence in Diseases of the Esophagus 408 Diseases of the Esophagus 409 Esophagitis 409 Esophageal Hemorrhage 410 Acute Esophagitis 412 Chronic Esophagitis 412 Ulcer of the Esophagus 412 Esophageal Diverticulmn (Pharyngocele) 413 Stricture of the Esophagus 414 Dilatation of the Esophagus 416 Spasm of the Esophagus (Esophagismus) 416 Carcinoma of the Esophagus 417 THE STOMACH AND INTESTINES. Examination of the Abdomen 418 Topography 418 Data Obtained by Questioning the Patient 421 Inspection of the Abdomen 423 Examination of the Stomach 427 Character of Evidence to be Obtained by Inquiry 427 Leading Features and their Significance 429 Physical Examination of the Stomach 438 Gastroscopy 446 X-ray Evidence of Diseases of the Gastro-intestinal Tract 453 Pathologic Signs 456 Gastric Contents 461 Microscopic Study of the Gastric Contents 471 DISEASES OF THE STOMACH. Neurosis of the Stomach 473 Neuroses of Secretion 475 Neuroses of MotUity 476 Tormina Ventricuh (Peristaltic Unrest) 477 Diminished Peristalsis 477 Atony (Atonic Dyspepsia) 477 Relaxation at the Orifices 479 Pneumatosis 479 Cardiospasm 479 Pylorospasm 479 Nervous Vomiting 479 Neuroses of Sensation 480 Acute Gastritis (Acute Gastric Catarrh) 482 10 CONTENTS. PAGB Toxic Gastritis 485 Pseudomembranous Gastritis 487 Acute Suppurative Gastritis (Phlegmonous Gastritis) 487 Chronic Gastritis (Chronic Catarrh of the Stomach; Chronic Catarrhal Dyspepsia) 488 Gastric Ulcer 491 Hour-glass Stomach 497 Carcinoma of the Stomach 498 Dilatation of the Stomach 504 Gastroptosis 608 THE INTESTINES. Methods of Examination 514 The Feces '. 514 Macroscopic and Microscopic Study of the Feces 517 Diseases of the Intestines 518 Duodenal Ulcer 518 Enteroptosis 522 Dilatation of the Colon (Ectasia of the Colon) 523 Intestinal Obstruction 525 Mucous Cohtis 528 Diminished Peristalsis 529 Enterospasm 529 Pliunbism (Lead Colic; Chronic Lead-poisoning; Saturnism) 530 Habitual Constipation (Costiveness) 534 Amyloid Disease of the Intestine 535 I Appendicitis 535 Chronic Appendicitis 542 Recurrent Appendicitis 543 Cholera Inf antimi 544 Nervous Diarrhea 545 Enteralgia (Intestinal Neuralgia) 545 Carcinoma of the Intestine . 546 Cholera Morbus (Cholera Nostras; Acute Dyspeptic Diarrhea) 548 DISEASES OF THE PERITONEUM. Acute General Peritonitis 549 Acute Localized Peritonitis 554 Subphrenic Peritonitis (Subdiaphragmatic Abscess) 556 Chronic Diffuse Peritonitis 558 Carcinoma of the Peritoneum 559 Tuberculosis of the Peritoneum 560 Sarcoma of the Retroperitoneal Glands (Lobstein's Cancer) 563 Ascites 564 Chylous Ascites 570 THE LIVER. Methods of Examination 572 Topographic Anatomy of the Normal Liver 572 Diseases of the Liver 573 Anomalies of Position r 575 Hypertrophic Cirrhosis 579 Carcinoma of the Liver 579 Hepatic Sarcoma 585 Acute Hyperemia 586 Passive Hyperemia 586 Acute Hepatic Abscess (Suppurative Hepatitis) 587 Distention of the Liver and of the Gall-bladder 590 Fatty Infiltration and Fatty Degeneration with Hepatic Enlargement 591 Fatty Degeneration of the Liver 593 Amyloid Disease of the Liver ; 593 Atrophic Cirrhosis 595 Acute Perihepatitis (Acute SyphiUtic Perihepatitis) 585 Tuberculosis of the Liver 595 The Liver in Phosphorus-poisoning 596 CONTENTS. 11 PAGE Diseases in which the Size of the Liver is Diminished 598 Atrophic Cirrhosis 598 GUssonian Cirrhosis 602 Acute Yellow Atrophy (Malignant Jaundice) 603 Jaundice and the Pathologic Conditions of the Liver, Gall-bladder, and Bile- Ducts in which Jaundice Forms a Prominent Symptom 604 Jaundice 604 Catarrhal Jaundice 606 Suppurative Catarrh of the BUe-ducts 608 Chronic Catarrh of the Bile-ducts 609 Cholehthiasis (Gall-stones; Biliary CalcuU; Calculous Cholecystitis) 609 Carcinoma of the Bile-duct 613 Obstruction and Stenosis of the Bile-duct 614 Diseases of the Portal Vein .'. 614 Thrombosis 614 Purulent Phlebitis 614 Icterus Neonatorum 615 THE PANCREAS. Methods of Examination 616 Diseases of the Pancreas 618 Acute Hemorrhagic Pancreatitis 618 Suppurative Pancreatitis 620 Gangrenous Pancreatitis 621 Chronic Pancreatitis 621 Pancreatic Hemorrhage (Apoplexy) 622 Pancreatic Carcinoma 623 Pancreatic CalcuU 624 Pancreatic Cyst 625 THE SPLEEN. Topography 625 Diseases of the Spleen 626 Displacement of the Spleen 626 Enlargement of the Spleen 626 Splenitis 630 Rupture of the Spleen 632 Splenomegaly (Type of So-called Splenic Anemia) 632 DISEASES OF THE URINARY SYSTEM. Topography of the Kidneys 634 X-ray Evidence in Diseases of the Kidneys, Ureters, and Bladder 634 Sweating 637 Examination of the Urine 639 Chyluria 639 Hematuria and Hemoglobinuria 640 Leukocyturia 642 Pyuria ■ 642 Albuminuria 643 Specific Gravity 647 Reaction of the Urine 647 Chlorids 648 Phosphates 649 Sulphates 650 Sulphur 650 Urea 651 Uric Acid 652 Carbohydrates 652 Choluria 655 Acetone 656 Oxaluria 657 Leucinuria and Tjrosinuria 658 12 CONTENTS. PAOB Cystinuria 659 Cholesterinuria 659 Indicanuria 660 Diazo-reaction 661 Diseases of the Kidney 661 Acute Nephritis (Acute Parenchymatous Nephritis; Acute Glomeruloneph- ritis) 661 Acute Interstitial Non-suppurative Nephritis 667 Chronic Nephritis (Exudative) 668 Chronic Interstitial Nephritis 674 Amyloid Disease 680 Hydronephrosis 681 PyeUtis (Pyelonephritis; Pyelonephrosis) '. . . 685 NephroUthaasis 690 Perinephritic Abscess 695 Carcinoma of the Kidneys 700 Sarcoma of the Kidney 700 Addison's Disease 702 THE BLADDER. of the Bladder 703 Vegetable Parasites in the Urine 703 Bacteriuria 703 Acute Cystitis 706 Chronic Cystitis 709 Neuroses of the Bladder 710 Incontinence of Urine 713 ACUTE INFECTIOUS DISEASES. Fever 715 Acute Tonsillitis 718 Chronic Tonsillitis 723 Tuberculous Enteritis (Tuberculosis of the Intestine; Tuberculous Dysentery; Consumption of the Bowel) 723 Phlegmonous Enteritis 725 Catarrhal Enteritis 725 Dysentery 727 Acute BaciUary Dysentery 728 Acute Catarrhal Dysentery 729 Pseudomembranous Dysentery 731 Secondary Pseudomembranous Dysentery 733 Chronic Dysentery 733 Asiatic Cholera , 734 Sprue (Psilosis) 738 Typhoid Fever 739 Paratyphoid Fever 757 Typhus Fever (Ship Fever; Camp Fever; Jail Fever) 758 Malta Fever (Mediterranean Fever; Undulant Fever) 762 Relapsing Fever (Febris Recurrens) 764 Yellow Fever , 767 Lobar Pneumonia (Croupous or Filjrinous Pneumonia; Pneumonitis; Lung Fever) 770 The Plague (Bubonic Plague; Black Death) 787 Influenza (La Grippe; Epidemic Catarrhal Fever) 788 Tuberculosis 793 Chronic Tuberculosis 796 Acute Tuberculosis 800 Mihary Tuberculosis (Acute General Tuberculosis; Acute Disseminated Tuber- culosis) 800 General Miliary Tuberculosis (Typhoid Form) 801 Acute Tuberculous Meningitis 802 Acute Miliary Pulmonary Tuberculosis 802 Acute Pulmonary Tuberculosis (Acute Pneumonic Phthisis) 803 Chronic Pulmonary Tuberculosis (Chronic Pulmonary Phthisis) 804 CONTENTS. 13 FAGS Incipient Phthisis 804 Advanced Tuberculosis 809 Fibroid Phthisis 819 Tuberculosis of the Serous Membranes 819 Tuberculous Meningitis 819 Tuberculous Pleurisy 819 Tuberculous Peritonitis 819 Tuberculous Endocarditis and Pericarditis 820 Tuberculosis of the Liver 820 Renal Tuberculosis 820 Tuberculosis of the Bladder, Prostate, and Ureters 820 Tuberculous Orchitis 820 Tuberculosis of the Ovaries and Fallopian Tubes 820 Tuberculous Arthritis 821 Tuberculosis of the Mesenteric Glands 821 Tuberculosis of the Tracheobronchial Lymph-nodes 821 Tuberculous Cervical Adenitis 822 SyphiUs 823 Acquired SyphUis 826 Hereditary Sjrplulis 829 Visceral Syphilis 831 SyphUis of the Liver 831 Syphilis of the Lung 832 SyphiUs of the Rectum 832 SyphiUs of the Testicles 832 SyphiUs of the Kidney 832 Syphilis of the Heart 832 SyphiUs of the Arteries 833 Leprosy 833 Cerebrospinal Meningitis (Spotted Fever; Cerebrospinal Fever) 835 Acute Anterior PoUomyeUtis (Infantile Spinal Palsy) 843 Scarlet Fever 847 Clinical Varieties 849 Diphtheria (Angina MaUgna; Diphtheritis) 861 TonsiUar Diphtheria (Mild Diphtheria) 864 Pharjfngeal Diphtheria 865 Nasal Diphtheria 865 Laryngeal Diphtheria 866 Wound Diphtheria 866 Further Considerations in the Prognosis of Diphtheria 867 Measles 871 Rubella (Rotheln; German Measles) 878 Mumps (Epidemic Parotitis) 880 Whooping-cough (Pertussis) 882 Dengue (Break-bone Fever) 884 Erysipelas (St. Anthony's Fire) 887 Acute Articular Rheumatism 892 Gonorrheal Arthritis 897 Variola (SmaUpox) 899 Vaccinia (Cowpox) 906 Varicella (Chicken-pox) 907 Hydrophobia (Rabies) 908 Tetanus (Trismus; Lock-jaw) 910 Glanders (Farcy) 913 Anthrax (MaUgnant Pustule; Splenic Fever; Wool-sorter's Disease, etc.) 914 Septicemia 916 Pyemia 917 Actinomycosis (Big-jaw; Lumpy jaw) 919 Pulmonary Actinomycosis 920 Pulmonary Blastbmycosis 923 Streptothricosis 923 Thrush (Mycotic Stomatitis; Fungous Stomatitis) 925 Aspergillosis of the Lungs 927 Mycetoma 929 Probable Infectious Diseases 930 14 CONTENTS. PAGE Muscular Rheumatism (Myalgia) 930 Chronic Articular Rheumatism 932 Mountain Fever (Mountain Sickness) 933 Rocky Moimtain Fever 933 Milk-sickness (Trembles) 935 Miliary Fever (Sweating Disease) 936 Foot-and-mouth Disease (Epidemic Stomatitis; Aphthous Fever) 936 Glandular Fever .• • 937 Infectious Jaundice (Acute Febrile Jaundice; Fiedler's Disease; Weil's Dis- ease; Epidemic Catarrhal Jaundice) 937 Autumnal Catarrh (Hay-fever, Hay Asthma) 939 Hemorrhagic Diseases of the New-born 942 Epidemic Hemoglobinuria (Winckel's Disease) 942 Acute Fatty Degeneration of the New-born (Buhl's Disease) 942 Morbus Maculosus Neonatorum 942 Histoplasmosis 943 Sunstroke 943 ANIMAL PARASITIC DISEASES. Protozoan Disease 946 Malaria 946 Intermittent Fever 948 Estivo-autumnal (Malarial) Fever 951 Malarial Cachexia 954 Recurrent Malaria 954 Hemoglobimrria and Hematuria 956 Latent Malaria 956 Tr3rpanosomiasis (Kala-azar) 957 Nematodes 959 Filariasis 959 Schistosomum Haematobium (Bilharzia Haematobia; Blood-fluke) 961 Intestinal Animal Parasites and Their Ova 963 Amebic Dysentery 963 Flagellata 967 Balantidium Coli 967 Cestodes 967 Tape-worms 967 Taenia Saginata (Beef Tape-worm) 968 Taenia SoEum (Pork Tape-worm) 968 Dibothriocephalus Latus (Fish Worm) 969 Hymenolepis Nana 970 Hynaenolepis Diminuta 971 Taenia Marginata 971 DipjrUdium Caninum 971 Taenia Madagascariensis 972 Taenia Echinococcus 973 Trematodes or Flukes 974 Intestinal Nematodes 974. Round-worms 974 Ankylostomiasis (Uncinariasis; Hook-worm Disease) 976 Trichuris Trichiuria 979 Strongyloides IntestinaUs 979 Trichiniasis 979 Animal Parasites of the Liver 979 Echinococcic Disease 979 Liver Flukes 981 Nematodes (Round-worms) ^ 982 Amebic Abscess of the Liver 982 Animal Parasites of the Muscles ' 932 Trichiniasis '. 982 Parasites of the Bladder and Kidney [ 985 Parasitic Diseases of the Lungs 986 Echinococcus Disease 986 Amebic Abscess 988 Paragonimiasis (Endemic Hemoptysis) 988 CONTENTS. 15 Cutaneous Parasites ggg Dracunculus Medinensis (Guinea-worm) 989 Psorospenniasis ggo Parasites of the Eye ggO Cysticercus ggO Filaxia ,[',[ ggo Myiasis ggO Parasitic Disease of the Brain ggi CONSTITUTIONAL DISEASES. Diabetes MeUitus gg2 Diabetes Insipidus 1000 Rachitis (Rickets) lOOl Myeloma (Bence-Jones Albumosuria) 1004 Gout 1006 Lithemia 1009 Obesity (Polysarcia Adiposa; Lipomatosis Universalis) 1009 Adiposio Tuberosa Simplex 1011 DISEASES OF THE NERVOUS SYSTEM. By T. H. WEisESfBuBG, M.D. General Considerations 1012 The Upper and Lower Motor Neurons or Systems 1015 Reflexes 1016 Paralysis 1018 Sensory System 1018 The Transmission of Sensation to the Cerebral Cortex after Its Entry into the Spinal Cord 1022 Cerebral Localization 1027 The Cranial Nerves and Their Diseases 1035 The Olfactory Nerve 1035 The Optic Nerve 1035 The Oculomotor Nerve 1037 The Trochlear Nerve 1038 The Abducens Nerve 1038 The Trigeminus Nerve 1039 The Facial Nerve 1040 The Auditory Nerve 1041 The Glossopharyngeal, The Pneumogastric, and the Spinal Accessory Nerves 1042 The Hypoglossus Nerve 1042 Diseases of the Brain 1042 Epilepsy 1045 Partial or Total Paralysis 1048 Hemiplegia 1048 Apoplexy 1050 Diplegia 1054 Brain Tumors 1058 Abscess in the Brain 1071 Injuries to the Brain 1072 Chronic Bulbar Palsy (Glosso-labio-laiyngeal Paralysis) 1077 Diseases of the Spinal Cord 1080 Acute Ascending Paralysis (Landry's Paralysis) 1086 Chronic Poliomyelitis (Subacute Anterior PoliomyeUtis) ; Progressive Mus- cular Atrophy (Progressive Spinal Muscular Atrophy) 1088 Amyotrophic Lateral Sclerosis 1090 Lateral Sclerosis (Primary) 1091 Syringomyelia 1093 Posterolateral Sclerosis 1095 Friedreich's Ataxia 1097 Tabes Dorsalis (Locomotor Ataxia) 1099 Myelitis 1107 Tumors of the Spinal Cord 1111 Diseases of the Vertebra 1112 16 CONTENTS. PAGE Injuries of the Spinal Cord 1113 Unilateral Spinal Cord Lesions, or Brown-S6quard Paralysis 1115 Spina Bifida 1116 Disseminated or Multiple Sclerosis 1116 Syphilis of the Nervous System 1118 Diseases of the Meninges 1122 Cerebral Pachymeningitis 1122 Spinal Pachymeningitis 1122 Hypertrophic Cervical Pachymeningitis 1123 Inflammation of the Pia-arachnoid 1124 Purulent Meningitis 1124 Tuberculous Meningitis 1125 Serous Meningitis (Meningism) .' 1127 Muscular Dystrophy 1129 Peroneal or Distal Muscular Atrophy (Charcot-Marie-Tooth-Hoffman-Sachs Type) 1132 Diseases of the Peripheral Nerves 1133 Diseases or Injuries of the Spinal Nerves 1135 Brachial Neuritis 1136 Brachial Palsy 1138 Diseases of the Lumbar and Sacral Plexuses 1141 Tumors of the Nerves 1142 Multiple Neuritis 1142 AlcohoUc Multiple Neuritis 1144 Pseudo-tabes or Ataxic Multiple Neuritis 1145 Lead Multiple Neuritis 1145 Arsenical Neuritis 1146 Polyneuritis Due to Other Metallic Poisons 1146 Diphtheritic Paralysis 1146 Beriberi or Kakk6 Neuritis 1147 Multiple Neuritis Due to Other Causes 1147 Neuralgia 1147 Vasomotor and Trophic Diseases 1150 Vasomotor Diseases 1150 Angioneurotic Diseases 1151 Trophic Diseases 1152 Exophthalmic Goiter (Graves' Disease; Basedow's Disease) 1154 Acromegaly 1156 Progressive Facial Hemiatrophy 1158 Arthritis Deformans (Rheumatoid Arthritis) 1158 Osteomalacia 1161 Osteitis Deformans (Paget's Disease) 1162 Tetanus (Lockjaw; 'Trismus) 1163 Tetany 1164 Spasms, Tics, and Motor Neuroses 1165 Chorea (St. Vitus' Dance; Chorea Minor; Sydenham's Chorea) 1169 Huntington's Chorea 1171 Paralysis Agitans (Parkinson's Disease) 1171 Senile Tremor 1172 Myotonia Congenita (Thomsen's Disease) 1172 Amyotonia Congenita (Oppenheim's Disease) 1173 Neurasthenia 11'73 Hysteria 1177 Traumatic Neuroses 1188 General Paresis 1189 Migraine (Sick Headache; Hemicrania) 1191 Pellagra 1192 Index II95 INTRODUCTION. GENERAL AND SPECIAL CONSIDERATIONS. Diagnosis is the discrimination of diseases by their distinctive symptoms. In its legitimate scope, however, diagnosis appeals most strongly to path- ology for an elucidation of morbid processes, and to general pathology — morbid physiology — for an interpretation of the symptoms or abnormality of function resulting from structural changes. Moreover, it takes account of norrnal anatomy, physiology, chemistry, and physics. With these varied aids, it attempts to decide the seat and nature of disease, as well as additional themes of inquiry, by establishing the connection between cause and effect — between special pathologic processes and their sympto- matic manifestations. Diagnosis, therefore, inquires into many branches of medical science, and a divisional study of so complicated a subject is demanded to achieve satisfactory results. In endeavoring to trace the cUnical features of a given disease to their source, use is made of the physical signs and modern laboratory methods of investigating disease, as well as of all data relating to the anamnesis. The marks of disease are often decidedly obscure, and for their detection the diagnostician must call into requisition the various instruments of precision contributed by science, e. g., the microscope, stethoscope, hemoma- nometer, and many others, as well as the helps furnished from the laboratory expert. A broad conception of the subject of diagnosis recognizes both clinical and laboratory methods and regards them as being equally impor- tant in the investigation of disease. While, in a given case, it may appear that the older clinical methods alone suffice for a correct diagnosis, the practical aid furnished from the laboratory renders the natural history and the clinical distinctions of the complaint in question more intelligible. Not only are knowledge and experience with chemical and biologic methods essential to the armamentarium of the broadly trained clinician, but he often finds the data available through such methods the only means of enabling him to reach an accurate conclusion, and in general they serve admirably as aids or checks. The equipment of the present-day diagnosti- cian, therefore, comprises trained powers of observation and accurate clinical experience, — the corner-stone upon which diagnosis formerly rested, — coupled with the necessary acquaintance with the chemical and biologic methods to enable him to interpret their results. Any attempt, however, to replace a thorough anamnesis and careful, systematic physical examination by the laboratory findings, of whatever nature, is to be strenu- ously deprecated. The principal symptoms of most diseases may be allied to numerous other morbid entities, so that the correct assigning of significance to indi- ■ 2 17 18 INTRODUCTION. vidual features presupposes a knowledge of the varied pathologic states from which it may proceed. Single symptoms must, therefore, be weighed in the light of the attending phenomena and their causes — either textural or functional. The department of medicine consisting in a study and description of the pathologic changes in disease cannot obviously be con- sidered in this work, except brief reference to the same under the head of definition, for want of space, but it is the solid groundwork by which diagnosis is supported. With the thorough and vigorous methods to be carried forward at the bedside, therefore, studies in morbid anatomy in the deadhouse are to be constantly associated. The clinician who is at one and the same time a morbid anatomist is preeminently well equipped to clear up many obscure problems in clinical diagnosis. A complete diagnosis also embraces the stage and variety of the disease in question and an explanation of the habits, occupation, age, and temperar ment of the individual. In other words, diagnosis in a broad sense discerns the status reached by the pathologic changes of the affection which has been recognized, and the complicating conditions which may be present. In this manner alone can individualization of special cases, which is the prime object of bedside diagnosis, be accomplished. The physician is also called upon to make multiple diagnoses, in which instances it is often with exceeding difficulty that the primary and secon- dary affections are determined. Fortunately, the list of diseases of uncer- tain origin is steadily becoming smaller, thanks to the rapid advances of bacteriology, and multiple infecting microbes can be justly incriminated with causing the development of a primary and secondary affection in one and the same case. It is to be recollected that the most striking local and general features in such hybrids may be occasioned by some besetting complication, the underlying primary condition being either in great part or wholly veiled by the symptomatic disturbances set up by the secondary invaders. To determine the primary disease in cases of mixed infection, it is helpful to recollect the fact that the process of secondary infection is often due to the streptococcus, while less commonly the streptococcus and the colon bacillus manifest their deleterious action under conditions of diminished resistance brought about by the original complaint. Moreover, the testimony gained by a clear history, together with the data furnished by the laboratory, may suffice to put the clinician upon the right path. A critical analysis of the symptoms from the beginning, more especially if considered with reference to their histologic causes, may show two distinct pathologic conditions present, and indicate their development chronologically. In this connection it is to be observed that we are often called upon to deal with conditions presenting different pathologic forms rather than distinct pathologic entities. Facility to recognize special morbid processes, whether single or multiple, is acquired only through long, patient, conscientious study at the bedside, and the degree of success at- tained by the physician as a diagnostician is directly in proportion to the perfection of the technic employed, the extent of his knowledge of the scientific branches of medicine, and the proper utilization of the experience derived from previous investigations of similar diseases. The collection of a sufficiency of data must be followed by a careful sifting of the clinically important features from the ensemble of "data. Not tmcommonly the experienced diagnostician evolves the diagnosis while carrying forward the details of his examination, but the deductions reached GENERAL AND SPECIAL CONSIDERATIONS. 19 in this manner need confirmation. It is safer, and it is here recommended, to defer the final conclusions until he has the completed fund of data for inductive purposes, except in those rare diseases in which a certain diag- nosis rests principally upon a pathognomonic feature. There are a number of infective diseases that usually do not recur during the life of the indi- vidual, e. g., typhoid fever, measles, whooping-cough, scarlatina, and variola. We should be guarded, therefore, in the matter of arriving at the diagnosis of second attacks of these diseases when the evidence of the occurrence of a primary attack in the past is convincing. Hasty generalizations from partial or defective investigations of disease too commonly lead the observer to hold untenable ground in the field of diagnosis, and as certainly lead him to adopt disappointing lines of treat- ment. The scientific study of disease from the standpoint of diagnosis can never reach the high plane which its dignity and importance demand without receiving the continued impetus resulting from the combined application of all the known laboratory and clinical methods at our disposal. There is demanded a close examination of the particular parts — a process of thought in which the value of each symptom, sign, or laboratory finding, as the case may be, must be estimated dehberately and weighed against other features. A judicious balancing of the important diagnostics is then required preparatory to final induction by correct reasoning. After the examiner has gained a certain amount of experience in the taking of an anamnesis he can, during the process of eliciting the facts pertaining thereto, discriminate the more essential phenomena and disregard those that are of least significance, in order that the details shall not become too massive for ready inference. On the other hand, the beginner should note all data, however insignificant, lest important clues to more or less obscure condi- tions present be overlooked. In not a few cases the most experienced clinician, after forming a provisional judgment from the anamnesis, is forced to abandon it for another after he has noted the pathologic physical signs and obtained all the available laboratory findings. The physician is thus competent to recognize a disease — ^to evolve a diagnosis — ^but not with certainty until, with the aid of morbid physiology, he has correlated the symptoms with the bacteriologic and pathologic causes to which they owe their origin. A diagnosis formulated and founded in the manner indicated above becomes the sure foundation of rational prognosis and effective therapeutics. It should be an invariable rule when the diagnosis is made to still con- sider the possibility of the existence of a combined condition or affection, so common are complications and associated diseases. Indeed, in many cases it is impossible for the physician to form a diagnostic judgment with- out making a study of the distinctions between a suspected or recognized disease and others that present points of striking similarity. Under these circumstances the pathognomonic diagnostics are golden, and should be searched for diligently. This phase of our subject, known as differential diagnosis, often occasions difficulty, and it is discussed at considerable length throughout the pages of this work in connection with individual affections. There are a few methods of investigating disease which should be con- sidered connectedly in this place ; they are the Rontgen, cultural, chemical, and serum methods, and the opsonic index. The Rontgen method has become almost universally applicable, and 20 INTRODUCTION. jn many cases will give the most accurate information that is obtainable in the living subject. It should, however, be looked upon simply as one of the means of diagnosis, and all other methods should first be utilized, as a rule, after which it can be used to the greatest advantage in clearing up obscure points in the diagnosis. It is usually a waste of time and energy to employ the Rontgen method as a routine practice. The greatest field of usefulness of the a^rays in medical diagnosis is in studies of diseases of the chest and abdomen, although the method is by no means to be confined to these regions. In practically all diseases of the lungs some new light is afforded. In the study of the heart and blood- vessels the size, shape, and movements of these organs can be observed. In diseases of the abdominal organs the size, form, position, motility, and mobility of the stomach can be determined, as well as the effects upon this organ of the movements of the diaphragm and the contractions of the abdominal wall; the time required for the food to pass through the small intestine can be recorded; the size, form, and position of the colon can be observed; and any form of obstruction along the alimentary canal can be studied and much information as to its character be obtained. Renal, ureteral, and vesical calculi can be definitely located, and under favorable circumstances biliary calculi can be also photographed. In all diseases caused by specific organisms the isolation of the special microbe and the determination of its biologic properties is the most certain and rigidly scientific method of arriving at a diagnosis. Unfortunately, in many infective complaints the cultural method is too difficult for ordi- nary clinical purposes. In a considerable number of diseases an accurate diagnosis is established by the mere demonstration of the presence of the organism, e. g., malaria, lung tuberculosis, amebic dysentery, relapsing fever, lepra, diphtheria, Vincent's angina, gonorrhea, and the like. In other microbic affections the specific organism must also be isolated in pure cul- ture, as typhoid fever, the paratyphoid fevers, pneumonia, tetanus, the plague, influenza, cholera, and many others. In some cases it is further nec- essary to prove the pathogenicity of the organism isolated by resorting to animal inoculations, although the necessity for this step has been in great part removed by the more recent introduction of serum methods. It is sometimes more convenient to inoculate an animal with a pathologic exu- date or an excretion from the body of the sick (e. g., pleural effusion) than to employ an isolated organism in the same manner. The feeding of an exudate, of tuberculous origin, to animals is also of service. Serum diagnosis (like serum therapy) rests upon a knowledge of the bactericidal substances (antibodies) developed in the blood in the presence of a bacterial excitant. The antibodies are of two kinds: namely, those that defend the human organisms against the toxins of bacteria, antitoxins; and those that defend it against the bacteria themselves, agglutinins and lysins. The first application of the specific serum reaction to diagnosis was in typhoid fever, and in this disease the agglutinating property of the serum develops suflSciently early to be of great diagnostic value. A similar reac- tion is also of the highest importance in the recognition of so-called para- typhoid fevers. In the case of other bacterial diseases — e. g., dysentery, tuberculosis, the plague, lobar pneumonia, glanders, Asiatic cholera — ^in which the serum method has been employed, it has not attained to an as- sured place as a diagnostic measure, either because the reaction is not sufficiently constant or reliable, or because it appears too late to be of diagnostic significance. It must be recollected, however, that sero-reac- GENERAL AND SPECIAL CONSIDERATIONS. 21 tions are not equivalent to the direct demonstration of the specific bacteria. On the other hand, on account of their ready application, the serum methods possess a distinct advantage over the cultural methods. But, though the diagnosis will usually have been made in these affections before a positive reaction is obtainable, the serum test, like the Rontgen rays, should be employed, even as late as the period of convalescence, to clear up dubious cases. Thus, it may serve to distinguish between typhoid fever or para- typhoid fevers and other febrile affections. Recent progress in serum diagnosis also includes reactions for the detection of hemolysis and condi- tions depending upon syphilis. The test recently suggested by Wasser- mann, and its modification by Hideyo Noguchi, for syphilis, deserve men- tion in this connection. The r61e which the opsonic theory plays in medical diagnosis deserves brief notice in this connection. It has been known that the opsonins in the serum of healthy persons or those infected with microorganisms stimulate phagocytosis by making the bacteria more readily susceptible to inclusion in leukocytes, and the relative degree of phagocytosis bears a definite relation to the quantity of these substances present. Those cases of infec- tive disease which on repeated examination show a lowered opsonic index to any organism — as the tubercle bacilli — are supposed to be infected with that organism. In case two or more organisms are present, that toward which the present opsonic index is lowest is probably the most important in causing the disease. - The opsonic index is further of practical aid in that it affords a clear idea of the patient's resisting powers and of the degree of his susceptibility to secondary infection ; it thus likewise becomes of signal prognostic signifi- cance. For example, a staphylococcic infection showing a long-continued negative phase following injection gives little promise of being curable. Further improvement in the technic of determining quantitatively the opsonic power is greatly needed, with a view to diminishing the range of error, which up to the present has been rather extreme. The employment of the opsonic method by physicians skilled in labora- tory methods, however, may be regarded as a certain advance in diagnosis, although it is of vastly more value as a guide to therapy by vaccination methods. Undoubtedly, the appfication of the chemical methods of investigation to the determination of diagnostic indications, particularly in diseases of the kidneys, stomach, and pancreas, has been decidedly helpful. The> uses of this method, in relation to diseases of special organs, will be con- sidered hereafter in appropriate connections in this work. Our modern knowledge of diseases of metabolism rests upon the results of the earlier chemical studies of the organic functions, and in this field of chemical investigation recent deductions have taught us practical lessons of far- reaching importance. Among these are to be noted the well-established fact that an increase of urinary uric acid is not due to increased excretion of that substance, but rather to urinary conditions antagonistic to the solution of uric acid and its compounds. As regards carbohydrate metabolism, it may be said that chemical methods have assumed marked diagnostic importance in furnishing us the means of detecting sugar in the urine, and also those for distinguishing between sugar and other reducing bodies, as glycuronic acid, the alkapton bodies, and pentoses. Chemical methods have enabled us to appreciate the condi- tions resulting from a perversion of fatty metabolism. Thus, in some 22 INTRODUCTION. diseases — e. g., diabetes mellitus, the acute infections, and others — certain products of the katabolism of fat, as acetone, oxybutyric acid, and diacetic acid, are present in the urine. These substances may be met with in abnormal quantities due to increased destruction of fat, and may give indications of approaching complications of a serious character, which if recognized can often be obviated by appropriate therapy. It is a matter of keen regret, however, that the facilities for the application of reUable chemical studies to the investigation of disease are not so readily available for the benefit of the general practitioner as are bacteriologic methods. Additional aids, furnished by the biologic method, are those known as deviation of the complement and bacteriolysis, but since their accuracy and value remain to be demonstrated, further discussion is deemed unneces- sary. Among special biologic methods, blood culture is one of the most valuable. The bacteriologist can isolate specific organisms from the blood and thereby promptly establish an indubitable diagnosis; the method has been successfully applied to the differentiation of typhoid fever from the recognized forms of paratyphoid fever when the more usual distinctions fail. In general pneumonic infection and the various septicemic conditions, the results of blood culture may be the only available data by means of which the true nature of the condition can be established. The most illuminating teaching of internal medicine is that which suc- ceeds in demonstrating facts relating to the causes, symptoms, and physical signs, by laboratory study. This experimental method has already been applied for the verification of the physical signs in pleurisy (Opie), in the case of cardiac murmurs (McCallum and Thayer), and the accurate measure- ment of the blood-pressure in diseases or conditions artificially produced, e. g., the exalted tension from the use of adrenalin, experimentally. There is need of more experimental laboratory work as applied to the analytic study of symptoms, with a view to supporting or refuting the conclusions based on clinical observation. One of the principal objects of this work is to furnish a reliable guide to treatment in the widest sense. To this end a proper classification of the subjects treated is of the utmost importance from the viewpoint of both diagnosis and treatment. It is diagnostically useful to know that a certain disease belongs to a group of diseases presenting marked similarity in the main pathologic changes on which the symptoms depend. Such knowledge often points the way for the conduct of a judicial consideration of the differential diagnosis of the given case. In the same line of thought, a recognized member of the infectious class of diseases, more especially if atypical, calls for the closest scrutiny with reference to other affections belonging to the same category, as a rule. For example, if we were to regard typhoid fever as an intestinal disease, the general infections most likely to be confused with it, and needing to be considered in connection with the differential diagnosis, would be in danger of escaping our attention. A classification based upon the nature of the pathologic process involved also enlightens us respecting the line of treatment to be pursued, e. g., in any existing toxemia certain leading indications demand fulfilment, but if perchance an infective disease should be classed with a group of local com- plaints, these indications might not receive due attention. In general terms, then, the principle holds that an appropriate classification on a pathologic basis is to be adopted for both diagnostic and therapeutic reasons. INVESTIGATION OF INDIVIDUAL CASES. 23 INVESTIGATION OF INDIVIDUAL CASES. Coming now to the question of the investigation of individual cases •with a view to the recognition of human diseases in their multitudinous forms, two things are essential: (a) Close observation and scrutiny of the symptoms and signs and the utilization of the laboratory resources, according t6 the most approved method of conducting an examination; and (6) the harmonizing inductively of the essential features and data with a mental picture of definite morbid states or entities. ■ (a) Nothing is more important for the student or practitioner than the adoption and rigorous enforcement of a method or system in taking up the study and examination of special cases. This mode of procedure insures the accumulation of the largest possible mass of clinical data and minimizes the necessity for making a diagnosis by mere inference — always an uncer- tain product. The clinician who, during the earlier years of his professional career, unswervingly adheres to a proper system of investigating cases wiU meet with a progressively smaller number in which questions regarding diagnosis must remain sub judice. The well-poised, calm, logical practi- tioner, sldlled by a long process of self-imposed training, and armed with sharpened perceptivity and an extensive experience, may often infer a correct diagnosis from a limited number of essential facts, but this is a license which few have a right to enjoy. For every induction is apt to be faulty that does not proceed from full information gained by a thorough and systematic objective investigation, coupled with the result of accurate clinical observation. While it is impossible for any busy practitioner to keep abreast with the kaleidoscopic details of chemical and biologic technic, he should, with a view to becoming a trained clinical investigator, supplement bedside observation by familiarizing himself with the use of the microscope and other instruments of precision, as well as utilizing the advantages offered by even a small private laboratory. The clinician who is a trained micro- scopist and avails himself of the practical advantages of the bacteriologic laboratory can often make an etiologic diagnosis which no amount of clinical testimony can shake. At all events, every progressive physician must acquaint himself with the fundamental basis on which laboratory methods rest, since a ready interpretation of the results reported from public labora- tories is a dominating necessity. The method of noting down all data gained in study of a given case is conducive to precision of results and amplitude of view. The important matter of comparing one case with another is also thus facilitated. As regards the best method of conducting an examination, it may be stated that the details of the procedure should be arranged under various heads. It is one of the objects of this work to teach the method of conducting an examination of patients, and to that end we submit the subjoined scheme, believing that if its structural details are rigidly and systematically pursued, the results will be in a form that shall be of the greatest practical value to the examiner. The object of the plan is not merely to enable the student and physician to render a diagnosis with precision, or to quicken his intellectual acumen, but to afford them an essentially practical knowledge whereby the indica- tions — more especially those that spring from causative conditions and agencies — for the amelioration and cure of the complaints which are recog- 24 INTRODUCTION. nized may be comprehended. The hiighest aim of diagnosis must be to furnish a key to the successful treatment of each case or disease studied. The early recognition of a disease is highly desirable, in order that the physician may be thereby enabled to forecast its probable course and issue. Besides, the physician is under obligation to act solely in the interests of his patient. Under an appropriate schedule the examiner is sure to discover facts which will necessitate remedial action, and this information must be care- fully noted and subsequently utilized. In obscure cases reexaminations are to be encouraged and advised, such secondary exploitations often result- ing in a revision of opinion. Moreover, important light is often shed upon the diagnosis and treatment by the subsequent history and course of special cases. In taking the anamnesis it has been found impracticable to follow a defi- nite line of procedure in all cases. Among the most intelligent classes the patient may be allowed to tell the story of his illness, being merely guided by the examiner, but in most instances it isibest to obtain the major portion of the historic data by appropriate questions. It is generally conceded, however, that leading questions are to be rigorously avoided, since it is an easy matter to modify the answer by the way in which the query is propounded. This form of questioning also invites exaggerated replies, especially in the case of such familiar symptoms as pain, cough, insomnia, and the like. We must also guard against erroneous answers, either wilfuUy (for the purpose of deception) or unintentionally made; although if we except markedly hysterical females and an occasional malingerer among males, feigned diseases are rarely encountered in routine practice. More commonly, perhaps, the possible exciting cause, as well as the condition itself, is intentionally kept sub rosa by females from motives of delicacy, e. g., when suffering from carcinoma of the mammary glands, hemorrhoids, and uterine disorders. But though case-taking at the bedside in private practice among patients who are extremely weak or ill is not practicable in perhaps the majority of the cases, the examiner should pursue the same general order of procedure in his interrogatories, simply omitting certain details so as to lessen the number of replies. The physical examination may have to be briefer than seems desirable, for similar reasons. SCHEME FOR HISTORY-TAKING, PHYSICAL EXAMINATION, AND LABORA- TORY FINDINGS. Name: Address: Date: Family History. Previous History. Social History. Present lUness. Physical Examination. General Examination: 1. Posture: 2. Age — Actual: Apparent: 3. Weight: Height: 4. Skin and Mucous Membrane: 5. Edema: 6. Adiposity or Emaciation: 7. Glands: 8. Muscles: 9. Bones and Joints: 10. Psychic State: INVESTIGATION OP INDIVIDUAL CASES. 25 Local Examination: 1. Head: 2. Eyes: 3. Mouth and Pharynx: 4. Nose: 5. Ears: 6. Larynx: 7. Neck: 8. Thorax: Lungs: Inspection: Palpation: Percussion: Auscultation: Heart: Inspection: Palpation: Percussion: Auscultation: Pulse: Blood-pressiure : 9. Abdomen: Liver and Gall-bladder: Spleen: Stomach: Intestines: Kidneys and Bladder: Genital Apparatus: 10. Laboratory Findings: 11. X-ray Findings: For purposes of clinical teaching it is useful to record the principal com- plaint of, and symptoms presented by, the patient, and to note the obvious physical signs on admission to the hospital, and from these phenomena to make a provisional diagnosis. This method often enables the student to appreciate more fully the data collated by the systematic examination which is to foUow. In every-day practice, as with the undergraduate student, however, final judgment must rest upon a careful grouping of all data of diagnostic value afforded by a comprehensive description. We shall now consider in detail the different elements entering into the above schematic outline, passing over any application of the same to diseases of special organs or systems of the body, since this phase of the subject will be treated of directly in connection with the various sections of the work. Family History. — ^This aims at the detection of hereditary diseases in the antecedents or members of the immediate family. It is to be recol- lected that true inheritance of infectious diseases is rare. It is possible, however, that the toxins of such disorders or the effects of the growth of pathogenic organisms acting upon the germ-cells may influence the parental organism and lead to the offspring becoming modified in its development in one or other particular direction (Adami). After an individual begins its existence in utero, any modification is to be looked upon as of ante-natal acquirement. Certain metabolic disorders, e. g., gout, obesity, diabetes mellitus, and rheumatoid conditions, are probably attended with impaired nutrition of the germ-cells, thus affording an explanation of "the development and in- heritance of diatheses." Our inquiry should be extended to parents, the grandparents, brothers and sisters of the parents, and brothers and sisters of the patient. If the patient have children, inquiry regarding them is also to be made. Previous History. — The inquiry should be directed first to any infec- tious diseases of infancy and childhood, more especially measles, whooping- cough, scarlet fever, diphtheria, and follicular tonsillitis; next in chronologic sequence to the previous occurrence of other infections, as variola, typhoid fever, malaria, erysipelas, tuberculosis, and syphilis; chlorosis in the female. 26 INTRODUCTION. The age at which past complaints occurred, their duration, severity, com- plications, character of convalescence, and whether or not complete recov- ery ensued. Any previous illness like the present; if so, an analysis of the symptoms and the course. Antecedent injuries. Social History. — ^Whether bottle- or breast-fed. Note the age, sex, married or single, profession or occupation (now and in the past), place of residence, temperament; if female, the condition of the menstrual func- tion from the time of puberty to the present, giving details; if married, the number of pregnancies, childbed — normal or complicated, and if so, the character of the complication, and whether forceps were used; any sequelae; version or operation (specifying), miscarriages, noting peculiari- ties and results; pelvic operations, if any; time and nature of same. Habits regarding exercise, its character and amoimt, whether systematic or irregular; habits of eating, as to mastication, regularity or irregularity of meal-time, character of the food employed, time allowance for eating; use of stimulants, as tea, coffee, malt and spirituous liquors, with details as to duration, quantities consumed, and hours of the day when taken. Present niness. — ^The first point of information to be gained is the date of onset; this will indicate to the mind of the examiner whether the patient is the victim of an acute or a chronic disorder. We next inquire as to what the patient thinks is the cause of the illness (catching cold, trauma, etc.), the precise mode of onset, sudden or gradual, noting first the initial symptom or symptoms, their character and order of development. The attention is apt to be directed to particular organs or systems of the body by the patient. These should be interrogated, and afterward the remaining systems in a similar manner seriatim, observing the points set forth below. Nervous System. — Pain? Its location, nature, severity; whether con- stant or paroxysmal? Other sensory and motor disturbances: Headache? Insomnia? Emotional alterations? Depression of spirits? Any distur- bance of the mental faculties? Respiratory Apparatus. — Pain, its location? Excited by breathing, coughing, or movements? Dyspnea, constant or paroxysmal? Induced by exertion or other exciting causes? Rate of respiration (also during parox- ysm)? Cough, constant or paroxysmal? Time and duration of coughing attacks? With or without expectoration? Character and daily amount of sputum? Its color, from admixture of blood? Consistence and other peculiarities? Circulatory System. — Pain in precordium (left arm, neck, back)? Exciting causes of pain (exertion, mental excitement)? Palpitation, con- tinuous or paroxysmal? Accompanied by mental apprehension, or pain, or dyspnea? Apparent excitants of paroxysms? Effect of tobacco? Ef- fect of heavy meals? Any irregularity or intermittence (skipping) of heart- beats? Stomach. — Pain, constant or intermittent? Precise time of onset of the pain, before or after food, or during the night? Effect of the ingestion of food on the pain? Its location, character, and radiations, if any? Appe- tite? Nausea, with or without vomiting? The appearance (blood, mucus, and undigested food), amount, and character of the vomitus? The precise time of vomiting, in relation to food taken? Eructations of gas or liquid (acid, bitter)? Intestines. — Pain, its precise location, character, and particular radia- tion (whether downward to thigh, to back, etc.)? Constipation? Diarrhea? Number of bowel movements daily? Accompanied with pain, tenesmus? PHYSICAL EXAMINATION. 27 Character of the discharges (mucus, pus, blood, scybala)? Color, amount, and consistence of feces? Urinary System. — Pain, constant or paroxysmal in region of kidney or bladder? Primary seat and radiation of pain? Approximate daily quan- tity of urine? Frequency of urination? Accompanied with pain or tenes- mus? Naked-eye changes of the urine? Is it turbid, smoky, or bloody? Amount and gross appearance of sediment on standing? Have stones or sand been passed? Other Features. — Weakness? Loss of weight? Fever (temperature)? Night-sweats? PHYSICAL EXAMINATION. General Examination. — 1. Posture. Sitting up, semirecumbent, or lying in bed. Decubitus (dorsal, ventral, or lateral). Whether position of body is fixed. Spine bent. Knees drawn up. Lying fixed on side. 2. Age — actual and apparent. 3. Weight and height. 4. Skin and mucous membranes: Among the points to be noted are the state of skin with reference to temperature (see fever), dryness, or moisture. If the cutaneous surface be moist, the degree of coldness should be recorded, since a cold,, wet skin is ominous, especially if prolonged. The skin may be tense or relaxed and lying in folds even (e. g., in diseases attended with marked emaciation). Note the color of the skin, whether pale, sallow, yel- lowish (as in jaundice); gray, caused by silver nitrate; abnormally red without cyanosis; also any marks, scars, swelling, or active eruptions which may be present. Cutaneous hemorrhages, as puncta, petechia, and ecchy- moses occur. Small hemorrhages are most apt to appear at the hair- follicles. These fail to disappear upon pressure, and are thus distinguishable from a minute area of inflammatory redness. The condition of the lymph-glands (size, consistence, degree of mobility, etc.). Bones and joints. Conditions of muscles (atrophy, hjrpertrophy, tonus of the muscles, trembling, chorea, athetosis); resistance of limbs toward passive movements (grasp, walking, standing, Romberg's phenom- enon), reflexes (tendon reflexes, skin reflexes), condition of general nutri- tion (adipose, emaciation). Psychic behavior, intelligence, consciousness (delirium, stupor, mental dullness, coma), speech (stuttering, aphasia). I/Ocal Examination. — Head. — Skull: Note size and conformation; condition of hair. Face: Expression, facial muscles, mobility of both halves, of eyelids, laughing, frowning. Ears: Note condition as to hearing, any discharges, effect of pressure on mastoid process, and external ear. Eyes: Conjunctiva (color, discharges); pupils (color, pupillary changes, reaction to light, convergence and accommodation, muscular action). Nose: Note its size, shape, any obstructions in the nasopharyngeal ring, discharges. Mouth and Pharynx: Condition of buccal mucosa, that of pharynx, of tonsils (ulcers, scars, swellings), masticating apparatus, and tongue (size, whether coated, protruded, straight, with or without tremor). Larynx: Inspection with the laryngoscope if there be hoarseness or other symptoms pointing to involvement of this organ. 28 INTRODUCTION. Neck: Length, circumference, thyroid gland. Note any tumor-masses, scars, eruptions, pulsations (whether venous or arterial). Esophagus: Swallowing, obstruction to passing sound. Thorax. — Lungs: Inspection: (a) The appearance of the external sur- face, evidence of emaciation, prominences, etc.; (6) the shape and size; (c) movements and degree of expansion (diseased side takes less part in breathing); and (d) fluoroscopic study. Palpation: (a) The principal results of inspection are confirmed; (6) the tactile fremitus is ehcited; this should be tested over every portion of the chest occupied by the lung; and (c) fluctuation may be detected, though rarely. Percussion: (a) Immediate percussion; (b) mediate percussion, which is divided under three subheads: (1) Finger percussion, (2) finger-pleximeter percussion; (3) human-pleximeter percussion. (For the technic of these methods see Diseases of the Lungs, page 55.) Note results of percussion with reference to pitch, volume, length or duration, and quality of sound. (It is to be recollected that when the vibrations are slow, the pitch is low and vice versa.) Comparison of apices of the lungs; respiratory changes of the lung boundaries; interpretation of sounds — normal resonance (with modifica- tions in health, according to age, the region percussed, and associated con- ditions), tympany, relative dullness; respiratory percussion (the patient holding the breath at full inspiration and full expiration); auscultatory percussion; palpatory percussion; amphoric resonance; special signs — bell tympany, cracked-pot sound, Wintrich's sign, Gerhardt's sign. Auscultation: Methods — (a) immediate, (6) mediate (for advantages of each method and technic see Diseases of the Lungs, page 63); modifica- tions of normal respiratory sounds (variations in vesicular breathing, bron- chovesicular, bronchial or tubular, cavernous, amphoric) ; changes in vocal resonance — diminished or increased (bronchophony, egophony, pectorilo- quy, amphoric whisper, etc.) ; adventitious sounds, rstles (sibilant, sonorous, crepitant, subcrepitant, mucus, ratthng sounds), friction rub. Heart: Inspection: Seat, quality and rhythm of apex-beat; abnormal pulsations elsewhere over chest-wall, especially over first and second inter- costal spaces; epigastric pulsation; cyanosis. Palpation: Seat, quality, and rhythm of impulse; presence or absence of thrill. Percussion: Note area of cardiac dullness (effects of respiratory move- ments, effect of change of position). Auscultation: The mediate method to be preferred; note any modifica- tions of normal heart sounds — first and second; if adventitious sounds be audible, note their point of maximum intensity, rhythm, area of transmission and quality; auscultate — (a) mitral area, (6) tricuspid area, (c) aortic area, (d) pulmonary area, (e) over vessels of neck, (/) over body of heart, (g) effect of exercise, (h) effect of change of position. Pulse: (1) Condition of right and left radial artery (rigidity, tortuosity) ; (2) rate of pulse; (3) rhythm; (4) force; (5) tension; (6) size. Blood-pressure. Vascular System. — (1) Arteries; (2) veins; (3) capillaries; (4) lymph- atics. Liver and Gall-bladder. — Palpation and percussion (auscultation of gall-bladder if calculi are suspected). Spleen. Stomach and Bowels. — Inspection: Shape, depressions, and swellings. BEDSIDE OBSERVATIONS. 29 Palpation: Tension, hernias, fluctuations, splashing sounds, painful spots, or diffuse tenderness. Percussion: Variations from normal tympanitic notes (muffled tympany, dullness) ; size and outline of stomach (if necessary, after inflation with air or by a>-ray examination); if necessary, stomach-tube and examination of stomach-contents; inflation of intestinal tract with air if necessary to de- tect tumor masses or obstructions and the like; examination of anus and rectum. Kidneys. — Palpation and percussion of the kidneys (see Diseases of the Kidneys, page 635) ; palpation and percussion over the bladder (urination, retention). Name,- -Age_ Service of Dr._ Diagnosis :_.- -Discharged.- MTOFTKE nsCASE 1 OfcTOFTHE MOHTH A.M P.M. R. P. T. ;. 42 ■41 firf ao ion • BO y > /^ y y > y > > y y y y REW>. X / y y y y y y y y y STOOLS y y y y y y y y y y y y ^L UllIHE y y y y y y y y y y y W«.H, Fig. 1. BEDSIDE OBSERVATIONS. Additions to the findings on physical examination and bedside observa- tion should be made from time to time under date; the temperature, pulse, and respiration being expressed in curves on the temperature chart; the daily quantity of urine, bowel movements, and weight at intervals are also to be recorded on this sheet. The subjoined temperature chart (Fig. 1) will assist the physician in keeping a complete record of further observations and examinations after the initial investigations into the case have been concluded. 30 INTRODUCTION. Hand in hand with bedside observations must go certain laboratory in- vestigations, for which the subjoined scheme may serve as a practical guide. The Urine. — ^An examination of the urine is essential in all cases, inde- pendent of the character of the complaint in question. In every case the quantity for twenty-four hours, reaction, specific gravity, a microscopic ex- amination of the sediment, and tests for albumin and . glucose should be recorded. Should disease of the pancreas be suspected, Cammidge's reaction is needed; and in those suffering from obscure bone deformities, Bence-Jones albumose is to be considered. In suspected cases of typhoid fever the diazo-reaction of Ehrlich is a valuable aid. In diseases of the kidneys the microscope is an all-important aid. A more complete analysis, e. g., the estimation of the urea output, the detec- tion of indican, acetone, diacetic acid, /S-oxybutjTic acid, bile pigment, and occult blood, and even a bacteriologic study of the urine may be of value in selected cases, e. g., pyelitis, cystitis, tuberculosis, etc. The Blood. — Generally speaking, an examination of the blood is de- manded in those showing the general features of anemia, however slight. The determination of the number of corpuscles and of the percentage of hemoglobin is also of service in the diagnosis of obesity, pneumonia, and certain other sthenic maladies. A microscopic study of the individual red cells for the existence of poikilocytosis, irregularity in size and degeneration of the erythrocytes, is of great importance, and is best illustrated by the anemia of lead-workers. Important is it to bear in mind that the number of red cells per cubic millimeter may exceed the normal in persons suffering from an actual anemia when there is associated cyanosis. In a study of the blood the most important information is obtained by the differential leukocyte count; next in order of value is the number of leukocytes in a cubic millimeter; and next, the hemoglobin percentage. Leukocytosis is found in pneumonia and the inflammatory processes gener- ally; leukopenia in typhoid fever, malaria, and other diseases. In pneu- monia the differential leukocyte count shows an increase of the polymor- phonuclear neutrophiles; in infection with animal parasites, such as anky- lostomiasis and trichiniasis, eosinophilia is frequently seen. Cultural study of the venous blood will show pathogenic bacteria in acute ulcerative endocarditis, glanders, anthrax, typhoid fever, and other complaints. In certain diseases the sero-reactions are invaluable diagnostic acids — e. g., typhoid fever. The sero-reaction of Wassermann is of the greatest diagnostic importance, especially in syphilis, which cannot be recognized by the ordinary examinations. Sputum. — ^The naked-eye appearance of the sputum is of more value than that of any one other secretion or exudate, e. g., bloody sputum is fairly characteristic of congestion or hemorrhage along the respiratory tract, the exceptions being where blood is cleared from the throat and from the posterior nares. Mention characteristic sputum of pneumonia, pul- monary cavity, bronchiectasis, etc. A clear watery (mucoid) sputum is fairly common in the incipient stage of pulmonary tuberculosis. A microscopic analysis should be conducted whenever it is possible to collect an appreciable quantity of sputum, and in all cases in which there is cough (every sputiun should be stained for the tubercle bacillus, and in suitable cases search for Curschmann's spirals, Charcot-Leyden crystals, and elastic fibers should be made). In all obscure cases a careful search for animal parasites should be made. Gastric Fluid. — The presence and quantitative estimation of free hy- BEDSIDE OBSERVATIONS. 31 drochloric acid, the total acidity, and reactions for the presence of lactic and butyric acids are always necessary. One or more tests should be em- ployed for the detection of blood (occult bleeding), since bleeding may be so shght as to escape detection by other methods. An estimation of the combined hydrochloric acid should be made, as a rule, and the presence or absence of acetic acid, peptone, and bile should be noted. The quantity of mucus present should be carefully observed. A microscopic study of the gastric fluid is of value in carcinoma of the stomach where it is customary to find sardnce and the Boas-Oppler bacillus, and indeed other microscopic findings of clinical value may be detected (e. g., pus, erythrocytes). The degree of disintegration (breaking up) of starch cells after a test-meal gives a more or less accurate estimation of the activity of the salivary glands, and also of the degree of acidity of the gastric fluid; the more hydrochloric add present, the less are the starch cells broken. Feces. — The microscopic examination of the feces for the detection of intestinal parasites, their embryos, or their ova, and for the detection of protozoa is important. The passage of prepared meat balls through the alimentary tract to determine the destruction of nuclei of the meat cells should be conducted whenever pancreatic disease is suspected. A microscopic study for the detection of fat-globules in the feces is also necessary in the diagnosis of pancreatic disease. In typhoid fever, dysentery, gastric carcinoma, tuberculosis of the colon, gastric and duodenal ulcer, a positive reaction for occult blood is a most valuable sign. A bacteriologic study of the feces is of value in the determination of various pathogenic organisms. Cultural studies are also necessary to recognize the bacillus of Shiga, streptococcus, staphylococcus, and other pathogenic bacteria. Exudates. — Pus and all questionable exudates are only recognized through microscopic and bacteriologic studies. The determination of the cytologic elements of the sediment in pleural, peritoneal, and cerebrospinal fluids often gives important information. In view of our present knowledge of the modes of infection by the ankylostoma, a microscopic study of the exudate and scrapings from cutaneous ulcers may give valuable data. DISEASES OF THE RESPIRATORY SYSTEM. DISEASES OF THE NOSE AND THROAT. LABORATORY EXAMINATIONS IN DISEASES OF THE NASO- PHARYNX. Discharges from the nose and the throat may be studied as smears or by cultm'al methods. For the former method the mucus or pus, removed by a sterile swab or platinum loop through a speculum, is smeared in a thin layer on a clean glass slide, and allowed to dry in the air. After being fixed by passing three times through the flame of an alcohol lamp or a bunsen Burner, the smear may be stained with LoefHer's alkaline methylene-blue, by Gram's method, or by the method of demonstrating acid-fast bacilli. For the purpose of making cultxures from either the nose or the throat, Loeffler's blood-serum is the most convenient culture- medium, although any of the standard media may be used. A small portion of the pathologic exudate is smeared on the surface of the medium with a sterile platinum loop or with a sterile cotton swab. Boards of Health issue outfits composed of a tube of LoefHer's blood-serum mixture and a sterilized cotton swab, contained in a pasteboard box, with a slip of cardboard for the necessary clinical data. These outfits are designed especially for the bacteriologic diagnosis of diphtheria and other pseudo- membranous inflammations of the throat; but they can readily be adapted to nasal discharges. During health few bacteria are found in the nares, but in acute rhinitis the mucus contains numerous bacteria, many of which grow readily upon culture-media. The specific action of any particular bacterium in the pro- duction of acute rhinitis remains a question. Smears show many squamous epithelial cells, leukocytes, and at times red blood-cells. In virulent types of infection the nasal discharge may be composed principally of pus and epithelial cells, together with cocci and bacilli. During the course of certain specific infections the bacterium known to be the cause of the infection may be recovered from the nasal secretion. In cases of cerebrospinal meningitis an intracellular diplococcus is often found in the nasal mucus. The bacillus diphtheriae is frequently found here in cases of active diphtheria and in cases of latent diphtheria. Bacillus pseudodiphtherise is often found in cases of acute rhinitis. Bacillus leprae is said to be demonstrable in the nasal mucus in cases of leprosy before the other symptoms are stifficiently charac- teristic to permit of a positive diagnosis. In chronic rhinitis the discharge is composed of yellowish or greenish crusts which have a fetid odor, and which are composed of epithelial cells, pus-cells, bacteria, and granular debris. The diplococcus ozsense may be found in cases of ozena, and sarcinae are sometimes present. In diphtheria (p. 861) and pharyngeal and laryngeal tuberculosis (p. 812) the character- istic organisms are found. 32 CHRONIC RHINITIS (CHRONIC NASAL CATARRH). 33 Suppurative inflammation of the accessory nasal sinuses is usually due to staphylococcus aureus, to streptococcus pyogenes, or to some other pus- producing organism. In the diagnosis of diphtheria little confidence is to be placed on the ex- amination of stained smears made from the pseudomembrane. DISEASES OF THE NOSE. ACUTE RHINITIS, Pathologic Definition. — An acute catarrh of the Schneiderian membrane. This inflammation sometimes tends to involve the adjacent sinuses and passages. It is known to the laity as "cold in the head." Predisposing and i^xciting Factors. — ^Exposure to drafts and the influence of atmospheric vicissitudes that are especially prevalent during the winter and spring seasons are the most potent factors. Inhalation of irritants (physical, chemical, and biologic) is also capable of exciting inflam- mation of the nasal mucous surface. At times the disease may display some evidence of an infectious nature, and at such times may occur in epidemics. Direct extension from other mucous surfaces may be accountable for acute rhinitis. General Complaint. — Sensations of chilliness, succeeded by fever- ishness, are common complaints. Frequent sneezing, headache, and malaise are prominent features, and there are apt to be experienced in unusually severe cases muscular pains in the back and extremities. Thirst is increased, anorexia complete, and constipation often attends. One of the most annoying features to the patient is that of a somewhat profuse watery discharge from the nose, which is later followed by reddening and at times excoriation of the alse nasi. Lacrimation is apparently in- creased, and is probably due to irritation of the mucous surface of the lacrimal canals. Adjacent mucous surfaces may also become involved, giving rise to conjunctivitis, catarrhal pharyngitis, laryngitis, and, in the severe forms, bronchitis. Nasolabial herpes may be present. Physical Signs. — ^The pulse is frequent, the skin dry and unduly warm. The nasal mucosa is reddened and swollen, thus interfering with the sense of smell and taste, and with breathing. The color of the mucous surface is deepened. At first it is covered with an opaque mucus, and later with a muco-purulent secretion. As the affection progresses the secretion becomes more abundant and turbid. Course. — ^In favorable cases all annoying symptoms begin to diminish from the third to the fifth days. The nasal discharge usually continues for a longer period unless controlled by medication. Complications. — ^The nasal inflammatory process may extend to the pharynx,- larynx, and at times to the trachea arid bronchi, in which instance the signs and symptoms of involvement of these surfaces are conspicuous. CHRONIC RHINITIS (CHRONIC NASAL CATARRH). Pathologic Definition. — A chronic inflammatory process involving the nasal mucous membrane and consisting pathologically of two distinct forms: (a) Hypertrophic, in which there is enlargement of the lower turbin- ated bones, together with reddening and swelling of the nasal mucosa that may be general or limited either to the anterior or posterior nares. (b) Atrophic^ in which there are atrophy and appreciable thinning of both 3 34 DISEASES OF THE NOSE AND THROAT. the nasal mucosa and underl3ang structures, which changes are followed by enlargement of the nasal cavities. Principal Complaint. — (a) In the hypertrophic form nasal respiration is impeded, owing to the hypertrophy of the turbinated bones. The sense of smell is not acute, and there is a muco-purulent discharge from the nares, particularly the posterior, inducing "hawking." (&) In the atrophic form the most conspicuous symptom is the peculiar odor of the nasal secretion, and the sense of smell is greatly diminished, or may even be destroyed. Physical Signs. — ^These are obtained satisfactorily by the use of the rhinoscope, which reveals the actual condition of the mucous surface of the nasal fossse, and upon this the diagnosis is based. Exciting Factors. — ^The disease is thought to result from repeated attacks of acute rhinitis, or from acute involvement of the nasal mucous membrane that has not been successfully treated. Abel believes that the "bacillus mucosus ozsense" is often an exciting factor in this condition. DISEASES OF THE LARYNX. ACUTE CATARRHAL LARYNGITIS (ACUTE ENDOLARYNGITIS). Pathologic Definition. — An acute catarrhal inflammation of the mucous surface of the larynx. Predisposing and ^Exciting Factors. — ^Exposure to cold and wet, excessive use of the voice, inhalation of irritating vapors, injury, exces- sive smoking, foreign bodies, and swallowing of corrosive substances are potent factors. The disease may be primary, but is more commonly asso- ciated with, and frequently follows, inflammation of the nose and pharynx. Principal Complaint. — ^The voice is husky or completely lost; there is a sensation of tickling in the larynx, with a frequent dry cough; and there may be a feeling of a sense of pressure over the larynx and upper portion of the chest. Laryngeal spasm may be present in selected cases (see Spasmodic Laryngitis). Dyspnea is an annoying symptom in severe types of the disease. Physical Signs. — ^The surface involved may be covered with a mucous secretion and is reddened and swollen. The vocal cords are swollen and reddened and lack their normal movements. Thermic Features. — ^Fever may be slight, fluctuating between 99° and 101° F. Diagnosis. — ^This is based upon the history of one or more of the pre- disposing factors, together with the characteristic changes in the voice. A laryngoscopic examination serves as a positive means of diagnosis. SPASMODIC LARYNGITIS (LARYNGISMUS STRIDULUS; FALSE CR.0\JP). Pathologic Definition. — A spasmodic affection usually seen in chil- dren during the course of acute catarrhal inflammation of the laryngeal mucous surface. Predisposing and Exciting Factors.— Conditions that predispose to acute laryngitis are also to be considered in connection with spasm of the larynx. It is sometimes excited by strong passion or emotion, and it may be associated with tetany. Rachitic subjects are especially liable. "The spasm of the adductors that causes the urgent dyspnea is probably reflex and due to peripheral irritation" (Anders). TUBERCULOUS LARYNGITIS. 35 Principal Complaint. — ^Two clinical varieties are to be distinguished: (a) Nervous type : That in which the larjnix is free from inflammation. This variety is characterized by sudden brief attacks of dyspnea either by day or night. General convulsions have been noted, but there is neither cough, fever, nor hoarseness. A repetition of these attacks may be ex- perienced during the day. (6) Spasm of the larynx associated with mild catarrhal laryngitis. The spasmodic attacks usually begin suddenly, upon awakening from a sound sleep. Positive evidence of the affection is afforded by the croupy, ringing cough, combined with the hard, stridulous breathing. A hoarse cough is often a precursor of the approaching spasm, as is also slightly stridulous breathing during sleep. Harsh breathing (stridor) is a vibrating noise produced by air passing in and out of the larynx or trachea, when one or both of these air-passages are partially obstructed. The following table is designed to set forth the various causes for this type of breathing: Causes Within the Lakynx ok the Trachea. Foreign bodies. Rupture of caseous glands. Plugging by mucus. Pus. Affections of the Walls. Diphtheria. Acute staphylococcal laiyngitis. Tuberculous ulceration. Potassium iodid poisoning. Posttjrphoidal ulceration. Syphilitic ulceration. Acute edema. Malignant ulceration. Bright s disease. Traumatic ulceration. Acute streptococcal laryngitis. Epithelioma of the vocal cords. Acute pneumococcal laryngitis. Fibroma of the vocal cords. Stenosis after tracheotomy or cut Syphilitic stenosis, throat. EpitheUoma of the trachea. COMPEESSION FKOM WITHOUT. Thoracic aneurysm. Malignancy of glands in the neck. Mediastinal new growth. Enlarged thyroid gland. Epithelioma of the esophagus. Enlarged thymus gland. Physical Signs. — The respirations are seen to be altered, the neck is short and thick, and the auxiliary muscles of respiration are brought into action. The child prefers to sit or inclines slightly forward. Cyanosis may become extreme during the spasm and convulsive seizures may be observed. Differential Diagnosis. — Spasmodic laryngitis is to be distinguished from laryngeal diphtheria, and the distinctive features are that laryngeal diphtheria develops more gradually and persists over a longer period than does spasmodic laryngitis. Prostration is also extreme in diphtheria, and moderate fever is present. (See p. 868.) The detection of a false membrane on the mucous surface of the nose or throat goes far to support the existence of diphtheria. Prognosis. — A fatal termination is unusual, although repeated attacks are to be expected where spasm of the larynx develops in children. TUBERCULOUS LARYNGITIS. Pathologic Definition. — ^A subacute or chronic inflammation of the mucous surface of the larynx excited by the tubercle bacillus, and characterized further by congestion, edema, and ulceration. Predisposing and Exciting Factors. — ^In the vast majority of in- stances tuberculous laryngitis develops secondary to pulmonary tuberculosis, certain authors regarding this form of tuberculosis as a complication of the pulmonary variety in from 18 to 30 per cent, of cases. 36 DISEASES OF THE NOSE AND THROAT. Principal Complaint.— The earliest symptom is that of hoarseness, which is followed by almost complete loss of the voice. After ulceration has become extensive and the surface of the epiglottis and pharjmx are involved, swallowing is painful, and it is extremely difficult for the patient to take food. Cough is decidedly painful, and may be more or less persistent. Cough is apt to be excited by talking. I/aryngoscopic examination shows the surface of the laryngeal membrane to be pale, and a variable number of broad, grayish, irregular, tuberculous ulcers are visible upon the posterior sm-face of the epiglottis and aryepiglottic folds. Diflferential Diagnosis. — ^In ill-defined cases laryngoscopic examina- tion is a necessary aid to distinguish between syphilitic and tuberculous laryngitis. The various tuberculin tests (p. 808) and the Wassermaim reaction are deciding factors. SYPHILITIC LARYNGITIS. Remarks. — ^A variety of laryngitis developing during both secondary and tertiary forms of syphilis. It may appear in those where the luetic taint is inherited. Principal Complaint. — Hoarseness is persistent and aphonia and dysphagia are also likely to develop. If it develops in secondary syphilis, the lesion is probably an erythema with superficial ulceration and a variable degree of catarrhal laryngitis. During the tertiary form of syphilis the lesion of the larynx is apt to consist in small gummata. Rather deep-seated ulceration may develop in this form of the disease and may result in more or less extensive destruction of the laryngeal tissue. Laryngeal stenosis may result from syphilitic involvement of this organ where there are extensive cicatricial contractures. EDEMATOUS LARYNGITIS. Pathologic Definition. — An infiltration of the mucous membrane of the lar3Tix by serum. Predisposing and Bxciting Factors. — ^Rarely it follows acute laryngitis, and develops during the course of erysipelas, diphtheria, scarlet fever, tj^ihus and typhoid fevers, and acute phlegmonous inflammation of the adjacent structures; during the course of syphilis, acute and chronic nephritis, and chronic heart and liver diseases. Pressure from within the thorax may also cause laryngeal edema. Principal Complaint. — ^The most prominent symptom is a rapidly developing dyspnea and huskiness of the voice, increasing from the onset. The respirations become stridulous. Diagnosis. — ^The diagnosis is made immediately by drawing the tongue forward, when swelling of the glottis is apparent. Laryngoscopic examinar- tion is of service in selected cases. The clinical history is of moderate value in connection with larjmgeal edema. CHRONIC LARYNGITIS. Pathologic Definition. — ^A chronic inflammatory process involving the mucous surface of the larynx, and characterized pathologically by thickening and congestion of the larjmgeal mucosa, while in certain cases there may be a variable degree of ulceration. DATA OBTAINED BY INQUIRY. 37 Predisposing: and Bxcitingr Factors.— Chronic laryngitis follows repeated acute attacks, especially in those who speak much in public or in the open air; excessive smoking and chronic alcoholism are also potent factors in the production of this condition. Rarely it follows acute laryn- gitis, while nasal stenosis and chronic phar3mgitis are occasional causes. Principal Complaint.— The voice is husky, roughened, and in severe types of this trouble there is almost complete aphonia. Cough is the rule and may be either mild or severe, paroxysmal, and is usually preceded by a peculiar tickling sensation in the larynx. Pain is an occasional com- plaint. lyaryngoscopic examination reveals slight swelling with moderate reddening of the mucous membrane and prominence of the mucous glands of the epiglottis. Patches of superficial erosion may be detected. TUMORS OF THE LARYNX. Among the symptoms of laryngeal tumor should be mentioned hoarse- ness, cough (laryngeal in nature), and aphonia. Difficulty in swallowing and urgent dyspnea are also annoying symptoms where the tumor is un- usually large. Laryngoscopic examination serves as a positive means of diagnosis. DISEASES OF THE BRONCHI, LUNGS, AND PLEURA. METHODS OF EXAMINATION. DATA OBTAINED BY INQUIRY. Probably in no other cUnical division is history-taking of so great im- portance as it is in connection with affections of the pleurae and lungs, and the method of obtaining cUnical evidence from the patient will, therefore, be outlined. Family History. — Heredity doubtless plays an important part, although with the advance of science the tendency at present is to regard heredity of less importance than it was considered twenty years ago. It should, however, hold first place in the findings obtained by inquiry. It is important to know whether or not any members of the patient's immediate family have suffered from pulmonary or pleural diseases, and it is likewise equally important to ascertain whether the male or the female members of the family are the ones so afflicted. When the women of a household (particularly the one who does the cooking) are tuberculous, the disease is more fikely to be conveyed to other members of the family than it is when the males are the afflicted subjects. The fact that asthma occurred in previous generations is of moderate importance, for in certain families both asthma and emphysema may exist for generations before tu- berculosis becomes a family disease. The general physique of the members of a family is quite an important fact to be ascertained, since tuberculosis and other diseases of the respiratory tract are to be expected in those cases in which narrow and contracted chests are family characteristics. Personal History. — ^The patient should be questioned carefully as to his general physical condition, for some years antedating his present ill- ness, and in pulmonary affections it is of vital importance to ascertain the 38 DISEASES OF THE BRONCHI, LUNGS, AND PLEURA. patient's weight during health, and whether fluctuations in weight were observed during different seasons prior to the onset of the present malady. Should the patient's weight have been below the normal for one of his height, this should be taken into consideration and the cause for it ascer- tained whenever possible. A comparatively light weight with reference to height may be a family characteristic, and will then be of but little or no clinical significance. Loss of weight, especially when such loss dates from the onset of the affection and is progressive in nature, is highly significant of pulmonary disease. Previous Diseases. — ^Those who have suffered from lobar pneu- monia are greatly predisposed to pleurisy, bronchitis, and pulmonary tu- berculosis. Rheumatism seems to bear an intimate relation to pneumonia and to diseases of the pleurae. Intercostal neuralgia is also at times a precursor of pleurisy and of pulmonary disease. Children and even adults who have suffered from adenitis (glandular tuberculosis) are subject to pulmonary or other forms of tuberculous involvement later in life. Sup- puration of the bones, hip-joint disease, etc., in early life are often expres- sions of tuberculosis. Valvular heart disease is to be taken into consideration in connection with diseases of the lung, although cardiac and pulmonary maladies occurring in the same individual are by no means common. Pul- monary symptoms (dyspnea, cough) may often be secondary to organic disease of the heart. (See p. 172.) Previous attacks of pleurisy are always suggestive of tuberculosis of the pleurse, and are likely to be followed by tuberculous involvement of the lung substance. Social History. — ^A general outline of the patient's mode of living and of his habits and customs is of great importance, and the present health of the other members of his family is to be considered in formulating a diagnosis. Age and sex exercise marked influence, and will be discussed at length under each particular disease. Occupation. — It is an established fact that persons exposed to the inhalation of particles of dust, e. g., stone-cutters, instrument-makers, diamond-cutters, brass-finishers, miners, glass-workers, and those employed in foundries, are especially likely to develop pulmonary tuberculosis, asthma, bronchitis, and pleurisy. Persons following indoor occupations, who do not get sufficient exercise, such as bookkeepers, barbers, clerks, seam- stresses, and cooks, are also likely to contract pulmonary afflictions. Oc- cupations that necessitate exposure to cold and wet may at times contribute toward the development of pulmonary diseases, but, as a rule, those who live out-of-doors are less hkely to become tuberculous than are those who are deprived of exercise and of invigorating air. Source of Infection. — If a patient suffering from tuberculosis has been intimately associated with other tuberculous patients, it is to be presumed that the source of infection is that of contact. In the majority of instances tuberculosis is not transmitted directly from one member of a family to another, but may be conveyed by infected members or by food that has been handled by tuberculous persons, who, during coughing, would send their sputum in a spray about the room where the food was handled. The routes through which tubercle bacilli may enter the human body are manifold, and no one particular mode of infection need be emphasized here. Cough. — Correlatively speaking, cough is reflex in origin. The me- chanism is that of a deep inspiration, which is immediately followed by closure of the glottis, when an expiratory effort suddenly follows, the glottis is forced open, and the sound is produced by the forcible escape of the air. DATA OBTAINED BY INQTJIHY. 39 Cough is a symptom of many pleural, pulmonary, and remote pathologic conditions, and may also occur as a hysteric manifestation. Cough of physiologic origin is seen during the early months of gestation. Causes. — (1) Either acute or chronic irritation of the bronchial mucous membrane is sufficient to excite cough. The act of coughing may also be a physiologic process, serving to expel mucus, pus, and any foreign substance that may have collected in the bronchi. Among diseases in which cough is an almost constant symptom should be mentioned pleurisy, empyema, pulmonary tuberculosis with cavity formation, bronchitis, asthma, and emphysema. In diseases of the larynx cough is a cardinal symptom. Pressure upon the recurrent laryngeal nerve gives rise to cough and aphonia. (See Aneurism, p. 314.) In thoracic aneurism the cough is quite characteristic, being harsh and rasping, and having a brassy or metallic ring. The cough of aneurism may be non-productive, or, as is often the case, paroxysms of coughing are followed by copious expectoration of mucopurulent material. Mediastinal and thoracic tumors may excite cough in persons in whom the lungs and pleura are healthy. In organic heart disease, the result either of valvulitis or of myocarditis, cough not infrequently occurs as the result of imperfect circulation and venous stasis in the lungs. Incorrect posture in those of lowered vitality results in hypostatic congestion at the bases of the lungs, and such congestion, in turn, is often productive of cough. This variety of cough is commonly encountered in those suffering from acute and chronic febrile and afebrile maladies. The character of the cough, as previously stated above, is equally significant in pleurisy and in lobar pneumonia. The cough of pleu- risy is short, non-productive, and hacking in character, and is accompanied by extreme pain in either side of the chest. In lobar pneumonia the cough is also short and harsh, but it is accompanied by slightly blood-streaked expectoration, and severe pain is present when the pleura is inflamed. Reflex Cough. — A lesion of the brain involving the respiratory center at the floor of the fourth ventricle is another cause for cough. The cough of hysteria is in no way characteristic, but is readily detected by the efforts of the patient to produce this symptom and by the associated phenomena. The barking cough of hydrophobia is also readily detected in a neurasthenic. Irritation of the pneumogastric nerve produces cough. Stomach Cough. — ^The experiments of Kohts do not prove that a cough may occur as the result of derangement of the stomach, yet patients having a decided cough are not infrequently also afflicted with gastro-intestinal catarrh. That certain coughs are due to gastric irritation is borne out by the fact that they disappear when the latter condition is relieved. In persons suffering from gastric catarrh a similar inflammatory process generally in- volves the pharyngeal and laryngeal mucous membrane, and this may explain the source of the so-called " stomach cough." Ear Cough. — During an examination of the external auditory canal the patient frequently gives a harsh, hacking cough. Foreign bodies and ab- scesses in the ear may also excite a short, harsh, and fairly characteristic cough. Tooth Cough.— The irritation from a diseased tooth may excite reflex cough in the adult, and in infants, during the process of dentition, cough is quite common. Whooping-cough. — This cough may be non-productive or accompanied by expectoration. A peculiar sound (a whoop) is heard during inspiration, and occurs generally after the child has made several rapid attempts at 40 DISEASES OF THE BRONCHI, LUNGS, AND PLEURA. coughing. The whoop is usually followed by vomiting, and there may be epistaxis and even hematemesis. In whooping-cough the attacks of cough- ing are paroxysmal, purely spasmodic, and excited by violent exercise, talk- ing, laughing, and the like. The Cough of Diphtheria, Pharyngitis, and Esophagitis. — This is really the cough of laryngitis, and occurs when the diphtheric process ex- tends to the vocal cords and larynx. (See Diphtheria, p. 867.) In pharyn- gitis and diseases of the esophagus cough may be a prominent symptom. PHYSICAL EXAMINATION OF THE CHEST. I/andmarks. — In order to examine the chest properly all clothing must be removed, or the patient's chest and abdomen exposed from the clavicle to the umbilicus. When the patient is able to sit or to stand, the method of examination is quite simple, but when the patient is confined to bed, it becomes quite difficult to obtain certain physical signs. Certain landmarks are always to be observed, regardless of the position of the patient. When examining the front of the chest, one always starts with the superior boundary or clavicles. These curved bones separate the supraclavicular from the infraclavicular regions on each side (Fig. 4), and, owing to the fact that they traverse the chest transversely, they are used at different points to mark certain lines required to divide the chest vertically. The sternum serves as an invaluable landmark, because it divides the chest vertically (Fig. 4), and its peculiar notch, which separates the ends of the clavicles at the top of the chest, furnishes a guide that seldom, if ever, changes as the result of disease. Again, it is of gi-eat importance to note that the suprasternal notch is at the level of the articular sur- face of the second and third thoracic vertebrse. About an inch below the suprasternal notch there is a distinct transverse ridge that marks the line of union between the first and second pieces of the sternum, and it is this sternal prominence that enables one to count the ribs. Another method of counting is to regard the articulation between the clavicle and the sternum as the first rib. The sternal ridge is on a level with the center of the body of the fifth thoracic vertebra. At the lower extremity of the sternum we olDserve the xiphoid cartilage. For the purpose of diagnosis the junction of the xiphoid cartilage with the greater portion of the sternum is on a level with the articular surface of the ninth and tenth thoracic vertebrm. Counting of the ribs forms one of the most important steps in diagnosis, and is applicable to diagnosis both of the chest and of the abdomen. In Fig. 2. — Relation of the Normal Lungs to the PLEUR.E, Costal Margins, and Clavicles. PHYSICAL EXAMINATION OF THE CHEST. 41 diagnosis we often speak of a certain rib or interspace as at some par- ticular line. These lines will be described later. Fig. 57 shows the actual relation existing between the lung, liver, and heart, and the points at which these viscera are contiguous one with another, as described by the clavicles, sternum, and ribs. Counting the ribs is further useful in dividing the chest transversely by imaginary lines at different levels, e. g., a line encircling the chest at a level with the nipples would pass through the center of the sixth inter- costal space at the midaxillary line; this is the point of election in as- piration of the pleurae for the removal of fluid. A point of great diagnostic importance is the fact that the ribs pass obliquely downward as they leave the vertebrae, so that their sternal junction is on a lower level than their vertebral articulation, e. g., the articulation of the cartilage of the third rib anteriorly is on a level with the body of the sixth thoracic vertebra. When studying the articulation between tlie third and the seventh rib, for example, the calculation is readily made by adding four to the number of the rib articulating with the sternum; thus, the seventh rib anteriorly corresponds to the eleventh vertebra. Landmarks of the Back of the Chest. — 1. The Scapulae. — These bones are situated conspicuously at the top and back of the chest, and extend from the second to the seventh ribs inclu- _ sive. The inner end of the scapular spine is on a level with the spine of the third thoracic vertebra, and the inferior scapular angle is on a level with the spine of the seventh thoracic verte- bra; consequently when the arms are permitted to hang at the sides and when both fojearms are folded across the chest the seventh rib passes be- neath the lower portion of the scapula. 2. The Spine. — The spinal column occupies the center of the posterior wall of the chest, and is outlined by a distinct groove. The spinous processes of the vertebrae are often visible as slight prominences along the column. In passing the hand from above down- ward over the spinal column, the proc- esses are rendered more conspicuous and are readily palpable by directing the patient to bend forward. The tips of the vertebral spine also serve as landmarks, the one usually selected being that of the seventh cervical ver- tebra — the so-called "vertebra prom- inens." The spinous process projects obliquely outward and downward, so that the tip of the spinous process is on a level with the articulating surface of the rib below, e. g., the second thoracic spine corresponds with the level of the third rib. The spmous process of the tenth vertebra is materially shorter than that of the others. A fact to be remembered is that the first thoracic vertebra is in direct articulation with the seventh cervical vertebra; consequently the ribs Fig. 3. — Arbitbabt Divisions of Postehiob AND Lateral Surfaces of Chest. 42 DISEASES OF THE BRONCHI, LUNGS, AND PLEURA. begin at this point. Tiie second rib articulates witli tiie second and third thoracic vertebras, and this plan of articulation is continued downward to the tenth rib articulation. The eleventh and twelfth ribs articulate with the eleventh and twelfth vertebrae. Epigastric Angle.— This angle is situated at the anterior portion and base of the chest ; the apex is directed upward, and is formed bv the xiphoid cartilage; its lateral boundaries are the converging cartilages of the ribs. During inspiration and expiration the degi'ee of this angle is materially altered. At times it forms almost a right angle, whereas on deep inspira- tion an obtuse angle results. Lines as Chest Landmarks. — In order to localize certain physical signs and to determine with ease certain definite points upon the chest-wall the chest is divided vertically by imaginary lines that transcribe definite arbi- trary regions (Figs. 2 and 4). These are: Anteriorly: (1) The mesosternal (midsternal) line, the middle line of the sternum. (2) The right and left sternal lines, corresponding to the lateral margins of tlie sternum. (3) The parasternal lines, midway between the border of the sternum and the nipple. (4) The midclavicular lines, usually passing through the nipples. Laterally, the chest is divided by three imaginary lines: (1) The anterior axillary lines, which cross those points where the great pectoral muscles leave the chest-wall when the arms are raised to the horizontal. (2) The mid- axillary lines, which pass through the center of the axilla, or midway between the anterior and the posterior margins of the axilla. (3) The posterior axiUary lines, which extend vertically through those points where the latissimus dorsi muscles leave the chest- wall (Fig. 3). Posteriorly, but two lines are gene- rally recognized: (1) The scapular lines, which pass vertically through the angles of the scapulae when the arm is allowed to rest by the side. (2) The midspinal line, which is drawn to correspond to the center of the vertebral column. Regional Anatomy.— Anteriorly, the chest is divided into regions, and the relative size, location, and form of such regions are clearly shown in the accom- panying illustration (Fig. 4). There- fore we will confine ourselves to naming the various viscera known to occupy each particular region. The Supraclavicular Regions.— On each side we find the apices of the lungs, and a short section of both the subclavian and the carotid arteries, and also the subclavian and the jugular veins. The apex of the luno-s rises' as a rule, to from one-half to one and one-half inches above the upper'border of the clavicle, the left lung generally extending a little higher than its fellow. A portion of the floor of the supraclavicular space is formed by the first rib on each side. Immediately above the inner portion of the clav- icle is the point at which pulsation from the subclavian artery may be felt. The Clavicular Regions.— This region is small, and is bounded by the Fig. 4. — Arbitrary Division of the Chest AND Abdomen. PHYSICAL EXAMINATION OF THE CHEST. 43 margins of the inner two-thirds of the clavicles. Upon each side is found the apex of the lungs. On the right and underneath the sternal articulation of the clavicle is the bifurcation of the innominate artery, and just external to this is the subclavian artery. At the left sternal articulation both the carotid and the subclavian arteries are deeply situated. The right infraclavicular region contains a portion of the upper lobe of the right lung, and beneath the right border of the sternum are the superior vena cava and the arch of the aorta. Underneath the second right costal cartilage the right bronchus rests. In the left infraclavicular region we find the upper lobe of the left lung, and at the border of the sternum, the left pulmonary artery and a portion of the left auricle. The Mammary Region. — In this region the two sides will be found to differ widely, the right side containing the lung, the dome of the liver, the extreme right portion of the heart, and the diaphragm, which fits snugly over the apex of the hver and extends well up into the lung — ^fourth inter- space (Fig. 5). It is the intrusion of the superior border of the liver upon the lung that causes the lung tissue to rest superficially throughout this region, although a thin layer of the lower border of the lung extends as low as the sixth rib. The fissure dividing the upper and middle lobes of the right lung runs obliquely upward and backward from the fourth costal cartilage, while the fissure dividing the middle and inferior lobes of the lung arises at the fifth interspace (Fig. 5). The right side of the heart extends into this region, and a portion of both the auricle and the ventricle is covered by lung, and rests to the right of the sternum, between the third and the sixth cartUages. The left mammary region contains the greater portion of the heart, which is partially overlapped by lung tissue. The outline of the heart in both health and disease is shown in the accompanying illustration (Fig. 57). A quadrilateral area of heart is uncovered by lung, and this portion corresponds to the right ventricle; the greater portion of the right auricle and of the left auricle and ventricle are deeply seated in this region. The apex of the heart ordinarily corresponds to the midclavicular line at the fifth interspace (Fig. 2). The fissure separating the superior from the inferior lobe of the left lung is situated at a point where the nipple-line crosses the sixth rib. The left lung also occupies this region. The Inframammary Regions. — ^These extend downward from the sixth rib on each side to the margin of the false ribs, and from the sternum they are bounded externally by the costal cartilages. To the right of the median line we find a portion of the right lobe of the liver, the diaphragm, and, during the act of forced inspiration, the lower border of the right lung. The lower border of the liver is found by following the costal margin from the point at which the midclavicular or nipple-line crosses the costal cartilages. The left inframammary region contains the lower margin of the left lung during inspiration, a portion of the left lobe of the liver, and the cardiac end of the stomach. It is somewhat diflicult to separate the epigastric region from the two mammary regions, for many of the viscera lie in both. We have adopted an arbitrary division of the abdomen somewhat different from that ordinarily employed, thus simplifying, in a measure, the topographic anatomy of the inframammary region. The right inframam- mary region contains a portion of the right lobe of the liver. The Sternal Regions. — ^That portion of the thorax underl5dng the sternum is divided into two parts: In the superior sternal region are found the inner edge of the lungs at and below the second costal cartilages, the bifurcation of the trachea, the 44 DISEASES OF THE BRONCHI, LUNGS, AND PLEURA. aortic arch, the puhnonary artery, the left innominate vein, and the vena cava. The inferior sternal region contains a portion of both the right and the left lung, the greater part of the right ventricle, the origin of the pulmonary artery, and the edge of the left ventricle, which is situated well posteriorly. The first part of the aorta, a portion of the right auricle, and a part of the liver are also found here, and within this area the pericardiac attachment of the diaphragm is located. The Lateral Thoracic Regions. — The Axillary Regions. — These are bounded by lines that extend from the upper anterior portion of the axilla to a level with the lower margin of the mammary regions (sixth rib), and posteriorly by a line drawn from the upper portion of the axilla through the point where the latissimus dorsi muscle leaves the thorax when the arms extend horizontally from the chest (Fig. 6). Both axUlary regions Superior lobe of lung Lower border of pleural sac Inferior margin of liver Fig. 5. — Lateral View Outline to Show the Relation of the Right Lung, Pleura, and Liver. contain lung tissue, and, more deeply seated, the bronchi and their smaller branches are found. The Infra-axillary Regions. — These are bounded superiorly by the lower border of the axillary regions, and below by the margin of the ribs. Posteriorly, they are contiguous with the infrascapular regions (Fig. 6). In the right infra-axillary region the lung will be found to slope downward and backward as low as the eighth rib, at the point where it is bisected by the midaxillary line. The liver is also contained in this region. The left region contains, in addition to the lung tissue, a portion of the stomach and the spleen. Posterior Regions. — The suprascapular regions (Figs. 3 and 6) contain the INSPECTION OF THE CHEST. 45 apices of the lungs, and it is the portion of the lung that occupies this region that is most liable to be attacked early by tuberculosis; in studying incipient pulmonary conditions, therefore, the suprascapular region should be examined most carefully. The scapular regions contain, for the most part, portions of the lungs, and the fissures dividing the pulmonary lobes are also situated in this region. The Inlrascapidar Regions. — These regions are bounded superiorly by a line drawn across the inferior angles of the scapula, and below by the edge of the thorax, and extend in the median hne downward to the eleventh vertebra. Anterolaterally these spaces are limited by the line bounding the infra-axillary region, which corresponds to the point at which the latis- simus dorsi muscle leaves the chest- wall (Fig. 6). On both sides are the lungs, and their inferior margins extend downward as far as the eleventh ribs. On the right side, below the lung, is a small portion of the liver, and lying immediately in contact with the spinal column is the upper portion of the right Iddney. To the left of the spine, passing from the median line outward, are the aorta, the left kidney, coils of intestines, and the spleen. The Interscapular Region. — ^The size of the interscapular region may be somewhat increased by directing the patient to bend forward and to fold the arms over the chest (Fig. 29). Upon both sides of the spine are por- tions of the lungs. At the fourth thoracic vertebra is the bifurcation of the trachea. The bronchial glands are also situated near this point. To the left of the spine, and at the third or fourth thoracic vertebra, is the descend- ing aorta, and in intimate relation with this are the thoracic duct and the esophagus. The bifurcation of the trachea is nearly on a level with the third and fourth thoracic vertebrae, corresponding anteriorly to the angle of Louis or the second costal cartilage. It must be remembered that the cahber of the right bronchus is considerably larger than that of the left, and that this canal passes in a horizontal direction immediately beneath the second rib. The left bronchus is situated slightly below the right, in the second interspace. Fig. 6. — Arbitrary Regional Division of Back with Relation to Axillary and Infra-axillary, Suprascapular, Scapu- lar, Infrascapular, and Lumbar Re- gions. INSPECTION OF THE CHEST. Preparation for Inspection. — It is impossible to obtain accurate information regarding the contour and movements of the thorax unless the patient is bared to the waist. Occasionally it is necessary to modify this general rule, but whenever such modification is made, there will always 46 DISEASES OF THE BRONCHI, LUNGS, AND PLEURA 1 be uncertainty as to whether or not the examiner has detected all existing abnormalities presented by the patient. Position of the Patient. — During an examination of the chest the patient should preferably be standing or sitting, in order that the examiner may step from side to side and from front to back, viewing the chest from every aspect. When it is necessary to examine a patient in the recumbent tummmmmmHamxM Fig. 7. — Inspecting the Abdomen and Chest. Fig. 8. — Inspection of the Chest and Abdomen. posture, the examiner should stand first at the feet and then at the head of the patient, and note particularly the character of the chest movements (Figs. 7 and 8). The patient should then be turned first upon one side and then upon the other, and while this is being done the general expression, rapidity of respirations, and the degree of lividity or cyanosis are to be noted. The general conformation of the chest, and its influence upon the various types of respiration, which will be described later, is of vital importance. INSPECTION OF THE CHEST. 47 I/igllt. — Whenever possible, the chest should be examined by daylight; for when this is done by artificial light, shadows, due to the various curves and prominences of the chest-wall, are likely to confuse the examiner. What is to be Ascertained by Inspection. — (a) The appearance of the external surface, evidences of emaciation, etc. ; (b) the shape and size; (c) movements and degree of expansion; and (d) fluoroscopic study. The Chest-wall. — The characteristic appearance of the healthy skin is materially altered in disease; thus it is extremely pale in all diseases asso- ciated with anemia, and in vagabondism, Addison's disease, abdominal tumors, and jaundice it is pigmented. It also becomes pigmented as the result of tinea circinata, syphilis, multiple abscesses, and the like. Disten- tion of the veins over the anterior surface of the chest is suggestive of pres- sure in the thorax, as from thoracic aneurism or enlarged bronchial glands. Fig. 9. — Inspection of Abdomen (Lateral View) to Ascertain the Movements of the Chest AND Abdomen. In the female lactation is the most common cause of such distention. If the veins of the neck are enlarged, cardiac incompetency is to be suspected, and if they pulsate synchronously with the heart's action, tricuspid regurgi- tation is probably present. The veins over the chest-wall may also be en- larged as the result of pressure or obstruction to the thoracic vessels. Thoracic edema is common in purulent exudates into the pleura. Sub- cutaneous emphysema may follow rupture of the lung, ulcer of the esophagus, and infection with gas-producing bacteria. In order to estimate the degree of emaciation that has taken place the patient's present condition must be compared with that known to have existed in health. Shape.— It is practically impossible to describe accurately the shape 48 DISEASES OF THE BRONCHI, LUNGS, AND PLEURA. of the chest, and a definite knowledge of its general conformation can be acquired only by making repeated examinations of the normal chest. _ In- deed, it is by this method alone that one can become familiar with the various types of chests to be found in healthy men, women, and children. Charac- teristic alterations in the conformation of the chests are seen in persons following certain occupations, as, for example, shoemakers, blacksmiths (uni- lateral overdevelopment), carpenters (funnel-shaped depression at xiphoid), coachmen (elevation of one shoulder), and those who have received train- ing in military academies and gymnasiums (bilateral overdevelopment) . The chest in health is practically symmetric, its symmetry being due in a measure to the presence of subcutaneous fat. The sternum projects slightly forward as it extends from above down- ward to the ensiform cartilage, the middle portion of the sternum being the most prominent part of the anterior surface of the chest. The ribs, upon their articulation with the cartilages that serve to connect them with the sternum, usually display a peculiar arched appearance, although not infrequently the anterior surface of the upper part of the chest is practically a b c Fig, lO.^NoRMAL Chest. Dxiring: u, Forced inspiration; &, forced expiration; c, at rest. flat, a condition referred to as the "flat type of chest." The xiphoid carti- lage may be depressed or may project anteriorly in the healthy chest. Bilateral Abnormalities of the Chest. — In athletes the chest is greatly enlarged, but this condition cannot be regarded as pathologic unless altera- tions in the viscera sufficient to cause the distention are present. In the barrel-shaped chest of emphysema (p. 127) the transverse diame- ter is normal or decreased, whereas the anteroposterior diameter of the chest exceeds the transverse. The clavicles and upper ribs are usually conspicu- ously elevated, giving the patient the appearance of having an unusually short neck. The pathologic changes necessary to produce the emphysema- tous chest will be discussed at length under Emphysema. As the result of the changes that produce the emphysematous chest there is also en- gorgement of the veins of the neck; this tends to render the cervical region thickened, and, as the result of venous congestion, it may even pulsate. The bases of the chest may be greatly enlarged as the result of the presence of transudates or exudates into the pleural sacs and by INSPECTION OF THE CHEST. 49 enlargement of the liver and spleen. The development of carcinoma ip. both lungs may also cause an abnormally large chest. Unilateral enlargement oj the chest is the result of pathologic changes causing an increase in the size of the viscera occupying one side of the chest, or is due to a lessening of the capacity of one lung, with compensatory emphysema of its fellow; thus, for example, following fibroid (adhesive) pleurisy of one side, the opposite side becomes abnormally enlarged in order to compensate for the lost breathing space. A large pleural effusion causes an abnormal distention of the affected side of the chest. When such effusion is present, the lung of the opposite side becomes emphysematous, and, in consequence, the entire chest is enlarged; the emphysema may be so marked as to lead one at first sight to suspect the enlargement to be the result of a bilateral pathologic condi- tion. Adhesive pleurisy, fibroid phthisis, a pulmonary cavity, and bron- chiectasis may cause a lessening in the dimensions of one side of the chest, but the opposite side rarely changes its size greatly as the result of compen- satory emphysema. New-growths of the thorax — e. g., thoracic aneurism — ^most often causes a prominence of the sternum, although it is not uncommon to find an aneuris- mal tumor protruding from the back, through the scapula, or from any portion of the chest-wall. Tumor of the mediastinal glands is a frequent cause of prominence of the sternum. Carcinoma and sarcoma of the lung and pulmonary abscess may cause unilateral deformities of the chest. The rickety chest follows rachitis, and in this condition the chest may assume almost any shape. Adenoid disease in children may cause chest de- formities that somewhat resemble those produced by rickets. Movements of the Chest. — Inspection of the chest enables us to ascer- tain the frequency of respiration, the rhythm, the diaphragmatic phenomena, and the degree of expansion. In health, inspiration is an active process, whereas expiration is passive. Physiologically, the act of expiration is slightly longer than is that of inspiration, and bears a ratio of six to five. There is sometimes a distinct pause following expiration. Generally speaking, it may be said that the chest expands in aU directions during inspiration and diminishes correspondingly in size during expiration. The character of the expansion during health can be learned only by inspecting the chest of several normal individuals. . In the normal male the respiratory movements vary between 16 and 24 a minute, whereas the adult female breathes from 20 to 22 times a minute. Breathing is much faster in children than in adults, and during the first year the average number of respirations is from 40 to 44 a minute, while at the age of five the child usually breathes 25 or 26 times in a minute. Posture, exercise, excitement, digestion, disease, and certain drugs increase the number of respirations, whereas posture, lack of mental excite- ment, and drugs diminish the frequency of the respiratory act. Types of Normal Respiration. — The Costo-abdominal Type. — ^This is fre- quently referred to as the diaphragmatic tj^e of breathing, and is charac- terized by the fact that while the patient is breathing quietly the chest movements are more marked at the lower half than they are at the upper half of the thorax. This form of breathing is more common in males than in females. During inspiration the sternum rises sUghtly, and the ribs are elevated, and at the same time extended downward, forward, and outward. Both the anteroposterior and the transverse diameters of the chest are increased with each normal inspiration, and the epigastric angle 4 50 DISEASES OF THE BRONCHI, LUNGS, AND PLEURA. occupying the interval between the costal cartilages at the base of the chest is changed from an acute to an obtuse angle. In the diaphragmatic type of breathing the movements of the diaphragm are conspicuous, and the muscle acts conjointly with the muscles of the thorax; thus, as the dia- phragm descends, there is a corresponding sweUing of the upper abdominal hemisphere. During expiration the chest gradually assumes its original shape and size. Costal Type. — In adult females the upper half or two-thirds of the chest moves more conspicuously than the lower portion, hence this variety of breathing is usually referred to as the upper thoracic type. In the clav- icular regions, the upper portion of the sternum, and as low as the third rib, there is marked expansion with each inspiration, whereas the lower portion of the chest remains almost stationary, and the results of the move- ments of the diaphragm are but feebly, if at all, apparent through abdominal swelling with inspiration. The costal type of breathing is also seen in children and in men during sleep. Movements of the Chest in Disease. — ^The chest movements are increased in practically all forms of difficult breathing, and the frequency of the move- ments is quite characteristic of certain affections — thus, a marked increase in the number of respirations may result from either pulmonary disease or other maladies. In children the movements are comparatively rapid. In fever and in nervous conditions the frequency of the chest movements are, as a rule, increased, whereas in coma and in certain cerebral diseases the respirations may be less frequent; indeed, this symptom follows certain toxic poisonings. From the degree of chest expansion we learn whether the respirations are deep or shallow; as previously stated, the ratio of the act of inspiration to expiration is as five is to six; in children, in most women, and in the aged, however, we find this ratio changed to from six to eight, the act of expiration being greatly prolonged. At times, where the degree of expansion and the duration of inspiration are increased, there is some obstruction in the upper air-passages, — e. g., in the trachea and larynx, — and the exaggerated expansion affects chiefly the upper part of the chest, when there is a corresponding retraction of the flexible wall at the base of the thorax. Dyspnea. — In dyspnea, or difficult breathing, the respirations, while deeper than normal, are not always increased in frequency. They may, however, be more frequent than normal. Dyspnea is a ■ common symptom in pulmonary disease, but it does not follow that extensive disease of the lung is always accompanied by difficult or hurried breathing. Patients suf- fering from dyspnea are usually reduced in weight, move slowly, and lack the normal vigor of health. Varieties of Dyspnea with Reference to its Exciting Cause. — Among the causes of dyspnea are: 1. Anything that lessens the normal amount of air intake required fully to oxygenate the blood — (a) Obstruction of the air-passages; (6) diminution of air-spaces from intra-thoracic (see Pleural Effusion, p. 142) and extra- thoracic (see Ascites, p. 564) exudates; (c) interference with the action of the muscles of respiration. 2. Maladies that are characterized by interference with the circulation through the lung. 3. Primary and secondary anemias. 4. Obstruction to the pulmonary circulation — e. g., pulmonary embo- lism, lobar pneumonia, pulmonary infarct. INSPECTION OF THE CHEST. 51 5. Interference with the nervous mechanism of respiration — cerebral tumor, cerebral hemorrhage, and the effects of uremic and other poisons upon the respiratory center. 6. A form of reflex dyspnea is occasionally seen in hysteria, gastric dis- turbances, and asthma. (See also Orthopnea, p. 173; Cheyne-Stokes respirations, below; cardiac dyspnea, p. 173.) The normal rhythmic movements of the soft parts at the baSe of the chest are altered in practically all types of dyspnea, and in most pathologic conditions of the lungs and pleurae. The act of expiration is prolonged in emphysema, and is a characteristic feature of this disease. Again, whenever the expiratory act is prolonged, the accessory muscles of respiration are brought into action, and the patient assumes a posture that facilitates emptying the lung. Cheyne-Stokes respiration is a disturbance in the rhythm of the respiratory acts characterized by distinct pauses. The respiratory acts forming the groups before and after a pause begin with a shallow inspiration; the inspira^ tions gradually become deeper until the maximum of depth is reached; then they become more and more shallow until they cease. Each group is composed of from 10 to 30 respiratory acts; the pause occupies from thirty to forty-five seconds. Fig. 11.- -Respiratobt Phases in Cheyne-Stokes Respiration, Giving the Respiratory Tr/cing Following a Pause (Boston and Ulman). Fig. 12.- -Respiratoey Tracing in Cheyne-Stokes Respiration Showing Complete Respiratory Movements, Preceded and Followed by a Pause (Boston and Ulman). The cycle of Cheyne-Stokes respiration, which includes the ascending and the descending phase, together with the pause, usually occupies one minute, and may be as short as one-half or as long as two minutes. This type of respiration occurs after severe surgical shock, and late during valvu- lar heart disease and kidney affections; it has been considered a symptom of nephritis (p. 661). Tumors of the brain, injuries, and hemorrhages in- volving the floor of the fourth ventricle frequently manifest Cheyne-Stokes respiration as one of their cardinal symptoms (Figs. 11, 12). Unilateral Changes in Respiration. — ^The movements of the affected side of the chest are diminished in pneumothorax, large pleural effusions, and, in massive pneumonia, when, as the result of overwork, the move- ments of the opposite side are at the same time exaggerated. A large peri- cardial effusion may inhibit the movements at the base of the left chest, but here there is also exaggerated movement of the upper portion of the same side. Fibroid phthisis involving one lung causes a decrease in move- ments upon one side of the chest, but movements are exaggerated on the opposite side. 52 DISEASES OF THE BRONCHI, LUNGS, AND PLEURA. I Local Abnormalities of Movement. — In this connection special at- tention is directed to the exaggerated movements of the bases of the lungs where the apices are affected with tuberculosis. Thoracic aneurism or thoracic tumor of whatever nature may give rise to unilateral abnormalities in the respiratory movements, such abnormalities varying with the location and the size of the tumor. Where tuberculous involvement of the apices of the lung is present, expansion may be slightly delayed at the affected point. An increased expansion is apt to occur over healthy lung when- ever a large portion of the 'breathing space has been consolidated from any cause. Pulsation of the chest may be the result of a dilated heart, or may be due to the heart being pulled out of its normal position by pleural adhesions. Epigastric pulsation is a symptom of cardiac dilatation. In empyema pul- sation may be present over the affected pleura. During phonation bulging of the intercostal space overlying the pleural effusion is rarely detected. Bulging is best produced by directing the patient to close his nostrils tightly and then partially to stop the exit of air by placing the hand over the mouth while he is speaking. PALPATION OF THE CHEST. By means of palpation most of the results obtained by inspection are confirmed. In palpation, as in inspection, more accurate results are ob- tained by baring the subjects chest, although it is frequently necessary to ].)alpate over a thin garment. Certain of the postures to be assumed Fig. 13. — Method of Palpating Over Apices of Lungs. by the patient and the position of the operator during palpation are shown in the accompanying illustrations (Figs. 13, 14). In palpating the chest it is most important that the tactile fremitus should be eUcited over practically every portion of the chest occupied by the l\mgs. The two sides of the chest must be studied comparatively, and palpation must be carefully performed over the axillary regions and bases. Tactile Fremitus.— Generally speaking, the vibrations transmitted to the finger during the act of talking are more pronounced over the right than over the left apex, and in males they are decidedly more prominent PALPATION OF THE CHEST. 53 than in females. The thickness of the chest has a direct influence on eUciting the tactile fremitus, since persons with a muscular or fatty chest- FiG. 14. — Method of Palpating Apices. Fia 15. — Determining the Exact Bodndart of an Area of Pulmonary Consolidation Through THE Degree of Vocal Tactile Fremitus (Boston, N. Y. Med. Jour., Nov. 1, 1913). The left index-finger recorded far more fremitus than did the right. wall show an apparent diminution in the vibrations transmitted to the examining hand. Vibrations are also imperfectly transmitted in children. 54 DISEASES OF THE BRONCHI, LUNGS, AND PLEXTRA. Increased Tactile Fremitus. — Among the conditions that may give rise to an increase in the tactile fremitus are: (1) Lobar pneumonia; Fig. 16. — Palpation of Two Small Areas Whehe Fremitus is Increased (Boston, N. Y. Med. Jour., Nov. 1, 1913). Fig. 17. — The Transverse Lines Represent the Areas Supplied by the Ulnar Nerve, the Ver- tical Lines Occupy that Area Supplied by the Radial Nerve, and the Oblique Lines Indi- cate Areas Supplied by the Median Nerve (Boston, N. Y. Med. Jour., Nov. 1, 1913). (2) bronchopneumonia; (3) tuberculous cavity, with a dense wall; (4) tuberculous consolidation; (5) fibroid induration of the limg; (6) fibroid PERCUSSION. 55 tuberculosis; (7) hemorrhagic infarct; (8) atelectasis, and rarely a thick- ened pleura. Diminislied or absent fremitus may result from the following pathologic conditions: (1) Pleuritic exudates and thickened pleurae; (2) bronchopneumonia; (3) dilated bronchi; (4) emphysema; (5) asthma. Fremitus is also absent in plugging of a bronchus, and limited areas over which it is impossible to detect fremitus may overlie thoracic aneurism, tumor of the lung, pneumothorax, and enlarged bronchial glands. Fluctuations. — Fluctuation is seldom obtained over the chest, but when present, it is of great clinical importance. The commonest cause of fluctuation is aneurism — where, through pressure, there has been an erosion of the bones of the chest, a portion of the aneurismal sac protruding beyond the bony casing (Fig. 130, p. 315). In aneurismal tumor outside of the chest the opening through the bones is, as a rule, very small, the blood tumor expanding after it escapes from the chest. In rare cases fluctuation may be obtained over a large pleural effusion — a sign more common in children. PERCUSSION. In diseases of the chest, and especially in pathologic conditions of the lung, percussion offers very valuable clinical data. This method has been practised since its introduction, by Auenbrugger, in 1761. Percussion consists in striking or tapping portions of the body in order to elicit vibrations; from the character of these vibrations it is possible to learn the conditions existing beneath the area percussed. In order to acquire skiU in this method of diagnosis far more practice is required than in any one other clinical method. Again, it is quite impossible to describe the practice necessary to accom- plish the desired end. In order to become skilled in the art of percussion it is necessary — (1) that the tactile sense of the physician be weU developed; (2) that he should be able to manipulate his hands and fingers with as much dexterity and ease as though he were playing a piano; (3) that he possess an acute faculty of distinguishing the degrees of vibrations. Whenever any one of these qualifications are lacking, the physician will never be able to obtain definite knowledge through the art of percussion. Methods of Percussion. — (1) Immediate percussion; (2) mediate percussion. The latter is divided into three subheads: (a) finger percus- sion; (b) finger-pleximeter percussion; (c) hammer-pleximeter percussion. 1. Technic for Direct (Immediate) Percussion. — By this method physical signs are elicited by percussing the body-waU with the flnger or fingers. Considerable practice is required to obtain success by this method, but when proficiency is attained, it is equaUy as valuable as indirect percussion. Direct percussion possesses one great advantage over other methods, since one is able to compare the notes obtained by percussion from each side of the body and from different points over the chest and abdomen. In hospital clinics it is our custom to strip the patient and to apply this method, beginning at the abdomen and continuing upward until the clavicles are reached; the same procedure is then applied to the back. By means of these methods one is often able to detect quickly the location of disease. 2. Mediate Percussion. — This method consists of placing a solid body (either the finger or a wooden or metaUic substance) against the body-wall, and then striking it with the finger (Fig. 18) or with a hammer especially de- vised for the purpose. The medium placed against the chest-wall and 56 DISEASES OF THE BRONCHI, LUNGS, AND PLEURA. Fig. 18. — Percussion over Supraclavicular Space. between it and the object with which the stroke is made is called a plexi- meter. This should be of such size and form as to fit well between the ribs. When the hammer is used to strike the pleximeter, it is called a plexor. After considerable experience the plexor can be used with sat- isfactory results. Some exam- iners obtain better results by using the finger of the opposite hand than by employing the pleximeter and plexor. By placing the finger against the body and over the area from which sounds are to be elicited we obtain additional informa- tion, since the sensation that is offered by the patient's body to the operator's finger is often of great importance, and affords the physician a douljle method of ascertaining data — that is, by the sense of touch and of hearing. The further technic of mediate percussion is clearly shown by the accompanying illustrations (Figs. 18, 19). The position of the patient is an important factor in percussion. When the patient is able to stand, the examiner should insist that he stand as nearly erect as possible, and that he extend his chest to as near the normal as he can. Complete relaxation is a valuable aid in obtaining definite signs by percussion. Again, undue thickness of the chest-wall may materially interfere with this clinical ob- servation. In percussing the back of the chest it is well to direct the patient to fold the arms across the front of the chest, and to bend forward slightly, thus widening the space be- tween the scapulse (Fig. 20) . The axillary region is readily exposed by directing the pa- tient to lift both arms to near a level with his head, or to clasp his hands over his head. The patient should then direct his arms slightly backward, permitting them to hang along the posterior axillary line. In a large proportion of cases one is compelled to per- cuss the chest-wall while the patient rests in bed, and it then becomes necessary to turn him from side to side. When percussing a patient in the recumiaent posture, the phy- sician must have clearly in mind the various positions the liver assumes as the result of posture. (See Diseases of Liver, p. 572.) -Application of Fingers over Apex of Lung for Percussion. Fig. 20. — Position of P.^tiknt for Percussion of B.\ck BETWEEN Scapula, Separating the Scapul.e and THUS Increasing Interscapular Area PERCUSSION. 57 Analysis of Results Obtained by Percussion.— Sounds are usually distinguished by their pitch, volume, length or duration, and quality. The pitch is higher when the vibrations are rapid, and it will be noticed that the pitch will vary greatly over different portions of the chest and over the abdomen; consequently when the sound obtained is low in pitch, the vibrations are correspond- ingly slow. Volume results from the amplitude of vibrations, therefore the degree of force exerted with each stroke of the percussing finger influ- ences directly the volume of sound produced. The accompanying illus- tration (Fig. 21) will serve as a diagrammatic represen- tation of pitch. Interpretation of Sounds. — Sounds can be correctly interpreted only after the operator has be- come thoroughly acquainted with the sounds to be elic- ited over different parts of the chest and over different organs during health. For example, it is impossible to describe with any degree of accuracy the note of pulmonary resonance or that of gastric tympany, tympany due to distention of the colon or to that of the small bowel, and it is likewise impos- sible to give a clear description of the note produced by hepatic dullness. When the ear becomes familiar with these sounds, it will readily detect any deviation from the normal, which, in the majority of instances, indicates the existence of a pathologic condition. The sounds may vary con- siderably in pitch, volume, and tone during health, but such variations should never be con- founded with those produced by disease. In order to detect the note of pathologic change, the examiner must first become thoroughly familiar with the sounds produced by extreme conditions during health. Modifications in Health. — The degree of resonance is best exemplified by percussing over the upper axillary region, at the angle of the scapula and at the second rib anteriorly. At the second interspace a slightly higher pitched note is obtained on the right than upon the left side of the chest. The higher pitched percussion-note over the right than over the left apex is probably due to the larger diameter and higher position of the right Tracheal or fubular /one Resonant^ tone. Tymporilffc rSVie. Volimie and durai^on Fig. 21.^ — Diagrammatic Representation of the Character of Sound. The perpendicular line shows the pitch; the horizontal hnes, the duration and volume. 58 DISEASES OF THE BRONCHI, LUNGS, AND PLEURA. bronchus. The note is again modified by the thickness and the tension of the chest-wall as the result of muscular contraction, etc. There is always a lack of clearness in tones obtained in senile individuals, whereas in children the resonance is full and clear. The examiner must be thoroughly acquainted with the various sounds elicited from different portions of the chest, bearing in mind that the note obtained over the axillary region would be pathologic if it were elicited elsewhere, and that the note obtained over the apex of the lung differs greatly from that found at the angle of the scapxila. The value of the evidence eUcited through percussion is dependent upon three factors: (1) The area over which a certain sound is obtained; (2) the dexterity of the operator; (3) degree of muscular tension and thickness of chest-wall. Tympany. — Pure tympany is obtained over a cavity or hollow viscus with smooth walls, and that is filled with air at the time of examination. The sound elicited is one of low pitch, great volume, and long duration. During health tympany is elicited over the area of the stomach, but it must be remembered that this sound differs sUghtly from tympany the result of pathologic processes in the lung, e. jr., a pulmonary cavity. If the hollow viscus or cavity over which tympany is produced is unusually large, the note has a peculiar metallic character, best obtained when there is free air in the pleura (pneumothorax). (See p. 164.) Caution. — ^Tympany over the base of the lungs posteriorly in children under two years of age is normal. Dullness. — ^This sound is obtained as the result of percussion over that portion of the heart and of the liver not covered by lung. Areas of dullness where, under normal conditions, resonance should be obtained, is of path- ologic significance. The peculiar types of dullness, that is, the pitch of the dull sound obtained and its duration and tone, are more or less intimately interwoven, so that a description here is scarcely practicable. In a word, dullness indicates that we are percussing over an organ that is practically airless, and, therefore, whenever this sign is obtained over the lung area, it signifies consolidation or an absence or diminution in the volume of air in that particular portion of the lung. Again, any deviation from the normal resonance that tends to approach the sound known as dullness shows that the volume of air in the lung occupying such area is less than that found under normal conditions. Relative Dullness. — ^This type of dullness is obtained over structures that are airless, but where a portion of an air-containing viscus is interposed between the airless body and the chest-wall, e. ^., over that portion of the heart that is overlapped by lung tissue, relative dullness is obtained; the same sound is obtained over the dome of the liver (Fig. 234, p. 574). Absolute dullness is outlined with great ease by any method of percussion, whereas the determination of the area of relative dullness demands increased dexterity on the part of the operator and a greater cultivation of his auditory sense. Ability to determine the exact area of relative dullness is, therefore, one of the greatest achievements known to physical diagnosis, for in many instances in diseases of the lungs a positive diagnosis is based largely upon this finding. Respiratory Percussion.— A physical sign that is especially applied to the difference of sounds over corresponding portions of the lung at the end of a full inspiration or a full expiration, the patient holding the breath after either act. Superficial and Deep Percussion. — ^These terms are used to designate the force applied to the blow given in order to elicit sounds from certain tissue. Thus, deep percussion is required to outline the relative dullness PERCUSSION. 59 of the liver or of the heart, whereas, on the other hand, superficial percussion would be employed for outhning the areas of superficial or absolute duUness of these organs. Both superficial and deep percussion are required in an examination of the lungs, and are often of service in abdominal disease Auscultatory Percussion.— This physical method combines percussion with auscultation by means of the stethoscope (Fig. 22), and is by far the most practical method for the outlining of various diseased portions of the lung and for ascertaining the size of solid viscera. In determining the size of a viscus or an area of consolidation the stethoscope is placed near the supposed center of the area to be determined, and then percussion is made from distant portions of the chest toward the bell of the stethoscope, ap- proaching the bell from all directions. Whenever the percussing finger reaches the margin of the solid body over which the stethoscope bell is Fig. 22. — Method of Auscultatort Percussion Employed to Outline the Heart. placed, a change of note will be audible. It is our custom to mark upon the chest-wall the point at which the note changes in percussing toward the bell of the stethoscope. When one has percussed in this way from practi- cally every direction, encircling the bell of the stethoscope, the sounds have been carried to the bell along the lines corresponding to the spokes of a wheel. (See also Disease of Heart, p. 223.) By means of this method the dullness of the liver is readily distinguished from that due to pulmonary consolidation of the right Ijase, and the distinc- tion between the flatness of pleural effusion and the dullness due to the liver is made with equal ease. Again, when examining the left side of the chest, this method is of great importance in determining the exact area of lung consolidation, and in differentiating such consolidation from heart dullness. Auscultatory percussion has been found a valuable aid in the diagnosis of tumors of the thorax and in outlining the heart. Lastly, better results are to be obtained through the use of auscultatory percussion by those having 60 DISEASES OF THE BRONCHI, LUNGS, AND PLEURA. but limited clinical training than by any of the other methods described here. The note obtained by auscultatory percussion over the stomach is quite characteristic, as is also that audible when this method is applied over the colon and small intestine; nevertheless auscultatory percussion should not be employed to the exclusion of ordinary percussion in determining the size and location of the hollow viscera. Palpatory Percussion. — This method consists in obtaining clinical evidence through two sources: (1) By an analysis of the type of sound that is produced by percussion; and (2) by an analysis of the character of sensa- tion (resistance) offered to the finger that is placed against the chest-wall. Diagnostic Significance of Special Signs in Disease.— The hyperresonant note, which approximates tympany, when found over both sides of the chest, is characteristic of emphysema (p. 124), but if the Wall of consolida- tion surrounding cavity Cavity Top of fluid in cav- ity showing bubbles Fig. 23. — Phthisis with Cavitt Formation. tension in_ the lung is extremely high, the tympanitic element of the note obtained is altered, and we have, instead, a variable or modified degree of dullness (wooden tympany). Dullness at one or both bases, from whatever cause, is usually associated with h}rperresonance at the apices (skodaic tympany, p. 128). Given a large pleural effusion, a skodaic note may be found in the region of the clavicle. Compensatory hyperresonance (skodaic tympany) is also found immediately surrounding areas of consolidation whenever the adjoining lung is healthy Dullness located at the apex of the lung deserves special consideration' since m the normal condition a variable degree of tympany— the so-called "bronchial percussion"— is present near the edge of the sternum and at the first and second interspaces. It is, therefore, necessary to percuss near the nipple-line in order to ascertain accurately the degree of hyper- PERCUSSION. 61 resonance surrounding apical consolidations. An increase in the area of cardiac dullness, when due to cardiac hypertrophy, dilatation, or the pres- ence of pericardial fluid, may be accompanied by a hyperresonant note at the apex, in front and over the left scapular region posteriorly. This phenome- non exemplifies the important physical fact that whenever a portion of a lung is rendered incapable of functionating, either through disease of the lung itself or through intrathoracic pressure, portions of the healthy lung become emphysematous to compensate for such incapacity. Tympany of the stomach has been discussed at length on p. 444. Some repetition is required, owing to the great importance that attaches itself to determining the actual boundaries of stomach tympany, which in the left anterior axillary line is a modified type of tympany at the fifth rib; when the stomach is distended, tympany may be found as high as the left fourth or even the third interspace. A localized area over which a tjTiipanitic note is obtained signifies phthisis with cavity formation, bronchiectasis (dilated bronchus), pulmonary gangrene with cavity, and pulmonary abscess with cavity. The conditions that render it easy to elicit a tympanitic note over a small cavity are: (1) A thin chest-wall; (2) a relaxed condition of the chest; (3) a cavity situated near the chest-wall; (4) a cavity communi- cating with the bronchus. Conditions exactly the reverse of those previously mentioned render it difiicult to obtain tympany over a pulmonary cavity, and make forcible (deep) percussion necessary. At this point it is well to call attention to a pathologic condition that is prone to be neglected; i. e., surrounding each cavity there is apt to be a thick [band of consolidated lung tissue (Fig. 23), consequently upon moderate percussion dullness is obtained, whereas upon deep percussion tympany is elicited. Amphoric resonance is the term applied to a variety of tympany to which is added a metallic quality; ordinarily it is somewhat high in pitch, but of shghtly longer duration than tympany. Amphoric tympany is best obtained in pneumothorax when percussion is made over a pleura that is filled with air (p. 163). The degree of tension under which air is held in the pleura materially modifies the amphoric note obtained over such pleura; thus, when the tension is unusually high, a wooden note — ^the so-called "dull tympany" — ^is elicited. Amphoric resonance, when present over a large pulmonary cavity, indicates that such cavity rests near the ribs, has a firm wall, and that its inner surface is comparatively smooth. Bell Tympany (Coin Percussion). — Whenever there is a suspicion of the presence of either general or localized pneumothorax, coin percussion should be applied; this is accomplished in the following manner: (1) Place a coin against the chest-wall and immediately over the center of the area of tympany; (2) place the ear against the opposite surface of the chest-wall, and then tap the coin gently with another coin or with some metallic substance. (See Fig. 54, p. 164.) If there is air in the pleural cavity, an intensified metallic echoing sound is usually transmitted to the ear. Certain writers have referred to this peculiar note as bell tympany, and indeed the sound resembles that of a bell. This sound is rarely obtained over a large pulmonary cavity. Cracked-pot Sound. — This is a variety of tympany to which is added a peculiar hissing and clinking sound. The cUnking quality resembles that resulting from the tapping of a broken metallic vessel; hence the name, "cracked-pot sound." The hissing quality is apparently produced by air being forced through a small opening. 62 DISEASES OP THE BRONCHI, LUNGS, AND PLEURA. Caution. — In order to obtain this sound over a cavity several things are necessary: (1) The chest-wall must be relaxed and thin; (2) the cavity must rest near the surface of the lung; (3) it must be large and its waU thin; (4) the cavity must communicate with a bronchus; (5) the patient's mouth must be open; (6) the percussion strokes must be firm, but slow, giving the Hstener ample time to analyze each note produced. Percussion must be made during the act of expiration. Lastly, the sound is absent when a cavity is filled with Hquid to a level above the communication with the bronchus (Fig. 23). Peculiarities.— TheoreticaHy, the cracked-pot sound should be elicited whenever the conditions just described are present, and, indeed, under such conditions this sound is obtained in the vast majority of cases. A peculiarity of this variety of tympany is that it is obtained over the chest of infants during health, and is invariably present when the child is crjdng. Occasionally, the cracked-pot sound is obtained over the chest of apparently healthy adults. A locaUzed pneumothorax may communicate through the lung with a bronchus, and the cracked-pot sound may be one of its clinical manifestations. An extremely rare condition to. find is a localized pneumothorax with an opening through the chest-wall. It is asserted by some that this variety of tympany may be elicited over that portion of the lung pushed well toward the apex of the chest as the result of a pleural effusion (p. 146), and that massive pneumonia may produce the same phenomenon. Wintrich's Sign. — Here, percussion enables us to determine whether or not a cavity communicates with a large bronchus, in which case the per- cussion-note becomes louder and is raised in pitch when the patient opens his mouth, elevates his chin, and protrudes his tongue. This sign is ob- tained at the end of inspiration, therefore the patient must inspire lightly and continue to do so until the percussion stroke is made. By directing the patient to inspire deeply and then to hold his breath, as is at times recommended, a louder sound is produced, but, according to H. S. Anders, this destroys much of the characteristic element of the sign. Exception. — If the cavity in the lung is filled with fluid to above a level of its communication with the bronchus, Wintrich's sign would be absent, but by changing the position of the patient the air in the vomica would communicate directly with the bronchus, when Wintrich's sign would be present — ^the so-called "interrupted Wintrich's phenomenon." Percussion over the trachea and over a dilated bronchus causes a similar note under these conditions. Wintrich's note may also be obtained by percussing over a pleura distended by air, provided there is a large open- ing from the bronchus to the pleural sac. To obtain Wintrich's sign percussion is first practised, directing the patient to hold the mouth open and to protrude the tongue; later he is directed to close the mouth and hps tightly, and in this manner the operator obtains the greater variation in sound. In pleural effusion, where there is decided skodaic tympany above the hquid, a sound may be obtained by firm percussion that simulates closely Wintrich's phenomenon. In robust individuals Wintrich's note may follow firm percussion over the upper portion of the sternum. This sign is occa- sionally found in the presence of mediastinal tumors, owing to the fact that such growths occupy all the space between the surface of the sternum and the bronchi. Friedreich's Sign. — Friedreich has called attention to a peculiar change in the degree of tympany when cavity in the lung is present; this observer AUSCULTATION. g3 noticed that when the cavity communicated directly with the bronchus, the pitch of the note obtained was higher during and at the end of inspiration than during expiration. This sign may be of some value, but its presence is never necessary in order to determine the character of the lung condition, nor is it equally reliable with cracked-pot sound. Gerhardt's Sign. — ^This phenomenon consists in a change in the pitch of the percussion sound obtained over a cavity with change in the position of the patient. Gerhardt's sign is obtained over a cavity in which one diam- eter is greater than the other, the cavity being partially filled with fluid. The change in the pitch of the percussion-note depends upon the alteration in shape of the air-containing portion of the cavity, as the result of change of position of fluid, and the lowest pitch is observed when the long diame- ter of the cavity is in the horizontal. Biermer observed that the same phenomenal conditions observed by Gerhardt in pulmonary cavity were also present in pyopneumothorax. AUSCULTATION. Definition. — ^The method of listening to various sounds produced within the human body in health and during disease. Chief among the organs giving off these sounds are the heart, the lungs, the trachea, the gastro-intestinal tract, and the impregnated uterus. Abnormal sounds may be produced over any portion of the circulatory system as the result of pathologic changes. As in percussion, so in auscultation, there are two methods of examina- tion — ^the immediate and the mediate. Methods. — In immediate auscultation the ear is placed directly against the wall of the patient's body, or separated merely by a thin towel. Mediate auscultation is a method in which an appliance, e. g., the stetho- scope, is used as an aid in conveying sounds to the ear. In examining the lung immediate auscultation is far more satisfactory than the mediate method, although the latter may be of value in certain special localized conditions. In examining the heart the mediate method should be ap- plied, since the stethoscope enables one to recognize sounds and to outline their points of greatest intensity, as well as their areas of transmission with ease. Advantages of Immediate (Direct) Auscultation. — Among these, special mention should be given of the following: (1) It is a ready method of making a rapid survey of the chest, as is often necessary in those who are extremely Ul, who are unable to sit for any length of time, and who must be examined quickly, and while they are in the recumbent posture. (2) The value of the true respiratory sounds is better appreciated. (3) Slight al- terations in sound are more likely to be detected. (4) When the ear is applied directly to the chest, the bruit of aneurism is more readily distin- guished from the sounds of the heart. (5) Tactile sensations, conveyed to the examiner's ear when it is applied against the chest-wall, enable him to form a clear idea of the character of the chest movements. (6) The actual harshness of friction murmurs and voice vibrations are best appre- ciated when the ear is applied directly to the chest. (7) The exact time of action of the chest muscles is also appreciated, and this information is of great clinical value in acute fibrinous pleurisy. Advantages of Indirect Auscultation. — Chief among these are: (1) It enables the listener to localize the point of greatest intensity of the sounds g4 DISEASES OF THE BRONCHI, LUNGS, AND PLEURA. to be analyzed. (2) A given sound may be followed over its various lines of distribution. (3) Pressure with the stethoscope over the thorax ma,y cause certain sounds to disappear, whereas others are in this way mtensihed.— a feature of some diagnostic importance. (4) It is possible to place the stettio- scope over certain areas where it would be impracticable to employ the immediate method. (5) It is easier to obtain a knowledge of the condition of the lung in those patients who are too ill to sit while being exammea. (6) It obviates direct contact ^mth those suffering from contagious maladies. (7) In clinic and hospital work the operator may remain at a distance trom his patient. (8) External sounds are excluded. (9) When combined with percussion, it serves as an excellent method for outlining viscera, areas ot consolidation, tumors, etc. (See Auscultatory Percussion, p. 59). Stethoscopic Auscultation.— While this is the mosz practical method for studying the condition of the heart, its field of usefulness is otherwise limited. The stethoscope does not give reliable results in ex- amination of the lungs of children, and even in neurasthenic women. It is essential that the physician be thoroughly skilled in both the im- mediate and the mediate methods, and he must not use one method to the exclusion of the other. Technic. — It is preferable that the patient sit upright during the examination. While auscultating the front of the chest, the arms should hang carelessly by the side. When auscultating behind, the patient should fold the arms and lean slightly forward (Fig. 20). Both sides shoidd have the same freedom of movement, which is at- tained only when the patient is sitting or standing. It is necessary to listen over the lungs during forced inspiration, forced expiration, and to keep the ear in contact with the chest be- tween these acts. Whenever possible, the chest should be bared, and a thin, unstarched towel placed between the examiner's ear and the chest-wall. In those cases in which it is not practical to remove all clothing, fairly good results may be obtained by auscultating through a thin unstarched garment. The room in which the examination is being made should, of course, be quiet. The best results are to be obtained by directing the patient how to inhale, speak, cough, clear the throat, and to whisper during this portion of a physical examination. Normal Breath-sounds. — ^Under normal conditions there are three distinct sounds to be heard over specified areas of the chest, and if the student is thoroughly skilled in the recognition of these sounds, he will be able to detect disease of the lung or of its coverings whenever such sounds are heard over areas where they are not audible during health. Bronchial Breathing.— This is a type of respiration heard nor- FiG. 24. — Method of Holding Child to Per- cusa and Auscultate Chest. AUSCULTATION. 65 maHy over the trachea (Fig. 25), but pathologic whenever heard over the substance of the lung. By placing the stethoscope over the trachea immediately above thej suprasternal notch, two distinct sounds are heard" (1) The one during inspiration; and (2) the one during expiration. These sounds are separated by a pause which is observed immediately before the end of inspiration. The sounds of both inspiration and expiration are prac- tically of the same length, and the quality is harsh, blowing, or, as is often stated, tubidar. The sound of bronchial breathing is loud and high pitched although this may vary somewhat between inspiration and expiration.' The sound during both acts, however, shows an elevation of pitch and in- Normal area of bron- chial breathing Normal area of bron- chovesicular breathing Fig. 25. — ^Area on Posterior Wall of Chest, where Bronchovesicular Breathing MALLY Present. is Nor- creased intensity. The areas over which bronchial breathing is to be found during health are shown in the accompanying illustrations (Figs. 25 and 26) . Bronchovesicular Breathing. — This breath-sound represents an im- perfect type of bronchial breathing, as well as an exaggerated type of vesicu- lar breathing. It is often referred to as a mixed type of breath-sound, since it displays definitely a certain amount of bronchial element, as well as an imperfect vesicular respiratory murmur. Bronchovesicular breathing is heard over a portion of the sternum, along the thoracic vertebree, and over certain other areas of the chest, as is shown in the illustrations (Figs. 25, 26, 5 66 DISEASES OF THE BRONCHI, LUNGS, AND PLEURA. 27 and 28). This type of breathing requires no description, for it may be obtained by auscultating the normal chest. Attention is however caUed to the fact that bronchovesicular breath-sounds are normal ^f ^^e back ot the chest as high as the vertebra prommens, and even to the t^^^d and tourth thoracic vertebra. Owing to the anatomic fo™^^t\«",«f'h/£a^ column this breath-sound is heard for some distance to the right of the spinal column Vesicular Breathing.— This is made up of a variety of breath-sounds heard over those portions of the lungs situated away from the areas over which bronchial and bronchovesicular breathing are normally present Vesicular breathing has been described as resembling the sound produced by a soft breeze or as slightly sighing currents of air; by some it has been compared to the gentle rustling of the leaves of a tree by the wmd " is impossible to give a correct description of this sound, but a thoiough Normal area of bron- chial breathing Normal area of bron- chovesicular breathing Fig. 26. — Bronchial and Bronchovesicular Breathing During Health. acquaintance with it should be had by every student of medicine. A char- acteristic feature of vesicular breathing is the peculiar, breezy nature of the sound, which is practically continuous; in other words, it is heard during the whole of inspiration, and is immediately followed by the shorter sound caused by expiration. Vesicular breathing is modified by directing the patient to inspire deeply or to hold his breath. During the act of inspiration the sound is moderately intense, but of low pitch, and is relatively three times as long as the expiratory murmur. Dur- ing expiration the sound may not be audible or it may be present during but a portion of the act; it is less intense and of somewhat lower pitch, although during this act there is added a slight blowing quality — merely a soft puff of air. As has elsewhere been stated, the chest movements of inspiration and AUSCULTATION. 67 expiration are to one another in time of duration as five is to six, although the sounds of vesicular respiration bear a ratio of three to one or four to one. Variations in Vesicular Breathing. — It is important that the variations in vesicular breathing capable of being excited through normal conditions be thoroughly understood. Breath-sounds normally show slight increase in sound Fig. 27. — Auscultation of Axilla for Bronchovkwicular Breathing. Normal area where bron- chovesicular breathing is heard. Fig. 28. — Auscultation of Axilla for BRONCHOvi'sicur-AR Breathing. Age. — Up until the twelfth year the vesicular quality that characterizes vesicular breathing (in the adult) is markedly exaggerated, and the breath- sounds are harsher and louder than after puberty. At the other ex.- treme of life, old age, the vesicular quality, while it retains this harsh sound is much more feeble than it is during early adult and middle life. 68 DISEASES OF THE BRONCHI, LUNGS, AND PLEURA. This condition is believed to depend upon a loss or weakening of the elas- ticity of the lung. Inspiration appears to be shorter, whereas expiration is slightly prolonged. Sex.— The respiratory murmur is appreciably louder in the female than in the male. Auscultating over the upper and anterior portion of the chest, the breath-sounds are much increased in intensity in women. Certain anatomic conditions may, in selected cases, account for the softness of the respiratory murmurs in males — e. g., the thickness of the chest-wall, firmness of the tissues, etc. Regions Where Increased Sounds are Heard.— During health the breath-sounds are slightly more distinct and louder upon the right side, and this feature is most pronounced in the infraclavicular region. The thickness of the chest-wall influences the degree of sound conveyed to the listening ear, consequently the sounds are clearer anter- iorly and in the axillary and in- fraclavicular regions than they are over the mammary and scapular regions. These varia- tions in the intensity of the iDreath-sounds may be found in doubtful pathologic pulmonary conditions. The appreciable weakness and almost absence of the ve- sicular murmur may also be physiologic when auscultating over thickened portions of the chest-wall, etc., for example, over heavy muscles, in obesity, in massiveness of the chest- wall. Jerky (Cog-wheel) Res- piration. — The so-called jerky or cog-wheel respiration is gen- erally conceded to be an early sign of tuberculosis, but this peculiar interruption in the respiratory murmur is also an occasional feature during health. Jerky respiration when present is best seen in those who breathe slowly, and this tj^ae of respiration is, as a rule, better brought out by directing the patient to inspire deeply. This type of breath- sound is common in children wMle fretting and when crying, and in hysteric women. Physiologic irregularity in the respiratory murmur is audible over all portions of the lung, whereas irregularity due to incipient tuberculosis is heard only over isolated areas. Systolic (Cardiac) Vesicular Breathing. — This respiratory murmur is characterized by a rhythmic exaggeration that is more or less jerky in character, and apparently influenced by the action of the heart. This peculiarity in the vesicular murmur is audible while the lung is expanding, and is limited to those portions of the lung overlapping the heart. The vesicular murmur gradually increases until the end of inspiration, after which there is an appreciable pause. Fig. 29. — ^Arbitrary Division or the Back. rAles (rhonchi; rattles). 69 RALES (Rhonchi, Rattles). Riles are adventitious sounds heard over the lungs. They have received various classifications, and Page distinguished three great classes: (1) The dry; (2) the moist, and (3) indeterminate forms. Dry Rales.^Of the several varieties of dry rdles, the following are the ones that must be recognized for diagnostic purposes: (a) Sibilant and (6) sonorous. Sibilant Riles. — These are high pitched and whistling in character, occurring with inspiration or with expiration, and may be present during both acts. The sibilant rile may be produced in the larynx or in the trachea, provided the caliber of either is sufficiently narrowed, and the same physical condition serves to explain the production of the sibilant rile in the larger bronchi. They are most commonly produced in the smaller bronchi, and result from the same mechanic conditions that give rise to coarse riles or from sweUing of the mucous membrane. Sibilant riles are audible during the dry stage of acute bronchitis and in asthma. Sonorous Riles. — These are loud, low-pitched, dry rales that accom- pany inspiration or expiration, and may even be heard during both acts. Ordinarily, the sonorous rile is produced in the larynx, the trachea, or the larger bronchi. Sonorous riles are produced in the larynx as the result of spasm of the glottis, hence they are a conspicuous sign in croup, whoop- ing-cough, thoracic aneurism, mediastinal tumor, conditions that exert undue pressure upon the recurrent laryngeal nerve. A sonorous rile may originate in the trachea if this tube is either partially closed, from the pressure of external tumors and growths, or if its lumen is diminished as the result of new-growths upon its mucous surface. Inflammatory and edemar tous as well as cicatricial changes may also cause narrowing of the trachea. Riles originating in the trachea are audible by the aid of the stetho- scope over all portions of the lung, but are most distinctly heard nearest the site of their production. The sonorous rile may also be produced in the larger bronchi as the result of narrowing of the lumen of such pulmonary tubules, regardless of whether the condition results from external pressure, chronic inflammation, edema or spasm of the lining mucous membrane, and, indeed, the accumulation of thick, tenacious mucus may produce such riles within the bronchi. Sonorous riles are, as a rule, temporary, often disappearing after the patient coughs or clears his throat, a clinical evidence that suggests that they are possibly due to a varying spasmodic condition and to vibrating mucus that is dislodged by the act of coughing. Should the condition that favors the production of the sonorous rile be a permanent one, but few riles may be audible. During bronchitis the sonorous rile may accompany the sibilant variety. Moist Rales.— These may be produced in the larynx, trachea, a pulmonary cavity, the bronchi, and in the air-cells. The moist rales that occur in the bronchi as the result of lowered vitality are an example of this particular type, and the sound thus produced is what is commonly known as the death-rattle. Moist riles are also heard over the entire surface of the chest in certain pulmonary conditions, but, as in the case of dry riles, it is possible to locate the area of their production by means of the stethoscope. In all instances where any type of rile is audible over the chest it is advisable to direct the patient to clear his throat or to cough, for in this way it may be possible to prevent temporarily the production of moist rales in the larynx and trachea. . *, Subvarieties of Moist Riles. — Certain subvarieties of the moist rale 70 DISEASES OF THE BRONCHI, LUNGS, AND PLEURA. are at times audible over the bronchi. For diagnostic purposes these have been divided into three subclasses: (1) Mucous; (2) submucous; and (3) subcrepitant. Mucous Rdles.—The mucous rale is a rather large, moist, bubbling sound, produced in the larger bronchi, and audible during the act of inspiration and of expiration. Mucous riles are materially modified by the act of coughing, and especially is this true when cough is accompanied by free expectoration. Fluid of whatever nature, when it accumulates in the larger bronchi, is Ukely to give rise to mucous reiles ; hence when a purulent, mucous, or bloody exudate exists upon the bronchial mucous membrane, such rales are present. Mucous rales frequently disappear after coughing, but may also be produced through the very act of coughing or clearing the throat. These rdles may be heard over localized areas of the lung, or, as is more commonly the case, they are audible over the greater portion of both lungs. Submucous Rdles.— These are moist, bubbling riles, apparently smaller than mucous riles. They are probably produced in the medium-sized bronchi. Like mucous riles, they are heard during the respiratory acts, and are influenced by cough, expectoration, etc. Subcrepitant (_Mucocrepitant) Rdles. — ^This variety represents the finest of the moist riles, and has its origin in the smaller bronchial tubes. This type of rile is heard chiefly on inspiration, and is not so readily influenced by coughing and clearing of the throat as are either mucous or submucous riles. This type of rile is probably caused by the inspired air forcibly separating the agglutinated walls of the finer ramifications of the lungs. In bronchopneumonia (capillary bronchitis) the subcrepitant rile is likely to be audible over the lower portion of both lungs posteriorly; it may also be a symptom of pulmonary edema, and is not infrequently detected during the stage of resolution in lobar pneumonia. The subcrepitant rile (crepitus redux) may be present in pulmonary hemorrhage, where the blood has es- caped into the lung tubules, and in a similar manner pus may give rise to the subcrepitant rile. During the early stage of phthisis this variety of rile may be elicited immediately over the area of congestion, and although it is heard at other stages of the disease, when so heard it possesses less clinical significance. Crepitant Rdles. — ^These are produced in the air-cells, and are the only vesicular riles audible. They are characterized by an unusually fine, uniform, crackling sound, heard just at the end of inspiration. Another characteristic of the crepitant rile is that it is not influenced by coughing. The theory offered for their production is that the inspired air forcibly separates the agglutinated walls of the air-cells. Some observers believe that it is of pleural origin. The crepitant rile is heard during the stage of congestion in croupous pneumonia. The crepitant rile may possibly have escaped notice during the first stage of pneumonia. It is absent during the second stage, while the air-cells are obliterated or filled with exudate. The rile heard in the third stage and known as the redux rale is in reaUty a subcrepitant rile. Mucous Click.— This is a single, fine, high-pitched, moist, clicking sound, heard over both lungs, and but sUghtly, if at all, altered by coughing. The time of its appearance varies somewhat, but it is usually heard during or near the end of inspiration. The mucous click is quite commonly detected during the courseof pulmonary tuberculosis, and over areas where there is incomplete consolidation. Gurgles.— These are exceptionally large, moist, bubbling riles, probably originating in a pulmonary cavity or in an expanded bronchus that is par- RALES (bhonchi; rattles). 71 tially filled with fluid. They vary greatly in size, and are both high and low in pitch, depending upon the size of the cavity and upon the degree of con- solidated tissue surrounding it. Gurgles are heard during both inspiration and expiration, but siuce inspired air enters the cavity with more force than is present during expiration, the sounds are louder during the inspiratory act. Intrapleural Moist Rdles (Friction Murmurs). — The pleuritic friction- sounds at times simulate closely those described as moist, bronchial, and vesicular r^les, and some writers suggest that both the subcrepitant and the crepitant riles are intrapleural in origin. In selected cases the intrapleural murmur resembles both the mucous and the submucous riles, and it was suggested by the late J. M. Da Costa that the human ear could not always determine the origin of such riles. The following features, however, are characteristic of pleural rales: They are always localized, are audible over but one lung, are unaltered by coughing, unattended with expectoration, and strike the ear as being distinctly superficial. "Intrapleural moist riles do not require actual inflammation of the pleurte for their production." Alterations in the nature of a pleural exudate doubtless contribute toward the production of riles simulating other types previously described. (See also Pleural Friction-sound, below.) Indeterminate Rale. — Under this head should be considered all other rales not included ia the foregoiag classification, and, generally speaking, they may be said to consist of crackhng, grumbling, bubbling, and splashing sounds, that appear at first to be in part moist, partially dry, and heard during the acts both of inspiration and of expiration. These indeterminate riles are extremely frequent dxu-ing the later stages of pulmonary tubercu- losis, and are also a more common symptom in complicated lobar pneu- monia, pulmonary abscess, and pulmonary gangrene. Friction-sounds. — ^These are induced through pleuritic inflammation, and their significance was described by Honor6 as early as 1819. The physiologic action of the pleurae consists in a gentle gliding of the two layers, which is dependent in part upon lubrication of the pleurae by a serous secre- tion. The plem-al friction-sound is heard when inflammatory or other changes of sufficient gravity have taken place in the pleurae, and have either roughened its surface or altered the character of the fluid which lubricates these surfaces; as a consequence, during the acts of respiration the dry, roughened surface gives rise to a rubbing, more or less grating, and crackling sound. Pleural friction murmurs are heard distinctly during inspiration, and it is possible for several friction-sounds of varying duration to be present, wMch gives the impression to the hstener's ear that the sound is interrupted. The pleural friction murmur is characteristic of the early stage of acute pleurisy, disappears during the stage of exudate, and frequently reappears following absorption or removal of the exudate by artificial means. In selected cases of acute pleurisy the diagnosis of a friction murmur is further substantiated by the detection of a friction fremitus by palpating over the area of greatest intensity of soimd. Splashing Sound (Succussion Splash). — ^The method by which such sounds are produced is termed succussion, and consists in shaking the patient while the ear is kept in direct contact with the chest-wall or the abdominal wall. (See Fig. 55.) The succussion sound may also be utilized in the diagnosis of diseases of the stoftiach (dilatation) and in intestinal obstruc- tion. It is practically always possible to elicit a splashing sound in the case of pyopneumothorax and of hydropneumothorax. This sound is said by some observers to be audible over a large pulmonary cavity. The 73 DISEASES OF THE BRONCHI, LUNGS, AND PLEUKA. splashing sound, when heard over the upper portion of the chest, is pathognomonic of either pyopneumothorax or pneumopericardium, the serous sacs involved containing a variable quantity of fluid. Cases have repeatedly been seen in which a distinct splashing sound was audible over the base of the chest in those suffering from subdiaphragmatic abscess (p. 595). A splashing sound present over the base of the chest, and particularly over the area of the stomach, is somewhat common in the negro. Succussion splash is a common sign in pneumothorax and in dilatation of the stomach, and it may rarely be encountered in connec- tion with other conditions. The following table will set forth the possible causes of this sign when the sound is produced within the layers of the diaphragm or within the thorax: 1. Hydropneumothorax. 9. Duodenal ulcer (perforating the dia- 2. Pyopneumothorax. phragm and pleura). 3. Hemopneumothorax. 10. Hepatic abscess (perforating the dia- 4. Subdiaphragmatic abscess, infected by phragm and pleura). the Bacillus coli communis. 11. Cancer of the esophagus (perforating 5. Pyopneumopericardium. the pleura). 6. Large pulmonary cavity. 12. Traumatism with perforation of the 7. Pleural effusion, infected by Bacillus pleura. coli communis. 13. Diaphragmatic hernia. 8. Gastric ulcer (perforating the dia- 14. Infection of pleura by Bacillus aero- phragm and pleura). genes capsulatus. (See also p. 506.) Metallic (Amphoric) Tinkle. — A peculiar tinkling sound displaying an initial amphoric quality, and heard over large cavities having a smooth inner surface. The following serves to explain this sound in a pulmonary cavity: Given a cavity of fair size with smooth walls, partially filled with liquid, and where the bronchus communicating with such cavity opens beneath the surface of the liquid: air entering frOm the bronchus when passing through the liquid produces an explosion or bubble, which, owing to the smooth cavity wall, is transmitted to the ear as a metallic tinkle. This sound is also believed to be produced by vibrations of viscid and semi- liquid substances contained within a cavity. The metallic tinkle is heard oftenest during inspiration, and may be produced by forced inspiration, speaking, coughing, and laughing. It is also heard in pyopneumothorax (see p. 164), in which conditions it is frequently heard following the suc- cussion splash which is produced by shaking the patient. (See p. 164.) Grunt. — ^The act of expiration may be accompanied by a distinct grunt- ing sound, which in well-marked eases may be audible at some distance from the patient's chest, although it is usually elicited by placing the ear over the affected side. This sound is fairly characteristic of the stage of consolida- tion in lobar pneumonia. Egophony. — Egophony is a variety of vocal resonance in which the sounds resemble the bleating of a goat. It is heard usually when there is a thin layer of fluid between the lung and the chest-wall. The most common seat of its production is at the angle of the scapula in cases of pleural effusion. It is also heard over superficial areas of collapse of the lung, and occasionally in cases of croupous pneumonia. Compensatory Emphysema. — Whenever a portion of the once healthy lung has become incapacitated from any cause, its fellow and remaining healthy portions of the same lung are forced to do extra work. In auscul- tating over portions of compensating lung the vesicular element is exagger- ated, and the sound obtained closely resembles that characteristic of the respiratory murmur of children. When the compensating lung is in close THE X-RAY EVIDENCE OF DISEASES OF THE BRONCHI, ETC. 73 proximity with a bronchus, the breathing is slightly more exaggerated, and is referred to as puerile respiration. This murmur, however, is usually detected over areas where bronchovesicular breathing is normally present. Voice Sounds in Health.— By applying the ear or the stethoscope to the chest of a patient and directing him to turn his face away from the examiner and to speak in an ordinary tone of voice, counting one, two, three, a breezy noise is heard, but articular sound is absent. This sound is obtained over areas where only vesicular breathing is heard. Voice-sounds in health are mfiuenced, first, by the character of the patient's voice, and, secondly, by the thickness of the chest-wall. The spoken voice apparently creates more and more sound as the listener approaches a large bronchus. The sounds heard over the lung have a similar significance to the vibrations transmitted from the larynx, trachea, bronchial air-columns, and substance of the lung and chest to the exaniiner's hand when palpating the chest. Vocal resonance consists of a form of vibrations that are appreciable only by the auditory sense. The peculiarities of the voice-sound and its relation to disease will be discussed at length imder each pathologic condition in which they form one of the physical signs. (See Pneumonia, Pulmonary Abscess, Tuberculosis.) THE X-RAY EVIDENCE OF DISEASES OF THE BRONCHI, LUNGS, PLEURA, AND DIAPHRAGM. By G. E. Pfahler, M.D. General Remarks. — In general, the x-rays are absorbed by the tissues through which they pass in proportion to their density and thickness, and therefore will cast corresponding shadows upon the fluorescent screen or photographic plate. Any disease that will vary the density, outline, or position of tissues or organs can be demonstrated; likewise any disease which wiU modify the movements of an organ. The shadows cast upon the plate or screen in any instance will vary much with the position of the tube in relation to the location of the lesion. There- fore, in order that the truest picture of the disease be obtained, it is important that the Rontgenologist have some general information as to the probable character and location of the disease preceding the examination. Like- wise, so far as possible, the a;-ray evidence must be interpreted in the light of the physical signs and clinical history. The most transparent tissue of the body is the lung. Disease may increase this transparence or render it less transparent. Any condition which will increase the air-content of the lungs (asthma, emphysema) or decrease the thickness of the chest-walls (emaciation) will render them more trans- parent. Any condition which will diminish the air-content of the lungs (con- solidations, neoplasms, etc.) or increase the thickness of the chest-wall (great muscular development, fat, edema, tumors) will decrease this transparency. DISEASES WHICH INCREASE THE TRANSPARENCY ON THE LUNG. l^mphysema. — ^The increase in transparency is marked unless ac- companied by edema or congestion. The interspaces are wider, the dia- phragm lower, and its movement less. Chronic asthma will, of course, give a similar appearance because of a secondary emphysema. 74 DISEASES OF THE BRONCHI, LUNGS, AND PLEURA. DISEASES WHICH DECREASE THE TRANSPARENCY OF THE LUNG. Pneumonia, — In a typical lobar pneumonia the entire affected area presents a dense and almost uniform shadow, which is rather sharply outlined. At times, the consolidated area is not sharply defined, or there may be some extension of the process or congestion in the neighboring lung tissue. At the beginning of the disease there is usually a faint shadow of consoli- dation in the region of the large bronchi. In a few hours, however, the shadow may extend over the entire lobe or lung and become absolutely and uniformly dense. This extension is usually from the root of the lung, but it may be from the periphery. When these early shadows are obtained, the physical signs may be entirely absent, because centrally located. When complete consoUdation has taken place, the density of the shadow may be so great as to obliterate the outlines of the ribs. Ordinarily, how- ever, the consolidated area is sufficiently transparent to make the ribs visible, and this shadow is not uniformly dense. At the time of the crisis the consolidated area increases in transparency, usually beginning at the hilus (Rieder and Steyrer), or diffusely (v. Jaksch and Ratky). This increase in transparency keeps pace with the physical signs, but even after all physical signs disappear, shadows may be found, indicating incomplete resolution lasting several weeks (de la Camp) . When such shadows are found, one must think of a recurrence, chronic pneumonia, tuberculosis, empyema, abscess, gangrene, and hydatid disease, though ordinarily they disappear without any further clinical evidence. I/Ocali^ed empyema will usually ^ve a dense, homogeneous shadow, with sharp outlines, which do not follow the outline of a pleural effusion. Abscess and gangrene give very similar pictures, and neither one can be definitely differentiated by the a:-ray evidence alone from tuber- culosis. When a cavity has formed and the evidence is weighed with the clinical findings, a diagnosis can be made and the disease definitely located if operation seems advisable. Adhesions to the pleura, diaphragm, or pericardium, which not in- frequently follow pneumonia, and which may interfere with the free move- ment of the diaphragm or heart, can be demonstrated upon the fluorescent screen and the photographic plate. Bronchopneumonia gives, as one would expect, shadows of smaller areas of consolidation, and in different parts of the same lung or both lungs. These shadows are less dense and more mottled. Miliary tuberculosis may give a picture similar to that of broncho- pneumonia. Tuberculosis can be demonstrated in the lungs because the normal air-space is replaced by a more or less solid substance, which casts a denser shadow upon the fluorescent screen or photographic plate, and the disease can be demonstrated as early as such replacement occurs. Under favorable conditions tubercular deposits an eighth to a quarter of an inch in diameter can be shown, and, as a rule, the disease can be demonstrated before definite physical signs manifest themselves. In contradistinction to the large and dense shadow cast in lobar pneumonia, in tuberculosis we have minute shadows, which may coalesce or overlie one another, and give a large area of the lung a mottled appear- ance. We seldom have the degree of density nor the uniformity seen in lobar pneumonia. THE DIAPHRAGM. 75 In early cases this mottled appearance is most likely to be found at the apices, and usually more on one side than the other, but it is often found early along the inner border or in the axillary region. As a rule, the disease is more extensive than is indicated by the physical signs. This is due to the fact that the deeper or centrally located lesions give less definite or no physical signs, while the shadows cast are equally as strong as the peripheral lesions. One must be cautious in interpreting the general increase in shadow at the apices as tuberculosis, for an increase in the thickness of the overlying tissue on one side (muscle, fat, enlarged supraclavicular glands) or a lack of expansion (therefore, lack of air) may give a similar appearance. In such instances the shadows are not mottled, and in the lack of expansion it is Ukely to be bilateral. l^nlarged bronchial glands give isolated, rather dense, round or oval shadows in the region of the large bronchi. This examination is especially important in children when tuberculosis is suspected from the clinical symptoms, even though the physical signs are absent. One must not misinterpret the radiating, rather large shadows in the region of the large bronchi, which are produced by the large blood-vessels. Chronic Tuberculosis. — ^The infiltrations of chronic tuberculosis can be clearly shown. As a rule, the more chronic the process, the more dense wiU be the shadow of lesions of similar size and the more clearly outlined (partly because of the surrounding compensatory emphysema). In the fibroid variety one sees the shadows extending radially rather than in an irregular mottled fashion. Cavities are recognized (when not filled with fluid) by their increased transparency, and consist usually of a light area surrounded by a dark wall of consolidation. Cavities the size of a pea have been recognized. Bronchiectasis may be demonstrated when the cavities are empty or only partially filled with fluid, and especially when they can be found fUled (dark area) in one instance and empty (light area) in another. Their transparency wiU be similar to tuberculous cavities, but the amount of surrounding shadow will depend upon the accompanying disease. Syphilis of the lung has been demonstrated in a few instances, but the appearances are similar to those of tuberculosis. These appearances become important only when the cUnical history is that of syphilis rather than of tuberculosis. Anthracosis ^ves a similar appearance in many respects to that of fibroid phthisis, but a very much more dense shadow. Neoplasms of the lung can, of course, be demonstrated, because there is a replacement of the transparent air-space by solid tissue. If this is a metastatic process and occurs in small multiple lesions, the appearance will be similar to tuberculosis, but the lesions seem to radiate more from the mediastinal region, and each lesion seems to have a more definite outline. When the lesion is large, it is more dense, more homogeneous in its shadow, and more clearly outUned than in tuberculosis. THE DIAPHRAGM. The Rontgen rays surely supersede all other methods in the examination of the diaphragm. Variations will occur in the outline, the position, and the movements. Here both a Rontgenoscopic and a Rontgenographic examination are useful. The normal position and movements of the diaphragm vary very much, 76 DISEASES OF THE BRONCHI, LUNGS, AND PLBUEA. and statements on this subject must be accepted as general and not taken as a standard. Measured orthodiagraphically in a healthy young subject with firm abdominal walls, anteriorly the right side is on a level with the upper border of the fifth rib, and the left side with the lower border of the fifth rib (Jamin). In quiet breathing the normal range of movement is 1 to 2 centimeters. With deep inspiration the diaphragm moves downward 2 to 4 centimeters. Practically, in healthy subjects, both sides should move equally, and therefore a difference in the degree of movement on the two sides will be important diagnostic evidence. Barly tuberculosis is Ukely to limit the degree of movement on the affected side (Williams' sign). Such limitation of the movement of the dia^ phragm on one side may be due to other conditions, such as painful affections above or below the diaphragm. The pain of pleurisy will therefore limit the movements of the diaphragm, and in the absence of physical signs, or when the pain is indefinite, it may be valuable evidence of a diaphragmatic pleurisy. Pleuritic adhesions will limit the movements of the diaphragm, but this limitation is likely to be localized, and is evidenced by humps or peaks in the upper curve. Hydatid cyst, if located on the upper surface of the liver, will give a localized elevation to the curve of the diaphragm, which is smooth in out- line. Subdiaphragmatic abscess will give an abnormally high position of the diaphragm on the affected side, will usually render it motionless (on account of pain), and will likely modify its contour. Diaphragmatic Hernia. — ^In this condition there is an area of ab- normal transparency above the line of the diaphragm in which the lung structure is absent, if large. If small, the overl3dng lung will cast some shadow. This condition must be differentiated from a localized pneumo- thorax, from a large cavity, and from eventration of the diaphragm. If the patient "strains" with the abdominal muscles, as if at stool, holding the breath, a hernia will increase, while a pneumothorax, a cavity, and eventration of the diaphragm will remain stationary. Further, by giving bismuth mixture one may be able to trace the food through the hernia. Eventratio diaphragmatica, or congenital atrophy of the dia- phragm, gives it a remarkably high position, uniformity in its outline, with hmitation or absence in movement. The heart will be displaced. In these differentiations, as in all others, much will depend upon the skill and resourcefulness of the Rontgenologist in eliminating error and arriving at a correct diagnosis. THE PLEURA. The normal pleura is not demonstrable by the rays. Thickened pleura will produce a shadow in proportion to its thick- ness and extent. When very thick, 2 to 3 cm., it may be confused with a new-growth. When a new-growth is single, if viewed from all sides, it should give a more definite outline. If multiple, it should give a nodular and less uniform appearance. The thickened pleura can usually be differentiated from the shadow cast by tuberculosis of the lung because it is more homo- geneous and fades gradually at its borders. If comphcated by overlying tuberculosis, it cannot be differentiated. Adherent pleura is recognized by its interference with the move- ments of the diaphragm or a portion of the lung, or when adherent to the pericardium, may interfere with the action of the heart. ' THE SPUTUM. 77 Pleural efiiision produces evidences according to its extent, its character, and the condition of the overlying tissue. If the lungs are con- gested, or the chest-walls thick, it is more difficult to recognize. Generally it can be demonstrated by the homogeneous shadow which it casts, which changes its level with a change in position, and by its displacement of the heart and diaphragm. Pneumotliorax is usually easily recognized by the very transparent area, together with the shadow of the visceral pleura and compressed lung, which is seen to be separated from the chest-wall; also by the displacement of the mediastinal organs. Localized or interlobular pneumothorax requires great care in making a diagnosis, but usually this can be done. Pyopneumotliorax gives perhaps the most striking picture observed in diseases of the chest. One sees the very transparent area of the pneumo- thorax, with the thickened pleura or compressed lung on the inner side and the level of the fluid below, which waves up and down with each movement of the diaphragm. When one shakes the patient, a distinct splash can be seen, fluoroscopically. THE SPUTUM. COLLECTION. In collecting the sputum for examination the ordinary vaselin bottle forms the most convenient receptacle. The bottle shoidd, of course, be carefully cleansed to remove the fat-globules, and should be sterilized, if possible. This should be placed at the patient's bedside or in his room, so that when he coughs in the morning he may expectorate directly into the bottle. After the bottle is half full, it should be corked tightly and wrapped in heavy paper, upon which the name of the patient should be written. Caution! Do not add water. CHARACTERISTICS OF THE SPUTUM IN DISEASE. Quantity. — ^The quantity of sputum ejected in pathologic conditions during twenty-four hours varies between a few cubic centimeters to 500 or even 1000 c.c, and bears a direct relation to the nature of the disease in ques- tion. Copious expectoration occurs in pulmonary hemorrhage, pulmonary edema, bronchiectasis, tuberculosis, rupture of an abscess into the lung (diaphragmatic, hepatic, mediastinal), and rarely in pleural effusions. The so-called albuminous sputum, which is associated with pulmonary gangrene, is often profuse. In acute inflammatory processes involving the lung the sputum is generally scanty. Odor. — ^The odor of the sputum can be regarded as characteristic in but two conditions — pulmonary gangrene and putrid bronchitis; in these diseases it has an offensive odor. At times the sputum of bronchiectasis gives off an unpleasant odor resembling that of gangrene. Sputum having a sweetish odor is characteristic of pulmonary ulceration, bronchitis, and empyema. An odor resembling that of rancid cheese suggests the addi- tion of tyrosin, which results only when extraneous pus enters the bron- chial tract. Fluidity and Tenacity. — ^The density of the sputum will be found to correspond more or less closely to the quantity expectorated. The 78 DISEASES OF THE BRONCHI, LUNGS, AND PLEURA. density varies from that of a watery fluid to that of a gelatinous mass. Spu- tum placed in a cylindric glass will be found, upon standing, to separate into strata, there being a superior or frothy layer, a clear liquid layer, a third layer containing floccuh and particles of mucus, and an inferior stratum of rather dense, ropy material, often containing pus and blood. A creamy sputum is not infrequently seen. A liquid sputum is significant of edema of the lungs, tuberculous laryngitis, the early stage of pulmonary tubercu- losis, or the perforation of an empyema or of a diaphragmatic or hepatic abscess. It also occurs in pulmonary abscess and gangrene. "Currant-jelly sputum" suggests malignancy, and "prune-juice sputum" appears where blood is derived from an edematous lung, as in adynamic lobar pneumonia. Specific Gravity. — ^The specific gravity of sputum is deperident upon the general character of the expectoration, mucous sputum having a specific gravity of 1.003 to 1.010; purulent and bloody specimens, one between 1.014 and 1.025, whereas highly bloody sputum may reach 1.035. Reaction. — Normal sputum has an alkaline reaction. Color. — ^The sputum varies in color from that of a perfectly clear, transparent fluid, through the successive shades of gray, yellow, amber, orange, olive green, red, chocolate, and black. When the expectoration is entirely mucoid, it is colorless and nearly transparent. Leukocytes render the sputum opalescent or turbid, according to the number of cells present; and, from the same cause, the color is first white, then yellow, and finally of a greenish hue. The presence of bile-pigments gives rise to a green sputum. A growth of bacteria (Bacillus pyocyaneus) may be accountable for a green color, and in cases of amebic abscess, whether hepatic or pulmonary, the sputum is chocolate colored. In paragonimus infection the sputum resembles anchovy sauce in appearance. Black Sputum. — ^The sputum becomes gray after the inhalation of particles of carbon, whereas the sputum of coal-miners and of those residing in the mining districts is often dark and at times black, due to the presence of coal-dust (Plate I). Particles of iron may give the sputum a yellow or red color. Bloody Sputum. — Sputum tinged with blood and studded with minute air-bubbles — "rusty sputum" — ^is characteristic of lobar pneumonia. Blood gives a red color to the sputum, varying in intensity with the amount present. It is _ most often encountered in pulmonary congestion and ulceration (phthisis). Hemorrhagic sputum may result from cardiac insufficiency. Whenever the blood is expectorated as soon as it escapes from the vessels, it is of a bright-red color. Bloody and dark-brown sputa are also observed in pulmonary abscess and in gangrene of the lung. The various tjrpes of hemoptysis, together with their clinical classifications as to source, excit- ing factors, etc., are given in the accompanying table: Dub to Pathologic Changes in the Lungs. 1. Phthisis pulmonalis. 2. Pneumonoooniosis : Metal workers lung, Coal miners lung, Stonemasons lung, Plaster workers lung. 3. Cardiac disease, especially mitral stenosis. 4. Violent coughing: Whooping cough, Asthma, Bronchitis, Cough accompanied by vomiting. Emphysema, 5. Traumatism: Blows upon the chest-wall, Fractured rib, Exploratory punctures. CHARACTERISTICS OF THE SPtJTXnVI IN DISEASE. 79 C. Lobar pneumonia (slight) : Bronchopneumonia (slight), Abscess, Septic pneumonia (slight). Gangrene, Pulmonary emboli. Pulmonary thrombosis. Hypostatic congestion, 7. New growths of the lung: Satrcoma, Carcinoma. 8. Sporotrichosis of the liing: Aspergillosis, Actinomycosis, Streptothoracosis. 9. Aortic aneurysm by pressure on and by ruptvu-e into the bronchial tract. 10. Parasites: Hydatid cyst, Primary amebic abscess, Hepatic amebic abscess (bursting Filiariasis, through the diaphragm into the Paxongonimus Westermanni (tropical lu^g) > hemoptysis) . Due to Ch-^xges in the Bronchioles, Bronchi, or Trachea. 11. Acute bronchitis, Bronchiectasis, Bronchorrhea, Tracheobronchitis. 12. Ulceration of the trachea. Lymphosarcoma, Ulceration of a bronchus. Esophageal or other neoplasm, Livasion of a bronchus by a mediastinal sarcoma. Due to Changes in the Larynx: 13. Acute laryngitis. Postdiphtheritic ulcer. Tuberculous ulceration. Typhoid ulcer (rare). Syphilitic ulceration. Traumatism, Epithelioma, Variolous ulceration (rare). Sarcoma, Leprosy of the larynx (rare). Due to Hemic Changes: 14. Purpura, Lymphatic leukemia. Scurvy, Pernicious anemia, Splenomedullary leukemia, Hodgkin's disease. Hemophilia, Uncommon Causes of Hemopttsis: 15. Interstitial nephritis. Vicarious menstruation. Arteriosclerosis, Varicose veins of pharjmx. Mucous Sputum. — ^This variety of sputum is clear, sticky, tough, and, during the early stage of bronchitis, scant in quantity. In the latter stage of bronchitis pus-cells are added, which render the sputum more copious and ^ve it a yellowish or a greenish color. Mucopurulent Sputtun. — ^This is a variety of sputum seen in many forms of pulmonary disease. It is of chnical value in pulmonary tuber- culosis, where, in the event of cavity formation, minute ragged clumps of mucopus, which are intimately surroimded by mucus, may be seen. Nummular Sputum. — In this variety coin-Uke masses, often regarded as characteristic of cavity formation when first expectorated, float upon the surface, but the sputum may contain grajTsh-white masses and round or irregular particles varjdng in size from that of a pin's point to that of a millet-seed (caseous particles). These masses are usually precipitated from the liquid portions of the sputum, collecting at the bottom. Serous Sputum. — A purely serous sputum is significant of edema of the lungs, and contains but few, if any, red blood-cells. When shaken, serous sputum displavs a soapy froth having a faint pink hue when it is mixed with blood. 80 DISEASES OF THE BBONCHI, LUNGS, AND PLETJRA. Albuminous sputum is seen in pu monary t^bercul^JJ^^te bronchitis, lobar pneumonia, and bronchiectasis. ,\>^sUy a^^^mous sputum is always suggestive of pulmonary tuberculosis, even m the ab sence of tubercle bacilli and of definite physical signs. Fig. 30. FlBRINODS Cast. Bronchial MICROSCOPIC STUDY OF THE SPUTUM. Organised Constituents— Fibrinous Coagula.— During the course of certain pathologic conditions an exudate is deposited in the smaller bronchi, and after undergoing degenerative changes, this exudate results in the formation of a complete cast of a small bronchus. During the act of coughing a small amount of this coagulum is dislodged, and appears' in the sputum as a gray, white, reddish-yellow, ma- hogany, or bloody particle. Detection. — Fibrinous casts may be recog- nized by placing suspicious particles of the fresh sputum between two shdes, and making rather firm pressure upon the upper slide. Fibrinous coagula are clearly seen when brought under a two-thirds inch objective (Fig. 30) . Significance. — Fibrinous casts are found in the sputum of fibrinous bronchitis, croupous pneumonia as the stage of resolution ap- proaches, and in the presence of a diphtheric process in the finer bronchi. Bronchial Spirals. — These bodies resemble bronchial casts (Fig. 31). Detecfeon.— Use the same technic directed for the detection of bronchial casts. At times it will be found necessary to use a high-power objective (one-sixth to one-eighth). Spirals ap- pear as faint, translucent, elongated masses. A delicate white fiber runs longitudinally through the center of each spiral. Leukocytes, epithelial cells, Charcot-Leyden crystals, and, rarely, erythrocytes are entangled in the spiral mass. Spirals are common in the sputum of asthma. They are seen in croupous pneumonia, acute bronchitis, chronic bronchitis, pulmonary tuberculosis, and valvular heart disease. Spirals are sug- gestive of a catarrhal process in the bronchi. Elastic Tissue. — Fibers of elastic tissue may occur in the sputum as single threads, arranged in a more or less per- fect alveolar series, or, as is most usual, in small bundles. They are demon- strated in the manner described for the detection of fibrinous coagula, a one-eighth inch objective being used. Collect the fibrinous plugs from the sputum, place them in a solution of sodium hydroxid, and boil the soda Fig. 31. — Sputum from a Case of Asthma, Showing Curschmann Spirals, Char- cot-Leyden Crystals, Leukocytes, AND Numerous Free Eosinophile Granules (Jakob). MICROSCOPIC STUDY OF THE SPUTUM. 81 solution and its contained sputum until a gelatinous mass results. Add four times the total quantity of water; place the mixture in a conic glass, and allow it to stand for several hours. Centrifugalize the sediment, and place a portion of the second sediment thus obtained under a one-eighth or one- twelfth inch oil-immersion objective, when elastic fibers will be readily- detected (Fig. 32). The presence of elastic fibers in the sputum indicates the existence of a destructive process in the lung. The true significance of these changes, however, is indicated only when they appear in the so-called alveolar arrangement, as they do in case of pulmonary cavity. Elastic fibers are rarely found in abscess of the lung, bronchiectasis, and pneumonia. Animal Parasites of the l,ung. — Paragonimus Westermanii.— This parasite has confined itself largely to Japan, Formosa, the Philippines, and Korea, although cases have been reported from other eastern countries! I . Fig. 32. — Fibers of Elastic Tissue from Sputum in a Case of Pulmonary Tuberculosis Ob- SERYEi) AT Pennsylvania Hospital (obj. B. and L. oQe-eighth) (Boston). Stiles and Hassall have recently recovered this parasite from the lungs of hogs raised in the United States, and MacKenzie has reported a case occurring in man from Portland, Oregon. Sputum. — ^The sputum looks bloody, but the color is due to the presence of the ova of the fluke, although more or less altered blood-corpuscles may be present. The sputum may closely resemble that of lobar pneumonia in color. Detection. — ^Place a portion of the bloody sputum upon a slide, apply a coyer-glass, and study under a one-fifth or one-eighth inch objective. The color of the sputum is dependent upon the presence of numerous ova and red blood-corpuscles. The ova are oval in outline and are furnished with a distinct lid. 82 DISEASES OF THE BRONCHI, LUNGS, AND PLEURA. Trichomonas. — This type of parasite (Fig. 343) has been found in the sputum of pulmonary gangrene and in that from pus-cavities. The Balantidium coli (Fig. 345) has been known to invade the respira- tory tract of persons residing in the tropics, but the Uterature on the subject appears to contain but few authentic reports. Bilharzia. — There are numerous rehable records of cases in which the ova of the Schistosomum hsematobium have been found in the sputum. (See Hematuria.) Amoeba Coli (Entamoeba Histolytica). — The ameba appears in the sputum when an amebic abscess of the lung is evacuated into the bronchial tract, or when an amebic abscess of the liver has ruptured through the diaphragm and communicated with a bronchus. (See Amebic Dysentery.) The sputum may at first be bloody, but later it may assume a yellowish or pearl-like color. Many epithelial cells are always present, and either pul- monary or hepatic tissue may at times be seen. Filaria. — Filaria embryos have been known to appear in the sputum of persons affected with filariasis, and it was formerly believed that there was a special type of parasite concerned (Filaria bronchialis) when these parasites were found in the sputum. It is now known that the embryo filarise retreat to the blood-vessels of the lung in the interval of their periodicity in the blood-current. In a concurrent de- structive lung disease these parasites might be found in the sputum. Taenia Echinococcus. — When- ever cysts of the dog tape-worm com- municate with the respiratory tract, both booklets and scolices of the parasite (Fig. 361) appear in the sputum. Ascarides. — Both the adult para- sites and their ova have been found in the sputum (Fig. 357). Fungi. — Among the fungi that are to be regarded as of pathologic interest, the most important are the actinomyces and the Aspergillus fumigatus. Actinomycosis. — ^The detection of small granules and thread-like particles (mycelia) (Fig. 33) in the sputum verifies the diagnosis of actino- mycosis of the respiratory tract. Actinomycosis may also involve the buccal cavity, in which case the ray-fungus is found in the sputum. Actino- mycosis of the pleurae usually causes a perforation of the chest-wall, and pus containing the fungus escapes externally. Aspergillosis. — Foreign observers have found the Aspergillus fumigatus in the sputum of those suffering from pneumomycosis. Aspergillus is recognized in the sputum by the detection of many thread-like particles (myceUa) (Fig. 331). It is not uncommon to find sputum secondarily infected with the Aspergillus niger (Fig. 331), and it is difficult to distinguish microscopically between the mycelium of this fungus and that of Asper- gillus fumigatus. This difficulty may be overcome by making a cultural study of these two fungi, when their identity will be readily discerned. The Mucor corymbifer is also encountered in the sputum, and, in addition, many different molds may develop in the sputum after it has been exposed to the air. Fig. 33. — Actinomyces (after von Jaksch). PLATE I A. Sputum showing tubercle bacilli stained with carbolfuchsin and Gabbet's methylene blue solution (obj. B. and L. one-twelfth oil-immersion). B. Sputum of anthi-acosis, showing particles of coal-dust stained with methylene-blu( (obj. Spencer one-twelftli oil-immei-sion). (Boston.) MICROSCOPIC STUDY OF THE SPUTUM. 83 •^^■Cteria. — Numerous species of bacteria are present in the sputum, although in a comparatively small number of instances a definite micro- organism will be found associated with a certain disease. The streptococcus, a large diplococcus, the pneumococcus. Bacillus typhosus, Bacillus coli communis, Friedlander's bacillus, Bacillus tuberculosis, and the streptothrix deserve special mention. Microscopic Study of the Bacteria of the Sputum.— Select from the sputum small caseous or bloody particles, place them upon a microscopic shde, crush, and_ spread into a thin layer. All sputa should be stained for the tubercle bacillus, and special stains are also necessary when searching for certain specific bacteria. As a rule, however, the method employed for staining the tubercle bacillus will be found also to stain satisfactorily many other microorganisms. Staining for the Tubercle Bacillus.— 1. Add a few drops of carbol- fuchsin (5 per cent, phenol, 90 parts; saturated alcohohc solution of fuchsin, 10 parts) to the specimen, and hold it above the flame until the staining solution begins to steam. Let this stain act for five minutes. 2. Wash in water, holding the forceps in such a manner that the stream strikes the shde near one end and then flows over the specimen. 3. Without drying, add to the specimen a few drops of Gabbett's methy- lene-blue solution (methylene-blue, 2 parts; solution of sulphuric acid (25 per cent.), 100 parts), and allow it to stand for two minutes; then wash in water and dry over the flame. In searching for the diplococcus and organisms other than the tubercle bacillus equally satisfactory results may be obtained by staining with Loffler's alkaline methylene-blue for thirty seconds, washing, and drying. Caution! Whenever the presence of tubercle bacilli in the sputum is suspected, the following method for their detection is to be recommended: Place the sputum in an ordinary vaselin bottle, tie three or four thicknesses of gauze tightly over the mouth of the bottle, to prevent dust from entering it. Allow it to stand for several days, and then examine for the tubercle bacillus. A still more satisfactory method is to smear the caseous particles of the sputum on shdes and dry in the air. Fix either by passing directly through the flame or by keeping it upon a hot stage for from twenty minutes to one- half hour. Stain the fixed specimen by immersing it in a weak solution of carbolfuchsin (carbolfuchsin, ^ dram; water, 2 ounces) for twenty-four hours. Differentiation. — Tubercle bacilli (Plate I) are to be differentiated from other acid-fast bacilli (by acid-fast bacilli are meant those that do not decolorize readily by acids or by alcohol), viz., the grass bacillus, the butter bacillus of Rabinowitch, Bacillus leprae, and the smegma bacillus. Significance. — ^Tubercle bacilli, when found in the sputum, furnish con- clusive evidence of the existence of a tuberculous lesion along the course of the respiratory tract. Even a small ulceration of the bronchus may furnish a great number of bacilli, hence the presence of a profuse number of bacilli in a given sputum is no guide as to the extent of disease existing in the lung. Tuberculous laryngitis generally displays a large number of tubercle bacilli in the sputum, and the same is true of extensive ulceration and pulmonary cavities; nevertheless, a pulmonary cavity the result of tuberculosis may be present and no tubercle bacilli demonstrable in the sputum. This has been amply confirmed by us at autopsy. Influenza. — ^The sputum contains slender bacilli that stain readily by 84 DISEASES OF THE BRONCHI, LUNGS, AND PLEUBA. the ordinary anilin dyes. In order to cultivate the influenza bacillus, a special medium is necessary. Loffler's blood-serum will be found to serve well for this purpose, after the surface has been smeared with fresh blood. The clinical significance that attaches itself to the detection of the influenza bacillus is still of doubtful value in the minds of many clinicians. Diphtheria. — During the course of diphtheria the sputum often con- tains the diphtheria bacillus. Acute Bronchitis. — ^The sputum displays many desquamated epithelial cells, which represent the various forms common to the respiratory tract. Leukocytes are always present in small numbers, and red corpuscles may be found. Later in the course of acute bronchitis the sputum becomes abundant, turbid, and yellowish or greenish in color. Bacteriology. — ^The terms st'reptococcous bronchitis and staphylococcous bronchitis have been suggested for different types of the disease. In strep- tococcous infection the sputum contains innumerable streptococci, and when the form of infection is mild, it can be differentiated from a staphylococcic bronchitis only by a cultural study. Chronic Bronchitis. — If expectoration is profuse, that is, if the sputum is expectorated in mouthfuls, the condition is known as bronchorrhea. This sputum is yellowish or yellowish-green in color, the color depending upon the number of pus-cells present and the stage of degeneration of such cells. A profusion of bac- teria is present, but they bear no clinical significance to the type of bronchitis in question. Pnemnonia. — ^The characteristic sputum of this disease is to be seen during the early stage of consohdation in lobar pneumonia, at which time it is scanty and tinged with blood (rusty), highly tenacious, and does not flow from the side of the sputum-cup. Red corpuscles and leukocytes are Fig 34 _ t!v " present, and when stained with hematoxylin and '°EH's ■ BAciJLm''TN eosin or with a polychrome methylene-blue method, Pns^FROM ^PuLMON- show many eosinophiUc cells. Alveolar epithelial (Boston). cells are also found, and many of these contain pigment and oil-globules. Pneumococeus. — The pneumococcus is a small diplococcus that occurs in the sputum of lobar pneumonia, in which it is often the only organism present in great numbers. The pneumococcus is well stained by Loffler's methylene-blue solution, but its characteristic contour (lance shape) is better demonstrated by the Gram method of staining. When carefully stained, each coccus is seen to be surrounded by a narrow hyaline space, which is bounded by a faint mar- ginal band (capsule). Encapsulated diplococci are always detected with difficulty. They are also commonly seen in the sputum of healthy persons, and are pathologic only when present in dense aggregations. Bacillus of Friedldnder.— This bacillus appears in great numbers in the bloody sputum of persons suffering from lobar pneumonia when the disease IS due to the presence of this bacillus. This organism stains by the same methods given for the pneumococcus (Fig. 34). A number of encapsulated bacilli are also present in Fnedlander's pneumonia. These bacilli may enter the blood, and are to be found in the pus from abscesses and from inflamed joints complicating an attack of Friedlander's pneumonia. MICROSCOPIC STUDY OF THE SPUTUM. 85 Bronchial Asthma.— At first the sputum is scanty, clear, grayish, or rarely reddish in color. It is always frothy, and is characterized micro- scopically by the presence of small, yellowish or grayish particles, "bronchial spirals" (Curschmann's spirals), Charcot-Leyden crystals (Fig. 31), and leukocytes. Many of the leukocytes show a special affinity for basic dyes while the majority of them are decidedly eosinophilic. ' Bronchopneumonia.— The sputum of this disease is not characteristic, containing many different bacteria— the pneumococcus. Staphylococcus pyogenes, bacillus of Friedlander, Streptococcus pyogenes, Bacillus pyo- cyaneus, Bacillus typhosus, diphtheria bacillus, Micrococcus tetragenus, and the meningococcus. Pulmonary Abscess. — The fresh sputum from an abscess of the lung contains hematoidin crystals, fragments of lung tissue, and numerous crystals— cholesterin (Fig. 265), fatty acid, etc. Fibers of elastic tissue are not unusually present (Fig. 32). Pulmonary Gaiigrene and Putrid Bronchitis. — The sputum of gan- grene, when placed in a conic glass and allowed to stand for several hours, separates into strata: the inferior stratum is grayish yellow or brown and contains pus, small particles of a brown or greenish tint that vary in size from that of a millet-seed to that of a kernel of com, and lung tissue. This sediment contains triple phosphates, leucin and tyrosin (Fig. 263, p. 658), and hematoidin crystals. Pus-cells and leukocytes are abundant, and the masses detected by the naked eye are found to be composed principally of pigment. Elastic fibers, oil-droplets, crystals of fatty acids, and bacteria (Lepto- thrix pulmonahs, which stains bluish with Lugol's iodin solution) are pres- ent. The detection of particles of pulmonary tissue (elastic tissue) is the distinguishing feature between gangrene, where it is present, and putrid bronchitis. The middle stratum of the sputum is transparent, and in it are sus- pended particles of mucus, whQe the superior stratum is usually of a dirty yellow color and is covered with a decided froth. Pulmonary Tuberculosis. — The sputum from a case of pulmonary tuberculosis is but fairly characteristic. Incipient Phthisis. — In this condition the sputum is scanty, grayish- yellow or whitish in color, frothy, and moderately tenacious. The larger portion is expectorated in the morning. As the disease advances the quan- tity increases, becoming copious and containing coin-like masses (nummular sputum) after cavity formation has taken place. The detection of the tubercle bacillus is the only positive evidence of the existence of tuberculosis. Spirochsetse have been found in bloody sputum, although they probably have no connection with tuberculosis. Hemorrhagic sputum may form a rather dense clot, and the presence of even a small quantity of blood colors the sputum. Dark sputum is occa- sionally seen, and in cases in which the hemorrhage is severe, it is often difficult to ascertain its origin. The accompanying table, modified from Boston, shows the points of differentiation between pulmonary and gastric hemorrhage: Pulmonary Hemorrhage. Gastric Hemorrhage. 1. Evidence of preexisting pulmonary 1. Referable to the throat, stomach, liver, disease. heart', or develops in females near the time of puberty. 86 DISEASES OP THE BBONCHI, LUNGS, AND PLEUBA. Pulmonary Hemorrhage. — (Continued.) Gastric Hemorrhage. — {Continued.) 2. Preceded by thoracic oppressions and 2. Preceded by giddiness, faintness, and a saline taste. nausea. 3. Blood ejected by coughing when 3. Blood ejected by vomiting or by clear- hemorrhage is small. ing the throat. 4. In profuse hemorrhage and when 4. Blood of gastric origin dark, as a rule; ejected immediately blood is arterial blood of pharyngeal origin, bright red. in color. 6. Alkaline reaction. 5. Gastric blood acid, pharyngeal blood alkaline, in reaction. 6. Blood mixed with particles of muco- 6. May contain undigested food. pus. 7. A pronounced beaded froth. 7. Froth less marked. 8. Microscopically, tubercle bacilli and 8. Microscopically, Sarcinse ventriculi, possibly fibers of elastic tissue. starch-granules, particles of food, and, in the case of carcinoma, large non- motile bacilli (Oppler-Boas) and, rarely, carcinomatous tissue. Heart Disease. — In organic heart disease the sputum may be blood- stained. Such sputum, however, is distinguished from that of pneumonia and other acute congestions of the lung by the presence of epithelial cells filled with yellowish pigment (hemosiderin) — the so-called heart-disease cells. Pnetomonokoniosis. — This is a deposition of inorganic substances in the bronchial mucous membrane, with the appearance of such particles in the sputum. Anthracosis. — Early in this disease, before the lung tissue has become seriously embarrassed by the deposit of dust, expectoration is slight, and takes place only upon rising and after a meal. When bronchitis is present, the sputum is copious in amount and contains large mucopurulent granules. Anthracotic sputum may present a variable degree of browning or an irregu- lar distribution of black pigment. The characteristic finding is small particles of coal-dust, which are readily detected under a one-fifth inch objective (Plate I). Chalicosis. — ^This is a condition in which the sputum contains small particles of silica, and is present in persons who are more or less constantly exposed to such dust. Siderosis. — ^The sputum in this condition resembles that of chronic bronchitis, although it may be brown or blackish. Alveolar epithehal cells and leukocytes are numerous, and brown or reddish pigment may be present. The addition of ammonium sulphid to sputum containing parti- cles of iron turns it a blackish color, and upon the addition of hydrochloric acid and potassium ferrocyanid, the color is further changed to a Prussian blue. Stycosis. — In this condition, which is most common in those working in plaster-of -Paris, about hme-kilns, etc., the sputum contains particles of lime. Cough and dyspnea are accompanied by free expectoration. It is more difficult to detect particles of lime than coal-dust, yet by careful focusing of the microscope it is usually possible to discover this fine pigment in the epithelial cells and leukocytes. Stonemason's lung is a condition that follows the inhalation of particles of stone, which are detected in the sputum by chemic reactions, such reac- tions being also applicable to the detection of particles of lime. A micro- scopic study should always be made before resorting to chemic analysis of such sputum. Generally speaking, the sputum of stonemason's limg is that seen in chronic bronchitis (p. 91). ACUTE BRONCHITIS. 87 CHEMIC STUDY OF THE SPUTUM. Organic Substances.— Proteids.— The sputa of pulmonary abscess, purulent bronchitis, croupous pneumonia, and cases in which many pus- cells are present contain peptone. Clinically, the detection of peptone in the sputum has thus far been found of questionable value. Serum-albumin. — An excess of serum-albumin is found in the sputum of pulmonary edema whenever the albuminous properties of the blood are expectorated (albuminous sputum). Sugar. — Glucose is rarely detected in the sputum. (See Glucose in Urine, p. 652.) Ferments and Fatty Acids. — Analysis for the ferments and fatty acids present in the sputum is a matter of chemic rather than of clinical value, and for the technic of this analysis the reader is referred to special works upon chemistry. DISEASES OF THE BRONCHI. General Remarks. — Inflammatory diseases of the bronchi and those of the lung are differentiated chiefly by the wide diversity in the physi- cal signs displayed by the two conditions. Bronchitis is an inflammation of the mucous membrane of the bronchi, either acute or chronic in character. The inflammatory process may attack any portion of the bronchial tree — the larger, medium, or even the smallest bronchial tubes. Inflammation of the bronchial mucous membrane may be acute or chronic in nature, and may be either primary (infectious) or secondary to diseases of the heart, liver, kidneys, and lungs. It is also a symptom of certain of the acute infections — e. g., measles, typhoid fever, and smaU-pox. (See Infectious Bronchitis, p. 90.) ACUTE BRONCHITIS. Pathologic Definition. — An acute disease characterized patho- logically by congestion of the bronchial mucous membrane, which becomes covered with mucus or mucopus. Later there are desquamation of the ciliated epitheUal cells, edema, and, in severe cases, infiltration of the mucosa with leukocytes. Exciting and Predisposing Factors. — In the majority of cases acute tracheobronchitis results from an inflammatory process that has extended from the upper air-passages, e. g., nares, pharynx, or larynx, and is secondary in nature. The bronchi may be the site of a primary acute catarrhal process, but such cases are by no means common. Mechanic, chemic, and biologic irritants that are known to act directly upon the bronchial mucous membrane may in themselves produce primary bronchitis. Among the predisposing factors are: (1) Age. — Bronchitis is most common at the extremes of life. (2) Lowered Vitality. — ^The debilitated are especially prone to this affection. (3) Occupation. — Those exposed to the inhalation of irritating dusts (lime, foundry dust, silicates) are predisposed to bronchitis. (4) Climate. — ^Those residing in sections where the temperature is known to fluctuate greatly within a short period are more susceptible to 88 DISEASES OF THE BRONCHI, LUNGS, AND PLEURA. the disease than are those living in sections having a more stable tempera- ture. Humidity has also been shown to exercise some influence upon the development of bronchitis. (5) Season.— The greater number of cases is seen during the fall and winter months, and at periods when colds are prevalent. Epidemics of any nature appear to increase the frequency of bronchitis, and this is es- pecially true of epidemics of influenza, measles, and scarlatina. (See Infectious Bronchitis, p. 90.) Acute bronchitis often develops as a com- pHcation of both acute infectious and chronic maladies. It is an almost constant feature of typhoid fever, small-pox, and certain other of the infec- tious diseases, and is a serious late complication of organic heart, liver, or kidney disease and the anemias. Principal Complaint. — The patient usually states that he has contracted a severe cold, and that the first symptoms recognized by him were repeated chilly sensations, sneezing, moderate coryza, sore throat, and hoarseness. In children there may be a history of one ormore con- vulsions at the onset. The patient declares that he is tired and indisposed. There is some soreness in the muscles of the back and limbs, and, at times, headache is present. When the attack is well developed, substernal soreness is a complaint, the patient often stating that there is a raw or burning sensation beneath the sternum upon deep inspiration; in the more severe cases substernal pain is present. Cough develops during the first few hours following the initial symptoms, and if severe, gives rise to intercostal soreness and aching, with soreness about the diaphragm. The character of the cough is quite significant, being at first harsh and non-productive, whereas later, i. e., on the second or third day, free expectoration occurs. There may be par- oxysms of coughing with or without expectoration, such paroxysms often being excited by a change of position— e. g., from sitting or standing to the recumbent posture, and upon rising after a night's rest. Thermic B'eatures. — The temperature is somewhat irregular, _ and may range between 100° and 101° F.; in severe types of infection it may reach 103° F. It is highly important that acute bronchitis be recognized when it develops as a complication of other febrile conditions, since it may cause an additional rise of temperature. Physical Signs. — Inspection. — The results of inspection are negative in adults, but in children rapid respirations are common. An examination of the larynx discloses the fact that the laryngeal mucous membrane is reddened and covered with an exudate. The fauces may also be congested. Percussion. — In the vast majority of cases percussion is negative. Slight impairment of resonance is rarely observed beneath the angles of the scapulae, and is present only when a large amount of mucus with proba- bly partial occlusion of the bronchi exists. This sign must not be confounded with a similar impairment due to an acute pneumonic process; a feature of importance in this connection is that in pneumonia the impairment of reso- nance is unilateral, whereas that due to acute bronchitis is bilateral. Auscultation. — ^The breath-sounds are increased in intensity, and over the anterior portion of the chest and near the apices the respiratory murmur may be harsh. Numerous r^les are heard over both the apices and over other portions of the lung; some are high-pitched and squeaking in char- acter, others being of the sibilant and sonorous variety. (See p. 69.) After a few days, both large and medium-sized mucous rales are audible. ACUTE BRONCHITIS. 89 The rdles may disappear after the patient clears his throat or coughs, but if he is examined one or two hours later, these moist rales will again be present. In order to distinguish between a murmur originating within the lung and one that is pleural in origin the patient should be directed to cough, and the effect upon any questionable rdle carefully noted. (See Intrapleural R41es, p. 71.) I/aboratory Diagnosis.— Sputum. — At first, especially during the first twenty-four hours of the disease, the sputum, while scanty, is decidedly viscid; later the expectoration becomes more profuse and muco- purulent in character, and by the third day, in severe cases, the ejecta is almost pure pus and may be of a greenish color. Microscopically, shreds of mucus and epithelial cells, a few being ciliated and others showing evidence of degeneration, are seen. Bacteria are numerous, the predominating organism varying in each particular case; thus at times it may be a large diplococcus, a streptococcus, the staphylococcus, and again the influenza bacillus. (See Infectious Bronchitis.) At least one slide should always be stained for the bacillus of tubercidosis. Illustrative Case. — K. J., male, age nineteen, a teamster by occupation, gives the following history: Has been healthy during the past five years, and during all this time there has been a gradual increase in his weight until he now weighs 145 pounds (height, 5 feet 8i inches). There is no history of having consulted a physician since the age of fifteen. Upon the day preceding his appearance at the medical clinic he suffered undue ex- posure to both cold and wet, and during the night following such exposure he awakened several times suffering from violent frontal headache and a sense of chilliness. Upon rising in the morning the mental condition was dull and cough was distressing, being accompanied by slight expectoration. When seen, the patient complained bitterly of a sense of constriction over the anterior surface of the chest, and also of substernal discomfort. He experienced a moderate amount of soreness at the base of the chest, on a level corresponding to the insertions of the diaphragm. Constipation was present. When first seen, the patient was sitting, and he then gave no evidence of having difiiculty in respiration, although it was found that exercise and talking induced cough. The chest was apparently normal, and the number of respirations a minute was slightly accelerated. The cutaneous surface appeared normal except for a moderate flushing of the cheeks. There was a mild congestion of the conjunctivae, and the pharyngeal mucous membrane was also reddened. Auscultation revealed the presence of many fine, crackling rales over those portions of the chest immediately overlying the large bronchi. When first examined the temperature was 101° F., and continued fluctuating between 99° and 102° F. for a period of three days during his stay in the hospital. Summary of Diagnosis. — A diagnosis is made from the following symptoms: (a) Slight fever; (&) cough, which is at first dry and later productive; (c) the character of the expectoration, together with the acute- ness of the onset, which is accompanied by chilly sensations; (d) the undue harshness of the respiratory murmur, numerous dry r41es during the first twenty-four hours, and the development of moist, bubbling riles later — all of which signs are audible over the entire chest. A history of exposure or the development of the condition during the course of a febrile or an afebrile malady always points strongly toward acute bronchitis. Differential Diagnosis. — Pleurisy with effusion differs from acute bronchitis in that flatness is present over the base of one pleura. Upon auscultation the signs of bronchitis may be present over that portion of lung above the fluid and over the unaffected side. The fact that pleural effusion is seldom bilateral, and that even when both pleurae are involved the signs of bronchitis are absent at the bases (patient erect), serves to dif- 90 DISEASES OF THE BRONCHI, LUNGS, AND PLEUKA. ferentiate these conditions. The history of a sharp, stabbing pain in the pleura is absent in acute bronchitis, as is also movable dullness. Bronchopneumonia may follow an attack of acute bronchitis, in which event the following additional symptoms and signs appear: increase in the number of respirations, cyanosis, frequent pulse-rate, and an elevation in temperature of one or two degrees. Here the aim is not to differentiate between bronchitis and bronchopneumonia, but rather to determine the time at which pneumonia develops. Incipient tuberculosis is distinguished from acute bronchitis by the fact that in tuberculosis the physical signs of bronchitis are distinctly localized, and are usually found at one or both apices, whereas in acute bronchitis the peculiar respirations and types of rales are heard over the entire lung surface. Miliary tuberculosis (pulmonary type) may exhibit the physical signs of acute bronchitis, but the general condition of the patient and the fact that he does not develop the characteristic sputum by the second or third day serve to differentiate bronchitis from this type of tuberculosis. (See Miliary Tuberculosis, Differential Diagnosis, p. 801.) In miliary tuberculosis a culture of the blood may disclose the presence of tubercle baciUi, which finding will serve early in this disease to make the diagnosis positive. Clinical Course. — Acute bronchitis runs a var5dng course, depend- ing largely upon the condition to which it is secondary. For example, if it follows direct extension from congestion of the upper respiratory tract, the course varies from a few days to two weeks, and rarely, indeed, does the disease continue for a longer period. A somewhat protracted course is commonly encountered in those who are debilitated, in the aged, and in persons suffering from either the gouty or the tuberculous diathesis. In tuberculous subjects there is at times a tendency for the bronchial con- gestion to extend to the finer tubules, and in these the general symptoms are severe. When bronchitis complicates one of the acute infections, its severity is more or less directly dependent upon the severity of the primary infection. INFECTIOUS BRONCHITIS. General Remarks. — In addition to the acute form of bronchitis known to extend from inflammatory processes of the upper air-passages, and that form which develops during the course of certain acute infectious fevers and afebrile conditions that are characterized by asthenia, the disease may form one of the leading and at times chief chnical features of certain acute conditions, such as hay-fever, measles, whooping-cough, typhoid fever, influenza, and acute "infectious" colds. Hay-fever. — In this disease a variable degree of bronchitis is fairly characteristic, and may develop with or even antedate the coryza, which is a characteristic feature. The general clinical picture of hay-fever has been described at length on p. 794, but for our present purpose attention is directed to the fact that the physical signs of acute bronchitis are invariably present, and, as a rule, their severity varies in direct proportion with the degree of irritation of the nasal mucosa. The bronchitis of hay-fever shows less tendency to terminate in early recovery than do other types of this malady, and this peculiarity of the disease warrants its separate classifi- cation. CHRONIC BRONCHITIS. 91 Influenza. — In the respiratory type of this infection (acute infec- tious colds), acute bronchitis is an early and prominent symptom. Laboratory Diagnosis. — Both the sputum and the nasal secretion contain the bacillus of influenza. Measles.— The symptoms and signs of acute bronchitis are among the earhest clinical manifestations of measles, and, indeed, may continue for days and, in unfavorable cases, even for weeks. The more severe the type of bronchitis present, the more serious is the case, and the more likely is it to develop pulmonary complications (bronchopneumonia). The physical signs differ in no way from those detailed under Acute Bronchitis. Laboratory Diagnosis. — The sputum is scanty at first, and free expec- toration seldom occurs until the eruption begins to fade. A microscopic analysis of the sputum gives no positive information with reference to the type of infection. "Wh.OOping'-coug'li. — An early evidence in this disease is the onset of acute bronchial catarrh, which is at first mild, but gradually increases in severity. Acute bronchitis extends over a period of weeks before the development of the whoop which characterizes the disease. The more severe the type of bronchitis, the more likely is the child to develop broncho- pneumonia. Late during the course of whooping-cough the bronchial condition assumes a svibacute nature, and chronic bronchitis commonly results. The expectoration reveals nothing diagnostic of this disease. CHRONIC BRONCHinS. Pathologic Definition. — A chronic inflammatory process involv- ing the bronchial mucous membrane, and characterized by the occurrence of destructive changes in the superficial epithelial layer, with thinning of the mucous membrane of the larger tubes as the result of atrophy of the muscular coat. The mucous glands are destroyed, and there are localized areas of infiltration (thickening) and dilatation of the bronchial tubes. Varieties. — The disease is rarely primary in origin, the vast majority of cases developing as the result of preexisting acute or chronic maladies. (1) There is a special type, commonly seen in men past middle life, who either display a gouty diathesis or have been sufferers from emphysema, organic heart disease, general arterial sclerosis, or renal disease. (2) Another variety is that known as dry catarrh, which is also observed in elderly individuals and almost always follows emphysema. This form of chronic bronchitis is characterized by a paroxysmal cough that may occur once or twice or oftener during the twenty-four hours, and is accom- panied by scanty but highly tenacious expectoration. (3) Special attention has been called to the chronic bronchitis of young females, and this type is characterized, first, by the class of individuals it attacks, and, second, by the fact that it does not materially impair the general nutrition. (4) Bronchorrhea is a condition in which the leading symptoms of chronic bronchitis are present, and, in addition, there is a profuse watery and at times mucopurulent expectoration. Bronchorrhea should be con- sidered in connection with putrid bronchitis and with bronchiectasis. (5) Fetid Bronchitis. — In this condition the sputum gives off an odor resembling that of decomposing animal tissue, which forms the character- istic clinical manifestation in this type of the disease. It should be re- 92 DISEASES OF THE BRONCHI, LUNGS, AND PLEURA. membered, however, that fetid expectoration is also a feature of pulmonary- gangrene (p. 119), pulmonary abscess (p. 122), and dilatation of a bronchus (p. 101). In making the diagnosis, therefore, these conditions should be carefully excluded. Predisposing Factors. — Age is not without influence, since the majority of cases occur after the fortieth year. The disease is seen, how- ever, in children, particularly after an attack of whooping-cough or of one of those diseases of childhood characterized by malnutrition. Season. — Cold appears to predispose to attacks of chronic bronchitis, and it is common to find that those free from the disease during the summer months are again attacked as the cold weather approaches, the condition continuing until spring or even summer returns. During the autumn months the pollen of certain plants appears to excite a chronic form of bronchitis in selected cases. Other Predisposing Conditions. — The disease frequently follows repeated attacks of acute bronchitis, and is especially likely to develop after an attack of influenza, measles, whooping-cough, small-pox, or scarlet fever. Alcoholism, chronic rheumatism, gout, and pulmonary tuberculosis frequently antedate chronic bronchitis. Organic disease of the heart, chronic obesity, emphysema, repeated attacks of asthma, and chronic nephritis manifest chronic bronchitis as a late symptom. Exposure predisposes to the development of chronic bronchitis in that it gives rise to repeated attacks of the acute variety. Those exposed to irritating dusts (coal-miners, workers in foundries and factories, hat-makers) are especially likely to develop chronic bronchitis after prolonged exposure to such mechanical irritants. Principal Complaint. — ^There is often a history of repeated attacks of acute bronchitis, or of the patient having at some time experienced an attack similar to that from which he is now suffering. Generally speak- ing, this condition resembles closely that described at length under Acute Bronchitis (p. 88), except that all the symptoms are less severe. The patient may complain of a sense of substernal constriction, but pain is rarely, if ever, experienced. Should the cough be pronounced, as it often is, the patient suffers from considerable discomfort and soreness about the base of the chest, and a sense of distress and even soreness is felt in the epigastrium and along the margin of the ribs. More or less cough is likely to be present continuously, but repeated paroxysms of coughing form the chief and most distressing complaint. Where expectoration is scanty and highly tenacious, cough is more severe and decidedly more distressing than where expectoration is free, with probable involvement of only the larger bronchial tubes. Physical Signs.— Inspection.— The neck is short and somewhat thickened, and there may be evidence of cyanosis, both of which conditions result from the associated emphysema. Other signs obtained by inspection are usually due to a coexistent condition, and are not in themselves depen- dent upon chronic bronchitis. Should chronic bronchitis continue for years, emphysema follows. Palpation, — A distinct fremitus may be transmitted from the larger bronchi to the palpating finger in those cases in which a quantity of mucus has collected in the bronchial tube. The respirations are often somewhat hurried, and the degree of expansion may be limited. Percussion yields a clear and rather hyperresonant note over the entire CHRONIC BRONCHITIS. 93 lung. Rarely, indeed, during acute exacerbations of a chronic bronchitis there may be moderate impairment at the bases posteriorly, a sign due to pulmonary congestion or possibly to locahzed pulmonary edema. Auscultation. — ^The respiratory murmur is less distinct than normally, and if there is associated emphysema, an appreciable prolongation of the expiratory murmur is heard. Both large and small bubbling riles or rhonchi are heard over the entire chest, and these are particularly audible at the angle of the scapula, over the bases, and at the junction of the third ribs with the costal cartilages. In the so-called "dry catarrh" the riles are often high pitched and wheezing, and at certain times may be accom- panied by moist rales. - The heart-sounds are normal at first, but when the disease has con- tinued for years, both the first and the second sound becomes altered, and there is generally accentuation of the second pulmonic sound, as the result of increased blood tension in the lung. (See Emphysema.) I/aboratoiy Diagnosis. — In the ordinary type of chronic bron- chitis there is cough with free expectoration upon rising in the morning, and, as a rule, one or two similar paroxysms during the day. The sputum displays no characteristics, but is a thick mucoid or mucopurulent fluid, and at times almost pure pus is ejected. In the so-called "dry catarrh" there is little, if any, expectoration. Microscopically, the sputum will be found to contain many cocci and baciUi, but none of these is known to be pathogenic in nature. Epithelial cells from the lining of the bronchial tubules are always present, and some show evidences of degeneration. Leukocytes and pus-cells are also common, and shreds of fibrinous coagula (see p. 80) may rarely be detected. In selected cases of chronic bronchitis the sputum displays an abnormally high percentage of cells that stain by eosin. The eosinophihc granules in the leukocytes found in the sputum are not clearly outlined, as they are in the leukocytes of the circulating blood. When there is an associated asthmatic condition, Curschmann's spirals (Fig. 31) and Char cot-Ley den crystals (Fig. 31) are commonly present. Stunmaiy of Diagnosis. — Chronic bronchitis is readily recognized from the following group of symptoms, which is unusually prominent: cough, expectoration, an absence of fever, and loss of strength and of weight. The fact that chronic bronchitis is, as a rule, a secondary condition is to be remembered, the heart, liver, lungs, and kidneys being studied carefully in order to determine the site of the primary disease. Differential Diagnosis. — Pulmonary Tuberculosis. — In those cases of bronchitis in which the disease has continued for months or even years it must be carefully differentiated from pulmonary tuberculosis. The leading differential points are given in the following table: Chkonic Bronchitis. Pulmonary Tuberculosis. 1. There is often a history of chronic 1. History of tuberculosis in family or heart, liver, or kidney disease. associates common. 2. Occupation may be that of a coal- 2. There may or may not be a history miner, glass-blower, stone-cutter, or of working in dust. worker in foundries. 3. Attacks recur with the approach 3. Apparently follows an acute cold or of cold weather, and are mild or an attack of pleurisy or influenza, disappear during the summer months. 4. There have often been periodic 4. Absent. attacks of asthma, which occur at cer- tain seasons — e. g., fall and summer. 94 DISEASES OF THE BRONCHI, LUNGS, AND PLEUKA. Chronic Bronchitis. — (Continued.) Pulmonary Tuberculosis — (Continued.) 6. Sputum does not contain tubercle 5. Tubercle bacilli present, bacilli, but a profusion of other bacteria (cocci and bacilli) are present. 6. Curschmann's spirals commonly seen. 6. Rare. 7. Pulmonary elastic tissue seldom, if 7. Common after cavity formation. ever, observed. 8. Physical signs obtained over both 8. Localized to one lung or to apices, lungs. rarely at one base. 9. Absent. 9. Puhnonary hemorrhage common. 10. Moderate loss of weight and strength. 10. Progressive weakness and emaciation. 11. Absent. 11. Fever present. After ulceration there is an evening temperature of from two to four degrees, whereas dur- ing the morning hours the tempera- ture is normal or subnormal. Fetid bronchitis is to be distinguished from other pulmonary con- ditions in which the sputum emits an offensive odor. Thus, in abscess of the lung the sputum contains shreds of lung tissue, elastic fibers, crystals of hematoidin, cholesterin, and amorphous blood-pigments, all of which substances are absent from the sputum of fetid bronchitis. Again, the physical signs in abscess are localized. Fever, which is a feature of abscess, is absent in fetid bronchitis. In pulmonary gangrene the odor of the sputum is one of its most prominent symptoms. Lung tissue may be present, although at times elastic fibers are dissolved by certain questionable ferments present in the sputum. Blood-pigment is also present. In gangrene the physical signs are either absent or distinctly localized, whereas in bronchitis the charac- teristic signs are heard over both lungs. Bronchiectasis is seldom bilateral, consequently- the physical signs are localized at one or both apices. This subject will be further discussed under Bronchiectasis. (See p. 100.) Clinical Course. — ^This varies greatly in different cases, but in the majority of instances complete recovery is unusual, although there are exacerbations of the condition, followed by prolonged intervals during which the leading symptoms, cough and expectoration, subside. The majority of cases terminate, after a course of months or years, in emphysema. In those cases in which the bronchial catarrh results from cardiac, liver, or kidney disease, the course is influenced entirely by the preexisting disease. FIBRINOUS BRONCHITIS (Plastic Bronchitis, Croupous Bronchitis, Hucous Bronchitis). Pathologic Definition. — ^This is a rare condition, characterized by either an acute or a chronic catarrhal inflammation of the bronchial mucosa, together with the production of a fibrinous exudate and the for- mation of fibrinous casts of the bronchial tubules. General Remarks. — The causes of fibrinous bronchitis are obscure. Autopsy has revealed the existence of such conditions as pneumonia, chronic pleurisy, and pulmonary tuberculosis. Varieties. — (1) The acute form, in which the attacks are unusually severe and lead one to look for an almost immediate fatal termination. (2) The chronic type, in which the attacks are mild, but occur somewhat regularly. FIBRINOUS BRONCHITIS. 95 Predisposing and Bxciting Factors.— No positive exciting factor is known, but various bacteria are often present in the sputum. Sex. — Males are affected in 66f per cent, of all cases. Age. — Practically all ages may suffer from this affliction, yet the majority of cases are seen during the second and third decads. Season plays an important etiologic r61e, spring furnishing the greatest number of cases. Rarely, indeed, a series of cases occurs in the same locality, and Pichini regards the disease as epidemic. Chronic diseases of the lung, as well as diseases of the skin (pemphigus, impetigo, and eczema), appear to predispose the patient to the development of fibrinous bronchitis. Principal Complaint.— In acute fibrinous bronchitis the disease is ushered in by a severe rigor, which is directly followed by high fever, urgent dyspnea, and paroxysmal cough. The patient states that after severe coughing he is often able to expectorate a small quantity of material that contains one or more bronchial plugs. Following a paroxysm of coughing there is generally blood-streaked expectoration. The most dangerous symptoms are dyspnea, general oppression, a severe cough, with little or no expectoration, and a tendency toward asphyxia. In chronic fibrinous bronchitis the attacks are less severe than in the acute variety, and an important feature is that these attacks occur at irregular intervals, varying from one week to one or more years. Rarely, cases are seen in which an attack of paroxysmal coughing with the ex- pectoration of fibrinous exudate may occur daily for an indefinite period. Generally speaking, the symptoms of chronic fibrinous bronchitis are those seen in chronic bronchitis, with the aforementioned exceptions. Thermic Features. — In the acute variety fever is to be expected, and in the chronic form there may be a mild febrile period. The fever is often the result of the preexisting condition, and is but slightly, if at all, influenced by the bronchial trouble. Physical Signs. — Inspection. — The attitude of the patient is that of one suffering from an asthmatic attack. (See p. 97.) Palpation. — ^When a portion of the bronchial tree is plugged by the fibrinous exudate, it is impossible for air to enter that section of the lung, and, as a consequence, fremitus and expansion are diminished over such limited area. Percussion over the affected area is often negative, yet there is usually a perceptible hyperresonant note over the surrounding healthy lung tissue, and in those cases in which large portions of the bronchial tree are involved, the percussion-note may be impaired over the affected section; but after dislodgment of the bronchial cast, however, normal resonance is restored. Auscultation. — The breath-sounds are the same as those of chronic bronchitis, and although both harsh and hurried respiratory murmurs and dry rdles are heard over different portions of the lung, they are in no way characteristic of this affection. Diagnosis and I/aboratory Diagnosis.— These rest entirely upon the finding of fibrinous coagula in the sputum. Such coagula, when spread thinly on a slide and studied under a low-power objective (two- thirds), must correspond in form to the peculiar arrangement of a section of the bronchial tubes. In true diphtheria a fibrinous exudate may appear in the sputum, but it has seldom been formed in the bronchial tubules. In order to determine the actual nature of the fibrinous exudate the cast must be hardened, sectioned, and studied for the bacillus of diph- theria. Fibrinous coagula from the bronchial tubules, when teased under 96 DISEASES OF THE BKONCHI, LUNGS, AND PLEURA. the microscope, will display a laminated structure, whereas the mem- brane dislodged as the result of infection by the Klebs-Loffler bacillus never presents this characteristic. ASTHMA (Bronchial Asthma). Pathologic Definition. — A chronic condition characterized by hyperemia of the bronchial mucosa and the presence of a mucous exudate, or by a neurosis of reflex origin, with the changes peculiar to chronic bron- chitis, including emphysema, hypertrophy, and dilatation of the right heart. Spasmodic constriction involving the mucous membrane of the bronchial tree may also be present. Asthma, according to certain writers, may be excited by arterial constriction. Remarks and Clinical Types. — In certain instances there appears to exist a constitutional susceptibility to spasm of the local muscular fibers. Among the conditions which appear to excite asthma and which stamp, more or less clearly, the various clinical types of the disease should be mentioned: (a) Acute bronchitis, in which there may be isolated sections of true inflammation of the bronchial mucosa. It should be borne in mind, how- ever, that where there is inflammation, bronchitis may in itself be excited by asthma. (6) The inhalation of certain irritants — e. g., gas and other vapors, tobacco smoke, dust from the street or that containing the pollen of plants — and even the odor of certain animals have been known to excite attacks of asthma. During the summer and autumn months many city dwellers, upon removing to the country, develop severe attacks; indeed, when the reverse obtains and those living in the country come to the city, similar attacks may be induced. (c) Secondary Asthma. — Periodic attacks of asthma often occur during the course of such chronic maladies as organic heart disease, nephritis, rheumatism, gout, syphilis, and emphysema, as well as in lesions located in the medulla. (d) Nervous Asthma. — Not infrequently a neurotic element is the causative factor in the production of asthma, severe attacks frequently following emotional excitement, disappointment, and grief. (e) Reflex Asthma. — ^Asthma may be reflex in origin, as is seen in those suffering from obstruction to the upper air-passages due to nasal polypi, spurs, and disease of the teeth. (/) Gastric asthma may follow dietetic errors, and constipation may result in the production of typical seizures (intestinal asthma). Some writers believe that in those suffering from asthma due to gastric derange- ments the diaphragm is abnormally contracted, and the base of the lung elevated above its normal position. Predisposing Factors.— Heredity plays an important part, and is shown to figure in at least 50 per cent, of all cases. Sex exercises great influence, practically two-thirds of all cases being seen in males. Season is of special importance in those particular cases in which asthma results from the irritation offered by the pollen of certain plants; conse- quently the greater number of these cases occur during late summer and autumn months. Most cases of asthma, however, develop during the winter and spring months, and this is probably explained by the fact that many ASTHMA. 97 cases follow an attack of hay-fever from which the patient suffered during the autumn. ° Principal Complaint,— In about 50 per cent, of cases the patient complains of one or more of the following prodromal symptoms: irritability of temper, mental buoyancy, or, on the other hand, mental hebetude, vertigo, dull headache, gastro-intestinal irritation (dyspepsia), and an increased frequency of urination. Paroxysm.— This may appear at any time during the twenty-four hours, but most often attacks the patient during the night, and frequently after he has enjoyed several hours' sleep. There is a tendency for the attack to return at the same time on successive nights. The onset is frequently sudden, the patient being awakened from a sound sleep by extreme dyspnea and paroxysmal cough, although, as a rule, a certain amount of thoracic constriction and moderate dyspnea is experienced for a short time — a few hours— preceding the attack. Suddenly the patient feels that he is smother- ing, sits up in bed, inclines forward, grasps his knees or some firm support in order to assist him in elevating his shoulders and bringing the accessory muscles of respiration into action. During a severe attack he frequently rushes to the open window. A favorite attitude is for the patient to sit on one chair and rest his arms upon another, again endeavoring to assist respiration by the use of the muscles of the neck and chest. On attempting to expel the air the patient gives a harsh, high-pitched, or rattling cough. Thermic Features.— The temperature rapidly falls to below the normal and remains subnormal during the height of the attack. Physical Signs. — Inspection.— Ge?ieraZ. — The patient sits inclined forward and grasps the knees or some firm object. The skin of the face is pale, whereas that of the fingers, lips, and eyelids, as the result of defective oxidation, is decidedly livid; the mucous membrane of the lips, mouth, and tongue may be cyanosed. The expression is anxious. Local. — ^The chest is enlarged, and in those who have suffered from repeated attacks covering a period of months or years the chest is more or less barrel-shaped (Fig. 37, p. 127) , due to inability on the part of the patient to expel the air. There is limited expansion of the chest, and the respirations number 10 to 14 a minute. A characteristic feature is alteration in the respiratory rhythm, inspiration being short, and immediately followed by a prolonged expiratory effort. The epigastrium is, as a rule, unusually prom- inent, due to lowering of the diaphragm. The neck is seen to be thick, and appears unusually short; the vessels of the carotid region stand out promi- nently, and pulsation over the right carotid region is common. The clavicles, as well as the shoulders, are elevated. The head is held in a somewhat fixed position. Speech is slow and interrupted. Palpation. — Pulsation of the vessels of the neck is often detected,, and not uncommonly there is a throbbing in the sternal notch. In those cases in which there is associated emphysema with dilatation of the right heart, distinct pulsation is detected in the epigastrium. The apex-beat may be absent, when this portion of the heart is covered by the emphysematous lung. The pulse is weak, thready, and rapid. The chest expansion is greatly restricted, and the movements, while not frequent, are jerking in character. Percussion. — A h3^erresonant note is obtained over both lungs, and in chronic cases, where there is associated emphysema, the percussion-note may be somewhat tympanitic in character. The area of absolute cardiac dullness is diminished, and if there is marked emphysema, this is absent. 7 98 DISEASES OF THE BRONCHI, LUNGS, AND PLEUKA. A limited area of impairment may be detected in the epigastrium as the result of a dilated right heart. Auscultation. — The inspiratory murmur is short and unusually feeble, whereas the expiratory sound is distinctly prolonged and accompanied by a low wheezing that may be heard even at some distance from the patient. Numerous dry r41es are audible, and the majority of these are high-pitched, squeaking, and both sibilant and sonorous in character. The character and location of certain r^les may vary at any time during or after an attack of asthma, and a certain type (see R41es, p. 69) may be present for but a short time during the entire attack. As the patient's condition improves and when the attack is about to terminate, moist rales are heard over both lungs. If moist r41es are heard during the paroxysm, this is an indication that the patient is suffering from an associated bronchitis. I/aboratory Diagnosis. — Early during an attack of asthma the sputum is scanty, clear, beaded with froth, and at times grayish or tinged with red, due to the admixture of blood-corpuscles. Numerous grayish, mucoid particles are visible to the naked eye, and when these are studied under a one-sixth inch objective, they display a characteristic spiral formation (Curschmann's spirals, see p. 80). Charcot-Leydeii crystals (Fig. 31) are an almost constant finding, and the sputum is always rich in leukocytes. Sputum stained with an alcoholic solution of eosin demonstrates that many of the leukocytes contain eosinophilic granules, whereas when stained with basic dyes, many of the white blood-cells show basic granules. Blood. — Owing to the extreme cyanosis, the number of red cells in a cubic millimeter will be found to be far above the normal, ranging between 5,000,000 and 10,000,000. Because of imperfect oxidation, the color index is high, and it is usually difficult to match the true blood color with the shades of the hemoglobinometer. During the prodromal stage the urine is increased in quantity, pale, and of low specific gravity. Illustrative Case. — Peter H., male, aged forty-six; height, 5 feet 7 inches; weight, 150 pounds. Family History. — Father hving at the age of sixty-eight, but has had gout for several years. Mother died at the age of forty-five, cause unknown. A sister, aged forty, suffers from periodic attacks of hay-fever, and a brother, aged thirty-six, is reported as enjoying good health. One younger sister died of meningitis (?) before puberty. Previous Medical History. — Patient had the diseases of childhood, including diph- theria at the age of twelve years, following which he claims there was a purulent dis- charge from the right ear; and for a number of years after, whenever he would contract a cold, the ear trouble returned. Ten years ago he suffered from stomach disorder (gas- tritis), and at this time he also had jaundice, which, as nearly as he could remember, lasted about three weeks. Social History. — Occupation, foreman in sales department of a retail clothing store. Married at the age of thirty; has one son and two daughters who are in good health. Another daughter became afflicted with infantile paralysis at the age of three and one-half years. Two years ago he took a sea voyage, leaving August first and remaining at sea for a period of ten days, when he landed at Liverpool, England. He set sail for America five days later, and did not experience any asthmatic symptoms until he reached home, when he had sensations referable to his old disturbance, but no distinct attack was experienced. Present Illness. — At the age of thirty-six he took a brief vacation in the country during the month of August, and states that he traveled over the hills of a farming district for eight or ten days, when suddenly he noticed that his nose discharged freely and that he had several severe attacks of sneezing. Coryza continued for a period of several days, when he was awakened during the night, suffering from what his physi- cian termed an asthmatic paroxysm. He has contracted asthma diiring the autumn ASTHMA. 99 months of each year since his initial attack, nine years ago, and has further observed that each attack is more severe than that of the preceding season. The attack appears during the night, although he states that he feels uncomfortable and has some aching of the muscles and moderate tightness over the chest one or two days before a distinct paroxysm develops. With the onset of each attack, if indoors, he feels that it is practically impossible for him to breathe, and sits up in bed, and at times is com- peUed to rush to an open window. He says that there is a severe sfense of constriction over the chest. The attacks begin in August or September, and usually continue for from two to four weeks. Their course does not appear to vary, regardless of the treatment instituted. He has also found that he is especially Uable to develop an attack of asthma upon changing his residence from the city to the country, but such attacks are milder than are those previously described. Cough continues throughout the attack, and during the paroxysms it is harsh and seldom accompanied by expectoration; when, however, the pulmonary symptoms, especially the dyspnea, begin to subside, the expectoration becomes more copious. The temperature is approximately normal during the greater part of the twenty- four hours, but when a violent paroxysm ensues, the temperature may be subnormal for a short period. Physical Examination. — General. — When seen during the attack, the patient's expression is anxious. He sits with his body inclined forward, and grasps his knees or some firm object with his hands. He is extremely irritable, shows evidence of great fear, and refuses to move. Local Examination. — ^The neck is shortened and appears swollen. The chest is unusually large, and expansion is very shght. The lips and even the tongue a,nd mucous membrane of the mouth may show distinct cyanosis, and a similar condition may affect the ears, finger-tips, and lower extremities during the paroxysm. Palpation. — ^This confirms inspection with reference to the movements of the chest. The apex-beat of the heart is often feeble, and at times scarcely perceptible. The pulse is small, but of fair tension, registering 90 to 100 beats a minute. Percussion. — There is hyperresonance over the surface of both lungs, and the area of cardiac dullness is appreciably diminished. Mensuration. — ^The circumference of the chest at the nipple-line is greater than normal, and varies only from one-half to one inch either on deep inspiration or on forced expiration. Auscultation. — ^The breathing is harsh, and can be heard several feet away from the patient. The breath-sounds over the base of both lungs are accompanied by fine, squeaking riles. Over the upper portion of the lungs numerous high-pitched, piping, and at times bubbling, rales are heard. At the intervals between the paroxysmal attacks the expiratory murmur appears to be prolonged and is low in pitch. Laboratory Diagnosis. — The sputum is scanty at times, or agam may be copious. Microscopically, it contains many fine, plug-hke particles, which, when examined under a one-sixth or one-eighth inch objective, display a pecuhar spiral network (Cursch- mann's spirals. Fig. 31). When stained with eosin and methylene-blue, the sputum shows a great number of eosinophihc cells. Various bacteria, bacilh, and cocci are also present. „, ,. . l j Diagnosis by Induction from Clinical Data.— The diagnosis was based upon the periodic attacks of spasmodic dyspnea, together with the characteristic physical signs of the disease. , , „ Course of the Disease.— The attack which develops each autumn generally con- tinues for from two to five weeks. At such times, when the patient was seen imme- diately after the onset of an attack, the paroxysms were distinctly lessened m seventy as the result of treatment. When, however, the condition existed for from seven to fourteen days before a physician was consulted, treatment gave but httle it any reliet. By October of each year he is no longer distressed by the disease although at practi- caUy any time during the year rales more or less characteristic of asthma are auaiDle over both lungs. Summary of Diagnosis.— The diagnosis is based almost exclusively upon the character of the paroxysm. The history of previous asthmatic seizures or of the existence of renal or cardiac disease, and a possible histoiy of dietetic error, are also of value. The character of the sputum,^ which is scanty during the early stage, and the detection of Curschmann s spirals, as, also, the absence of fever, constitute valuable evidence on which to for- mulate a diagnosis. 100 DISEASES OF THE BEONCHI, LXJNGS, AND PLBUKA. Dififerential Diagnosis. — Laryngeal affections may be distin- guished from asthma by the following clinical features: in disease of the larynx (edema of the larynx, spasm of the glottis) the voice is altered and aphonia generally ensues, both of which features are lacking in asthma. Again, the physical signs of asthma that are audible over both lungs are absent or greatly modified in laryngeal disease. In the latter condition the patient cannot inspire, whereas in asthma he is unable to expire and to rid his lung of air. Further, in laryngeal stenosis the chest is of normal size, whereas in asthma the dimensions of the chest are increased. Emphysema is distinguished from asthma first by the fact that in the former the dyspnea is continuous, and, secondly, that in emphysema there are certain characteristic physical signs that are not observed in uncompli- cated cases of asthma. (See Emphysema, p. 127.) Clinical Course and Duration. — In mild cases of asthma there may be one or at most four or five nocturnal paroxysms, with or without cough during the day. In still another class of cases the patient suffers but little, if any, inconvenience for a period of days or weeks, when suddenly and without apparent cause he develops a paroxysm. The cough, which is dis- tressing during and immediately after a seizure, may be more or less con- tinuous for a few days. Dyspnea, accompanied by cough and free expec- toration, is present. Even in this last class of cases paroxysmal attacks occur with a varying degree of periodicity. BRONCHIECTASIS. Pathologfic Definition. — ^This condition may be either congenital or acquired. The latter variety is characterized by atrophy of the various layers of the wall of the bronchus, and by both cylindric and sacculated dilatation of the bronchial tubes. Dilatation may affect either the large, medium-sized, or the comparatively small bronchial tubes, and may be more or less generalized or localized, bilateral or unilateral. In the congeni- tal type localized expansion of the bronchial tubes is also present. Predisposing and ISxciting Factors.— Age and Sex.— Bronchi- ectasis is most common in early adult and in middle life, and males are more often affected than females. Given a previously weakened bronchial wall, the extra strain of violent coughing is sufficient to produce dilatation; and however slight the dilatar tion, the accumulation of an exudate following such sacculation serves, by reason of its own weight, to favor the process of further dilatation. Again, as the result of the weight of the exudate in the sacculated portion and the strain of coughing, the elasticity of the lung becomes more and more im- paired. Bronchiectasis is usually a secondary condition, complicating chronic bronchitis, bronchopneumonia, and whooping-cough. Pressure of a thoracic aneurism upon a bronchus may in time weaken the bronchial wall and result in bronchiectatic expansion. Diseases of the pleurae in which there are marked fibroid change and inhibition of the respiratory function also favor the de- velopment of bronchiectasis. A bronchus often becomes dilated in those cases in which the surrounding lung tissue has undergone fibroid changes (fibroid phthisis) . Principal Complaint.— The patient complains bitterly of severe par- oxysmal coughing, which attacks him in the morning, upon rising, and probably once or twice during the day. The paroxysms are brought on by BRONCHIECTASIS. 101 change of position, such as turning from side to side while in bed. The cough is always accompanied by the expectoration of from four fluidounces to one pint of sputum during the twenty-four hours. There is usually a history of chronic bronchitis, asthma, emphysema, whooping-cough, or chronic disease of the lungs. Extreme prostration has not been observed, nor does decided loss in weight take place. Dyspnea is dependent upon the degree of dilatation of the bronchus, and may become extreme during paroxysmal coughing. Thermic F'eatures.— Uncomplicated cases of bronchiectasis run an afebrile course. Physical Signs. — ^These are dependent upon three conditions: (1) The size and location of the dilatation; (2) the histologic condition of the surrounding lung tissue; and (3) the thickness and general relaxation of the chest-wall. Inspection. — If the bronchial dilatation is large and is situated near the anterior surface of the chest, there will be an appreciable retraction of the chest-wall. The chest-wall is also retracted in those cases that have fol- lowed fibroid pleurisy and fibroid phthisis. The expansion of the chest is restricted over a large dilatation of a bronchus. Palpation. — ^Tactile fremitus is increased where the surrounding lung tissue is consolidated, but where the dilated portion of the bronchus comes into direct contact with the chest-wall, fremitus may be diminished or absent. The degree of fremitus is dependent upon the amount of solid substance that lies between the chest-wall and the wall of the dilated portion of the bronchus. Percussion. — ^The percussion-note is not influenced by the size or loca- tion of a dilated bronchus, but the alteration is dependent, as previously stated, upon the location of the sacculated bronchus and upon the condi- tion of the surrounding lung tissue and pleurse; consequently, given a mark- edly dilated bronchus situated near the chest-wall, the note may be hyper- resonant or even cavernous in nature ; whereas, on the other hand, a dilated bronchus with much partially consolidated lung surrounding it would give a decidedly dull note upon moderate percussion, but here too deep percussion will elicit a cavernous (semitympanitic) note. The percussion- note is dull when the sacculated portion of the bronchus is filled with exudate, and immediately after coughing and free expectoration a tympanitic note is often obtained over the same area. Auscultation. — ^As a rule, the breath-sounds are markedly exaggerated, and in many instances bronchial breathing is audible. The various types of riles (see p. 69) are extremely common, and may display a metallic quality. Over a dilatation situated immediately beneath the pleurae the breath-sounds, in addition to being harsh, possess an amphoric quahty that is practically indistinguishable from the so-called cavernous breathing— i. e., a distinct pause occurs between the inspiratory and the expiratory murmur. I/Eboratory Diagnosis.— The sputum, as a rule, is grayish or brown in color and mucopurulent in consistence. At times it gives off a sour odor, and again it may be fetid. A somewhat characteristic feature of the sputum is that, upon standing, it separates into three strata: (1) a superior layer, composed of brown, frothy material; (2) a middle stratum of watery or serous consistence; and (3) an inferior layer of thick, granular debris. Microscopically, the sputum contains many pus-cells, Charcot-Leyden crystals (Fig. 31, p. 80), and crystals of the fatty acids (Fig. 31, p. 80). Many bacteria (bacilli and cocci) are present. MyceUal threads (fungi) are occasionally seen. Rarely, indeed, fibers of elastic tissue are present. 102 DISEASES OF THE BEONCHI, LUNGS, AND PLEURA. but their presence is dependent entirely upon destructive changes in the lung substance. In those cases in which there is actual destruction of the lung tissue with congestion or ulceration the sputum may contain red blood-corpuscles. Summary of Diagnosis.— This is based largely upon the history of preexisting maladies that materially favor the development of bronchiectasis, and upon the fact that there has been no decided loss of strength and of weight. When the disease is running an afebrile course, this points strongly to the existence of bronchiectasis, and excludes a diagnosis of pulmonary tuberculosis. The character of the sputum and the fact that the recurrent paroxysmal cough is not accompanied by hemorrhage from the lung strongly suggest dilatation of the bronchus. The physical signs so closely resemble those present in pulmonary disease with cavity formation that while their presence is necessary in order to establish a diagnosis of dilated bronchus, such diagnosis cannot be based solely on the existence of these signs. Dififerential Diagnosis.— The following table sets forth the dis- tinctive features that separate bronchiectasis, pulmonary cavity, and thora- cic aneurism: Bronchiectasis. 1. History of asthma or pertussis of long stand- ing. 2. There is but moderate emaciation, without decided weakness. 3. Characteristic fetid spu- tum. Pulmonary Cavity. 1. History of tuberculo- 2. Marked progressive emaciation with weakness. 3. Nummular sputum containing tubercle bacilli. 4. Pulmonary hemorrhage 4. Common. absent. Physical signs of cavity without impairment of the percussion-note at apices. Dullness, which may change to a semi- tympanitic note after coughing. 5. Impairment at apices an almost constant finding, except where cavity involves the base of one lung. 6. Same. Thoracic Aneurism. 1. Heavy lifting, high liv- ing, and previous at- tacks of acute endo- carditis, rheumatism, or syphilis. 2. Not characteristic. 3. Large quantities of spu- tum, often blood- tinged, are expector- ated when the aneu- rism rests upon and causes partial obstruc- tion of a bronchus. 4. Rare. 5. Flatness is obtained over aneurism. Area of dullness not altered by coughing or by posture. Circumscribed empyema, when it communicates with a bronchus through a fistulous opening, may somewhat resemble bronchiectasis, the differential features being that empyema is always marked, at some time in its course, by high temperature and leukocytosis, with an increase in the number of polymorphonuclear leukocytes. Emaciation and weakness char- acterize empyema. Actinomycosis of the thorax may communicate with a bronchus or, less often, may perforate externally. The distinctive feature between ac- tinomycosis and bronchiectasis is that in the former condition actinomyces fungus is present in the sputum. Clinical Course. — ^This is, as a rule, favorable as to life, although a BRONCHIAL STENOSIS. 103 permanent cure seldom follows, the condition continuing for years without marked interference with the patient's general nutrition. BRONCHIAL STENOSIS. Pathologic Definition. — A condition characterized by partial occlusion of the lumen of a bronchus, either as the result of disease or of foreign bodies, etc., within the bronchus itself, or, more commonly, from pressure from without, as the result of thoracic aneurism, enlarged bronchial glands, and the like. Principal Complaint. — The most urgent complaint is that of dyspnea, which may be so pronounced as to bring into action the accessory muscles of respiration. Cough and expectoration are usually present. Thermic Features. — Moderate fever is the rule, though by no means a constant finding. Physical Signs. — Inspection. — In well-marked cases the skin and mucous surfaces are cyanosed. Chest expansion is unequal on the two sides, and there is often retraction of the interspaces on the affected side during the inspiratory act. Tracheobronchoscopy. — By means of this special method it is possible, with the aid of the bronchoscope, to inspect the upper and lower air-passages and ascertain the existence of stricture and of disease of the mucous lining of the bronchial tubes. Stenosis is recognized by this method, and it is possible to distinguish between stenosis the result of external pressure and that re- sulting from changes in the bronchus itself. For a more detailed description of this method the reader is referred to special works upon this subject.* Palpation. — Tactile fremitus is diminished and often absent, over the area of lung supplied by the diseased bronchus. Percussion. — During the early stages of bronchial stenosis no positive evidences are elicited by percussion, but atelectasis may occur as a late com- plication, and in this case dullness is obtained over the area of lung involved. A fact to be considered in connection with every case of bronchial stenosis is that the area of lung affected is often small and completely covered by surrounding healthy, but emphysematous, lung tissue, which tends to obscure the evidences of disease. Auscultation. — The vesicular murmur is feeble over the affected area, due to the diminished volume of air entering the peripheral portions of the lung. Numerous rales, both sibilant and sonorous, are present over the site of the obstruction. Summary of Diagnosis. — Auscultation offers the most positive diag- nostic sign— the detection of sibilant and sonorous r41es at a point corre- sponding to the position of a bronchus. A history of thoracic tumor, particularly if such tumor is aneurismal in character, should always create suspicion of the existence of bronchial stenosis. The fact that at some time the bronchus was wounded by the lodgment of foreign bodies, etc., is also of great importance in formulating a diagnosis. Retraction of the inter- spaces is a valuable sign in those cases in which it is possible to eUminate the preexistence of pleurisy with adhesions. X-Ray Diagnosis. — ^The a;-ray will serve to demonstrate the presence of foreign bodies when present. * Chevalier Jackson, of Pittsburg, has produced a monograph giving the techmc, etc., for the use of the bronchoscope, and has also devised an instrument (*ig. 1»U, p. 448) that has proved satisfactory in the hands of many investigators. 104 DISEASES OF THE BRONCHI, LUNGS, AND PLEURA. DISEASES OF THE LUNGS. CONGESTION OF THE LUNGS. Varieties. — (1) Active congestion, a secondary condition, which accompanies such pulmonary affections as pneumonia, tuberculosis, bron- chitis, and pleurisy. Some authors claim, and correctly so, that primary pulmonary congestion, while rare, may occur, and is probably the fore- runner of pulmonary edema. During pulmonary congestion the bronchial mucosa is also involved. (2) Passive congestion may be present either as a general passive hy- peremia of the lung tissue, mechanic in nature, or as a localized hyperemia (hypostatic congestion). In the mechanic variety of passive congestion (brown induration) the lung tissue is distended and crepitation is appre- ciably diminished. Even the interstitial connective tissue may be edema- tous, and an extravasation of blood-pigment may have taken place into the alveolar cells. The hypostatic variety seen in acute infectious diseases produces a condition known as hypostatic pneumonia. Predisposing and Bxciting- Factors. — ^Active Hyperemia. — Generally speaking, this condition is a symptom that accompanies some form of pulmonary disease in which there is an active inflammatory process. The inhalation of irritating substances — e. g., gases, foul air, flame, and hot air — may also give rise to active hyperemia. Rarely congestion follows violent exercise, such as running and other athletic feats, and it has been known to follow the excessive use of alcohol. Passive Hyperemia. — ^Mechanic passive hyperemia results from an interference with the current of blood flowing between the right and left heart through the lung. The commonest causes are mitral stenosis, mitral regurgitation, and dilatation of the right ventricle. It occasionally follows traumatism to the head, apoplexy, and cerebral tumor. Hypostatic congestion may develop as a complication of other febrile or afebrile maladies in which there is an appreciable enfeeblement of the heart's action, as in the aged and in such maladies as t}rphoid and other fevers; it may also occur as a late complication in cardiac disease, liver affections, the anemias, tuberculosis, and malignant disease. Hypostatic congestion is favored in those cases in which the patient rests for a long time in one position, and particularly when he lies upon his back. Symptomatology of Pulmonary Congestion. — The symptoms of pulmonary congestion are vague. There is cough, accompanied by free expectoration. The sputum is covered with a thick .froth, and contains shreds of mucus. In those cases in which the degree of congestion is marked, the sputum is blood-streaked, and may contain alveolar epithelial cells in which particles of blood-pigment are deposited. Physical Signs. — Inspection. — The respirations are increased in frequency and shallow, and movement of the nostrils is distinctly per- ceptible. There is cyanosis of the lips and finger-tips, mild or intense, ac- cording to the degree of congestion present, and there may be lividity of the face. Palpation often reveals a slight increase in the tactile fremitus over the bases, and when congestion develops during the course of acute fever, this sign is most often obtained posteriorly. Percussion.-T-The note is impaired over the congested area, but seldom PULMONARY EDEMA. 105 sufficiently to be regarded as dullness. A comparative study of the uDDer and the lower portion of the lung is necessary in order to detect pulmonary congestion, either passive or active, since the condition is a bilateral one that attacks the bases first. • -^"scultation.— The breath-sounds over the congested lung are somewhat increased (bronchovesicular), and rarely, indeed, is true bronchial breathing auuibie. ° Summary of Diagnosis.— This is based largely upon the heart's action, a feeble heart always giving rise to a suspicion of the existence of pulmonary congestion. The presence of mitral or tricuspid disease is also of importance m formulating a diagnosis. The physical signs obtained by palpation and percussion, when sufficiently distinct, are almost positive evidence of the presence of pulmonary congestion. The frequency and char- acter of the respirations are the only constant features, and, indeed, these may be absent when pulmonary congestion follows traumatism to the' brain paralysis, or cerebral tumor. ' _ Clinica,! _ Course. — This is dependent almost entirely upon the pre- existing condition. In valvular heart disease pulmonary congestion often subsides after the administration of cardiac stimulants and sufficient rest. In those cases resulting from exposure to irritating gases, etc., the condition tends rapidly toward recovery. The course is hkely to be more protracted in the cases of hypostatic congestion resulting from acute infectious and debilitating disease. PULMONARY EDEMA (Edema of the Lungs). Pathologic Definition. — ^An effusion of serous fluid into the in- terstitial lung tissue, and an exudation of such serum into the air-vesicles. etiology and Varieties. — Pulmonary collateral edema is rarely, if ever, a primary condition, but is secondary to other inflammatory proc- esses — e. g., lobar pneumonia, bronchopneumonia, pulmonary infarct, hypostatic congestion, and abscess. This form of inflammatory edema attacks only the lung tissue surrounding an acute inflammatory process, a variable degree of emphysema- being adjacent to it. General !Edema. — ^This process usually begins at the bases, but in marked cases may have invaded the entire lung substance of both sides. The mode of production of pulmonary edema is questionable, the following conditions apparently being in intimate relation with it: (1) Increased tension of the blood-vessels of the lung, from whatever cause — mitral, pulmonary, or tricuspid disease, '\^^len aortic disease produces an obstruc- tion to the escape of blood from the left heart, this in turn causes damming back of the blood into the lung, increasing the blood-pressure there. (2) An increase in the fluidity of the blood. (3) Disease of the pulmonary vessels — e. g., impaired nutrition — may also interfere with the circulation through the lung, and this pathologic state probably explains the pulmonary edema, seen in both acute and chronic Bright's disease. (4) Pulmonary edema may develop in profound septic conditions and acute and chronic maladies in which toxic poisoning is a marked feature, the edema being due to the action of such toxins upon the heart muscle (weak heart) or upon the nervous system. (5) Pulmonary edema may also follow irritation of certain portions of the vasomotor system, which in turn encourages a relaxa- tion of the pulmonary tissue. (6) General pulmonary edema is of common 106 DISEASES or THE BRONCHI, LUNGS, AND PLEURA. occurrence late during the course of unfavorable cases of lobar pneumonia and in all pulmonary inflammations. It may also appear as a terminal condition in both the essential and the symptomatic anemias, hepatic cirrhosis, brain tumor, cerebral hemorrhage, valvular heart disease, pul- monary tuberculosis, and acute infections in which exhaustion is promi- nent. Symptoms. — Except in well-marked cases, these are, as a rule, vague. Cough is always present, and is accompanied by free exjjectoration of frothy, serous fluid (bronchorrhea). The patient usually complains of cold extremities and of extreme dyspnea, which latter is increased upon the slightest exertion. Thermic Features. — Pulmonary edema does not cause a rise in temperature, therefore any febrile symptoms that are present should be regarded as indicative of the preexisting condition. Physical Signs. — Inspection. — ^The skin of the face and extremi- ties becomes livid, and the lips and tongue are distinctly cyanosed. In selected cases the skin may be covered with beads of perspiration, but this is by no means a constant finding. The movements of the chest are feeble, and the respirations are rapid. Palpation. — ^The pulse is weak and rapid, and later becomes dicrotic. The skin of the extremities is cold, whereas that covering other portions of the body is clammy. Percussion. — ^The note is usually irnpaired at the bases, and there may be a variable degree of impairment over the greater portion of both lungs. Rarely, indeed, there is dullness over localized areas of the lung, surf ace, a feature more common in localized than in general pulmonary edema. Auscultation. — ^The true vesicular quality of the respiratory sound may be absent, and bronchovesicular breathing be audible in its place. Numer- ous small moist rales are to be heard over the entire chest, but are usually more marked as the bases of the lungs are approached. In those cases in which there is an associated bronchitis, large piping rdles are heard at the apices, along the sternal border, and are often audible at the angles of the scapulae. The heart-sounds are increased in frequency, and an appreciable accentuation of the second pulmonic sound is heard early. Late in pulmon- ary edema it is not uncommon to find cardiac dilatation, in which case both the first and the second sound of the heart resemble those of the fetus. Summary of Diagnosis. — This is based largely upon the physical signs, particularly the increase in frequency of the respirations, the weak, rapid pulse, and the presence of numerous moist rales over the greater por- tion of both lungs. The absence of fever is a favorable clinical feature when pulmonary edema complicates an afebrile condition. Differential Diagnosis.— Hydrothorax, when it complicates val- vular heart disease or pulmonary disease, may be distinguished from pul- monary edema by the fact that in hydrothorax there is flatness at the bases (Fig. 45), and the upper level of this flat note changes with the posi- tion of the patient (see Pleurisy, Fig. 49), a phenomenon that does not occur in pulmonary edema. In pulmonary edema numerous moist rales are present over the area where the percussion-note is impaired, and the breath- sounds are slightly intensified; in hydrothorax, on the other hand, no riles are audible over this area, and the breath-sounds are absent. The sputum in hydrothorax is scanty, as a rule, while in pulmonary edema bronchor- rhea exists. BRONCHOPNEUMONIA. 107 BRONCHOPNEUMONIA (Capillary Bronchitis, Catarrhal Pneumonia). Pathologic Definition.— An inflammatory pulmonary consolidation, often developing secondary to bronchitis, various infectious diseases, and as a terminal infection. It is characterized by the presence of an acute inflamma- tion of the smaller bronchi and air-vesicles, with isolated areas of consolida- tion in both lungs (Fig. 35). The size of the consolidated areas varies from that of a pin's point to that of a pea, and these minute consolidations may coalesce, thus causing consolidation of a variable portion of one lobe. Surrounding each area of consolidation there are evidences of an attempt at compensatory emphysema. Clinical Varieties.— (ct) Suffocative Catarrh.— This term was employed by the earher writers to describe that type of disease, due to ex- posure to certain poisonous gases, in which the cerebral centers were affected and the patient remained in a somewhat stuporous condition. Dyspnea and cyanosis are constant, features and increase rapidly. Cough, which may be present early, disappears as the stupor increases. The respirations become more and more rapid and very shallow. Large, moist riles are audible over the entire chest; the heart-sounds become weak, and finally acute dilatation of the right heart results, which presages a fatal termination. (&) The Primary Form of Children. — In children under two years of age the disease frequently begins abruptly, the fever rising rapidly to from 102° to 104° F. It is possible at times to localize isolated areas of pulmonary consohdation with the aid of the stethoscope and the employment of auscul- tatory percussion. (See p. 59.) This tjrpe of bronchopneumonia in many respects resembles true lobar pneumonia, although its clinical course is, as a rule, somewhat diferent. (c) The Primary Form of Adults. — Where the patient is seen early, the signs and symptoms are those of a severe acute bronchitis, although the high fever, racking cough, increasing dyspnea, and profound prostration are more marked than in bronchitis. The sputum is scanty, and the general clinical picture resembles that of lobar pneumonia, differing only in the fact that definite physical signs — i. e., consolidation and bronchial breathing — are lacking. (d) Bronchopneumonia with Remittent Fever. — This type of catarrhal pneumonia is doubtless more common than is generally believed, and, be- cause of its peculiar temperature-curve, may occasionally be mistaken for some other condition. The febrile peculiarities are more often seen in children than in adults, although they may occur in the aged. This va- riety is of special interest, since it serves to explain the peculiar intermit- tency of the temperature during the course of many chronic febrile and afebrile maladies. (e) Cerebral Type. — In certain selected cases bronchopneumonia de- veloping in children may be ushered in with severe nervous symptoms, such as intense headache, convulsions, delirium, stupor, or even coma. In these cases, also, gastro-intestinal symptoms, such as nausea, severe vomiting, and diarrhea, with abdominal pain, are not infrequently present. The abdominal symptoms are often so severe that bronchopneumonia may not be recognized. A careful analysis of the character ,of\ the respira^iqns, the temperature, and the increasing rapidity of the heart's actioh,\ with a les- sening in the volume of the pulse, is often necesskry- in o]^der-to recognize this type of catarrhal pneumonia. 108 DISEASES OF THE BBONCHI, LUNGS, AND PLEUKA. (/) Ordinary Type. — Catarrhal pneumonia may develop during the course of acute, subacute, or chronic bronchitis, as well as during convales- cence from such acute infections as measles, whooping-cough, scarlet fever, diphtheria, typhoid fever, and influenza, or during the course of certam chronic maladies, such as nephritis, hepatic cirrhosis, carcinoma, and the anemias. This distinctly secondary type of the disease often develops insidiously, and the first evidence of its existence is had when the patient displays an irregular type of temperature, or when the temperature that was present in the primary condition becomes higher. The clinical features of this type of disease will be discussed below. Bxciting- and Predisposing: Factors.— Bacteriology.— It is extremely difficult to draw deductions from the pathologic evidence found at autopsy in those dead of bronchopneumonia. Weichselbaum and other observers have found in the minute areas of consoHdation, and by both the direct and cultural methods, streptococci, pneumococci, staphylococci, and the influenza bacillus. These and other bacteria have also been re- covered from individual cases that have come under our notice. When bronchopneumonia has complicated typhoid fever, the typhoid bacillus is not an unusual finding. Colon bacilli are commonly cultivated from the area of consolidation, the rule being, however, to find more than one organ- ism; as previously stated, this makes it impracticable to estimate the pathogenicity of any organism cultivated from the areas of consolidation in bronchopneumonia. A bacteriologic study of the sputum, therefore, will reveal a number of types of bacteria, many of which are known to be pathogenic. (a) The disease may occur by direct extension of an acute inflammatory process due to the inhalation of some irritating substance, such as gas or ether. (6) It may follow the inhalation of particles of mucus, which not uncommonly occurs in laryngeal diphtheria and other conditions with ob- struction in the larynx, producing the so-called "inspiration pneumonia." (c) It may arise as the result of the entrance of liquid or semiliquid food into the trachea, an accident that seldom, if ever, takes place unless paralysis of the muscles of deglutition or impairment of sensation of the larynx and trachea is present. Inhalation pneumonia may also result from the in- spiration of blood during surgical operations upon the larynx, mouth, and tonsils, and is also a frequent complication arising during the course of carcinoma of the throat and of the esophagus. In the new-born pneumonia may follow the inspiration of amniotic fluid or of mucus from the birth- canal. It has also been found that, during the administration of ether to certain selected cases, — e. g., syphilitics, — ^there is likely to be a hypersecre- tion of mucus from the upper air-passages and buccal cavity, and particles of such mucus are occasionally inspired. Symptomatology. — Clinically, two quite distinct forms of catarrhal pneumonia may be said to exist — primary and secondary. Primary Bronchopneumonia. — This type is found more often among adults than among children, and is characterized by a somewhat acute onset, the symptoms being those common to acute bronchitis — i. e., pronounced dyspnea, severe cough with but slight expectoration, an irregular tempera- ture, varying b^etween 99° and 102° F., rarely reaching 104° F. In severe types of the disease the temperature may assume the continuous tjqje for from two to four days, decUning, as a rule, by lysis. The cough is always accompanied by a moderate amount of expectoration, which is at first glairy or frothy, and rather tenacious, and in occasional cases may be tinged BRONCHOPNEUMONIA. 109 with blood, the latter being more common when the pneumonia has been preceded by valvular heart disease. Secondary bronchopneumonia is a catarrhal pneumonia that develops during the course of some primary malady, the symptoms of pneumonia being frequently obscured by those of the primary affection. This type of catarrhal pneumonia seldom manifests itself until inflammatory changes in the bronchial mucosa have taken place. Secondary catarrhal pneumonia is readily recognized when the physician is thoroughly acquainted with the condition of his patient, and suddenly observes that the respirations are increased in frequency and become more and more rapid until, within the course of twenty-four to forty-eight hours, they may number from 30 to 60 or even 80 a minute. The patient, as the result of the primary disease from which he is suffering, is unconscious of the development of any acute symp- toms that mark the onset of catarrhal pneumonia — e. g., chill, nausea, muscu- lar pains, etc. _ The first manifestation observed by the patient is cough, with difficulty in breathing. Occasionally he complains that cough evokes a pain about the base of the chest, and that although he expectorates freely, he does not obtain any relief from the dyspnea. Thermic Features. — In both primary and secondary bronchopneu- monia the temperature is controlled largely by the preexisting condition, and is in no way characteristic, although, as a rule, it continues of an irregu- lar remittent type. Physical Sigfns. — Inspection. — In those cases in which there are numerous isolated pneumonic areas throughout the lungs the skin becomes dusky, the lips and finger-tips are cyanosed, the nostrils move quickly, and the respiratory movements are rapid, although the degree of chest expansion is somewhat limited. Extensive consolidation may follow as the result of coalescence of numerous small consolidated areas, in which case inspiratory retraction of the lower ribs and of the lower portion of the sternum has been observed, and is indicative of imperfect lung expansion. Palpation confirms inspection as to the limited expansion of the chest. Tactile fremitus may be increased in those cases in which areas of consolida- tion are situated immediately beneath the pleural surface, provided the patient's chest-wall is thin. The pulse becomes rapid during the first few hours after the onset of catarrhal pneumonia, reaching 120 to 140 beats a minute. As the disease advances the tension of the pulse is lowered, the wave becomes feeble and the rhythm irregular, and, as a late feature, the pulse is dicrotic and compressible. When catarrhal pneumonia develops during the course of certain maladies in which a pulse of high tension is a characteristic symptom, such as nephritis or scarlet fever, this change in tension and frequency may be a valuable prognostic guide. Percussion. — The percussion-note is influenced entirely by the location and size of the area of consolidation; thus, if there are a number of small pneumonic areas near the chest-wall, the percussion-note will be hyper- resonant, owing to the fact that each pneumonic area is surrounded by a zone of emphysema. On the other hand, where several of these isolated pneumonic patches coalesce to form one larger area of consolidation (Fig. 35), distinct dullness is obtained, but surrounding this large area of pneu- monic lung there is also a band over which hyperresonance is obtained. It is practically impossible to elicit impairment or dullness over a small area of consohdation unless this area is situated immediately beneath the pleura and the chest-wall is thin. Auscultation furnishes most valuable data, revealing, as it does, the no DISEASES OF THE BEONCHI, LUNGS, AND PLEURA. presence of numerous fine crepitant r41es over the pneumonic portions of the lung. The respiratory murmur will be found to have lost its normal quality and is distinctly bronchovesicular, whereas m those cases in wmcti several smaU areas of consolidation have united to form a large hepato- genous mass, true bronchial breathing is audible. Most important in con- nection with auscultation is the fact that alterations in the breath-sounds are always detected at the base of the chest, and occasionally at the apex, but are the same over both lungs. u + • I^aboratory Diagnosis.— The sputum is scanty at first, but in those cases in which catarrh of the respiratory tract has previously existed, it may be profuse. As a rule, it is frothy, glairy, and, in certain instances, may be streaked with blood. The sputum is tenacious, but not to the degree observed in the sputum of lobar pneumonia. A bactenologic study ot the sputum shows the pres- ence of numerous bac- teria. (See p. 108, Bac- teriology.') Leukocytosis may or may not be present, its presence or absence de- pending upon the general vitality of the patient, the nature of the preexisting disease, and the type of organism that has excited the pneumonic process. When present, it is merely an expression of the pa- tient's reaction against the disease. Illustrative Case of Bronchopneumonia Com= plicating Influenza. — S. W. W., male, age fifty-seven; height, 5 feet 9i inches; weight, 167 pounds. Family History. — Father died at the age of eighty-four; cause unknown. Mother died of pneumonia at the age of sixty-one. Three younger brothers liv- thirty years. No history of Fig. 35.- -Bronchopneumonia, Showing Isolated Area of Consolidation. ing. A sister died during childbirth at the age of malignancy or of constitutional disease in the family. Previous History. — Does not recall having any of the diseases of childhood except measles, at fourteen years of age. Had typhoid fever at the age of thirty-four, and an attack of some stomach disorder at the age of forty-three years. Since then he does not recall having consulted his physician except for an occasional cold. Social History. — Married, and has two daughters living. He is a business man, and although he spends most of his time indoors, he has always devoted a certain portion of the day to outdoor exercise, e. g., driving, horseback riding, and walking. Present Illness. — Began five days ago with headache, chiUy sensations, pains in the loins and limbs, extreme prostration, cough, and constipation. The weakness was progressive until, by the second day, he was unable even to sit up in bed. There were frequent attacks of sneezing, marked coryza, and lacrimation. Headache and muscular pains were intense during the first twenty-four hours, but subsided somewhat by the second and disappeared on the third day. The cough was harsh, occurring often in severe paroxysms, but was accompanied by sUght, if BRONCHOPNEUMONIA. 1 1 1 any, expectoration. On the third day, despite the fact that the patient's condition with reference to the respiratory tract seemed less favorable, the cough subsided. The patient was unusually nervous from the onset of the disease. On the night of the thu:d day there was mild delirium, and on the fourth and fifth days low muttering delirium was present, and continued throughout the course of the disease. Later there was muscular twitching, and the patient picked at the bed-clothes. At the onset the temperature varied between 99° and 101.5° F., but on the fourth day the physical signs of bronchopneumonia developed, and the general symptoms became intensified. The temperature rose to 102.5° F., and afterward continued to run an irregu- lar course throughout the disease. Physical Examination. — General. — At the time of onset the patient's expression was anxious. Upon attempting to move it was at once apparent that extreme prostra- tion was present, even the voice being weak. After the fourth day the patient rested upon his back, and when placed in one position, showed no inclination to move. The face and the skin in general were of a more or less dusky hue. Local Examination. — The face was flushed. The lacrimal secretion was exces- sive, and he was also greatly annoyed by the discharge from the nose. The mucous membrane of the nasal cavity, throat, and conjunctivae was congested. After the fourth day of the disease marked cyanosis of the lips, finger-tips, and tongue was present. The respiratipns were now rapid, and there was distinct working of the nostrils. Palpation. — Palpation confirmed inspection with reference to the rapidity of chest movements, and it was found that there were two small areas over the left side of the chest and one on the right, through which the spoken voice-sound was unusually well transmitted. The action of the heart was weak and rapid — about 120 beats a minute. The pulse was small, weak, readily compressible, and showed a tendency to become dicrotic. After the fourth and especially upon the sixth day it was practically impossible to count the radial pulse. Percussion over both lungs was negative, except over the small areas where vocal tactile fremitus had been found increased, and here, upon deep percussion, a variable degree of impairment of the percussion-note was observed. Upon the fifth day of the disease the percussion-note was impaired posteriorly over the bases of both lungs. AxLscultation. — ^The breath-sounds were harsh, and during the first two days of the illness were accompanied by a few scattered dry and moist rales. During the third and fourth days numerous rales, chiefly subcrepitant, were heard over various portions of both lungs, and the breath-sounds over the small areas showing impaired resonance were bronchovesicular. Upon the fifth day the breath-sounds were accompanied by large numbers of bubbUng rdles, and at this time pulmonary edema was probably present. This tjrpe of respiration continued until the end. The heart-sounds, while rapid, showed a lowering of the muscular quality, and during the fourth and fifth days of the illness the first sound had practically lost its booming quality, and the so-called "fetal" heart-sounds were audible. Laboratory Findings. — As soon as the symptoms became distinctive, specimens of the secretion from the nose, throat, and conjunctivae were stained, with a view to detecting the presence of the influenza baciUus. They showed the presence of many slender bacilli, morphologically identical with the bacillus of Pfeiffer. Cultures from the same source made upon blood-serum that had previously been treated with hemo- globin also showed the influenza baciflus. The urine became scanty during the third day, and at the fifth day anuria developed. The urine gave a well-marked reaction for albumin, but casts were not found until the fourth day of the disease, and were of the granular variety. Course of the Disease. — ^When first seen by the physician, the ..cKnical picture was that of influenza, and a diagnosis of this disease was made and was later confirmed by the laboratory findings. The case continued to be one of uncomplicated influenza until the third or the beginning of the fourth day of the illness, when the symptoms of bronchopneumonia were added. After the fourth day the patient's general condition progressed from bad to worse, and on the fifth day pulmonary edema developed. Death occurred on the sixth day. Summary of Diagnosis. — ^The diagnosis is made first from a thorough study of the preexisting condition, or from a history of exposure to the excit- ing causes — (a) inhalation of gas, anesthesia, and operations upon the mouth, nose, and throat. (6) The previous existence of a disease that has had de- lirium as one of its clinical manifestations should always arouse suspicion 112 DISEASES OF THE BRONCHI, LUNGS, AND PLEUBA. of bronchopneumonia, and should encourage a careful physical examination of the chest, (c) While the preexistence of bronchitis is also of importance in formulating a diagnosis of catarrhal pneumonia, in addition there must be detected isolated areas of pulmonary congestion or consolidation, (d) Dyspnea and cyanosis are among the most constant symptoms of this affec- tion, and are dependent upon the number of areas of consolidation and the extent of their distribution throughout both lungs, (e) The somewhat pro- longed duration of the course, the fact that the febrile manifestation does not terminate by crisis, and the irregular (remittent) type of fever are impor- tant factors in the diagnosis. (/) The heart's action, as shown by the in- creased rapidity and decided weakness of the pulse, is to be considered in making a diagnosis of bronchopneumonia, and there is, as a rule, a variable degree of dilatation of the right heart. Dififerential Diagnosis. — Occasionally bronchopneumonia may be mistaken for lobar pneumonia that is tuberculous in origin. The rule, however, is that tuberculous processes involve the apices rather than the bases of the lungs, but this is by no means a constant finding. Occasionally cases of so-called simple catarrhal pneumonia are seen in which the apex of one or of both lungs is involved. During the early stages it is quite difficult to distinguish between these two conditions, but as the disease advances the physical signs of a tuberculous process, including cavity formation, become distinct, and a microscopic examination of the sputum may disclose positive evidence of the existence of tuberculosis. In acute tuberculosis the feces often contain tubercle bacilli. The accompanying table, modified from Anders, sets forth the distinctive features between bronchopneumonia (catarrhal pneumonia) and lobar pneumonia : Bbonchopneumonia. Lobar Pneumonia. Etiology. 1. Presence of pathogenic organisms* 1. Presence of the Diplococcus pneu- (streptoeocci). moniae. 2. Usually secondary to bronchitis and 2. Usually a primary disease, acute infectious diseases, e. g., measles, whooping-cough. Clinical History. 3. Onset gradual, without rigor. 3. Onset abrupt, with rigor; previous health generally good. 4. Fever is governed by the extent of the 4. Fever is high, of continuous type, and inflammation, is of irregular type, and falls by crisis between the fifth and after a variable duration, declines by ninth days. lysis. 5. Sputum glairy, tenacious, and in adults 5. Sputum characteristic (rusty or prune- may be blood-tinged. juice and very tenacious). 6. Dyspnea and cyano'sis prominent. 6. Dyspnea and cyanosis relatively less __,.,. . ,. , , marked; countenance anxious. 7. Physical signs of generalized bronchi- 7. Signs of bronchitis generally absent- tis always marked, and usually pre- those of lobar consolidation al- ponderating over those of consoli- ways preponderating dation. 8. Consolidation commonly bilateral. 8. Commonly unilateral 9. Duration indefinite, often extending 9. Duration definite, as a rule; convales- ,« ^''^'" ,'?ia^y,^eeks. cence follows crisis. 10. Consolidated areas hkely to become 10. Far less likely to become the seat of the seat of tuberculous infection. tuberculous infection. _ * The discovery of streptococci in the sputum is of questionable diagnostic value, since numerous other organisms have been found in the sputum of bronchopneumonia when streptococci were absent. The Streptococcus pneumonia of Weichselbaum has also been found in a number of cases of lobar pneumonia. CHRONIC INTERSTITIAL PNEUMONIA. 113 Clinical Course. — This is governed entirely by the degree of dis- semination of the minute areas of consolidation in each lung. In those cases in which primary bronchopneumonia foUows the inhalation of irritating and foreign substances the clinical course is rapid and reaches its height within from twenty-four to seventy-two hours. In the mUd forms of primary catarrhal pneumonia recovery generally ensues in from seven to fourteen days. In secondary pneumonia the chnical course and prognosis are governed largely by the preexisting disease, and when this has been of a mild type, a favorable termination may be expected in the course of two or three weeks. In those suffering from a severe type of typhoid fever, influenza, scarlet fever, etc., the catarrhal pneumonia is also hkely to be of a severe grade, and continues for three or more weeks unless a fatal termination ensues. Death occurs in from 28 to 50 per cent, of such cases. LOBAR PNEUMONIA (Croupous or Fibrinous Pneumonia? Pneumonitis? Lung Fever). Pathologic Definition. — An acute infectious disease caused by the Diplococeus pneumoniae, which produces an acute inflammation of the sub- stance of the lung. It is characterized pathologically and clinically by three stages: (1) The stage of congestion; (2) the stage of red hepatization, and (3) the stage of gray hepatization. (See Infectious Diseases, p. 770.) CHRONIC INTERSTITIAL PNEUMONIA (Fibroid Induration? Cirrhosis of the Lung). Pathologic Definition. — A primary or secondary, subacute or chronic, disease, characterized by the overproduction of pulmonary connec- tive tissue. Varieties. — Local interstitial pneumonia is a term used to describe a condition in which but a portion of one lobe or of one lung has become sclerotic and contracted; diffuse interstitial pneumonia differs from the localized type only in the fact that in the former there is an overproduction of the pidmonary fibrous connective tissue in both lungs, such fibrous growth generally involving the greater portion of the entire pulmonary tissue. Predisposing and :Bxciting Factors. — Interstitial pneumonia is occasionally encountered as an apparent primary condition, but in the majority of cases it is secondary to some prolonged inflammatory process involving the lung tissue. Pneumonokoniosis, or continuous exposure to the inhalation of certain irritants, — e. g., dust, particles of steel, hme, and the like, — may produce chronic interstitial changes in the lung tissue. Local- ized interstitial pneumonia not infrequently complicates acute pneumonia, pulmonary abscess, and, less often, it is the result of pulmonary tuberculosis, syphilis, disease of the pleurae, cysts of the lung, and emphysema. Diffuse interstitial changes in the lung may occur: (1) After low-grade types of lobar pneumonia or bronchopneumonia in which resolution has been delayed. (2) They may develop as a sequel to influenza in which there have been indefinite symptoms of pneumonia. (3) They may occur in cases in which a portion of the lung becomes atelectatic, due either to disease of the lung itself or to pressure from without. (4) Interstitial changes may take place in and about the pneumonic areas of those recovering from bron- 8 114 DISEASES OF THE BHONCHI, LUNGS, AND PLEURA. chopneumonia, and after some time has elapsed the entire lung may become highly sclerotic. (5) Bronchopneumonia excited by the tubercle bacillus often shows a special tendency toward the development of fibroid changes in the lung, and this condition has been designated pulmonary tuberculosis with the production of fibroid tissue. (6) In certain cases of pleurisy there is a decided tendency toward the formation of connective tissue, and this pathologic change may extend from the pleura to the lung tissue, imtil finally the greater portion of the lung is bound down by dense, fibroid bands, or may be penetrated by fibrous tissue that extends deeply into the lung substance. (7) As a rule, both the lung and pleurae are affected by the fibrous change, but a high grade of fibrosis of the lung may occur without coincident change in the pleura, or the reverse condition may obtain. Principal Complaint.— There is a definite history of a continuous loss of flesh and of strength, which may have covered weeks, months, or even years. The patient usually complains bitterly of cough, which grows progressively worse, and is always accompanied by a mucoid or mucoserous and, at times, bloody expectoration. If the disease is due to pneumonokonio- sis, the sputum may be discolored by the substance inhaled. Dyspnea occurs upon the slightest exertion. Pain may or may not be present, but in those cases in which there are many pleural adhesions it is an annoying symptom. Owing to the high grade of interstitial change that frequently takes place, constriction of certain portions of a bronchus, with an appre- ciable expansion of another portion of the same bronchus, may occur, and, as a sequence, the patient may exhibit symptoms of bronchiectasis. Thermic Features. — ^The temperature is normal in imcomplicated cases of chronic interstitial pneumonia. Physical Signs. — Inspection. — ^According to whether the condition is bilateral (rare) or unilateral the chest-wall is retracted, and this retraction is usually most conspicuous at the apices, although there may be basilar contractions with overdistention of other portions of the chest. Generally, however, the contour of the chest in chronic interstitial pneumonia is irreg- ular. By inspection certain portions of the chest will be seen to expand freely, while other portions remain unchanged or expand but feebly. In those cases in which the left lung is most affected the heart is likely to be displaced upward and probably to the left. In right-sided chronic in- terstitial pneumonia it is not uncommon to find the heart drawn well to the right of the sternum. Palpation confirms inspection with reference to the expansion and con- tour of the chest. Tactile fremitus is, as a rule, increased, and particularly is this the case over those portions of the chest-wall that have sunken as the result of fibrous pulmonary changes. Occasionally, as the result of certain changes in the pleurae, the tactile fremitus is found to be decreased. Percussion. — ^The percussion-note will vary within wide limits over different portions of the same lung; thus, dullness and almost flatness may be obtained where marked sclerotic change in the lung tissue and decided thickening of the pleura have taken place, while but a short distance away from this point the percussion resonance may be hyperresonant or even tympanitic in character, the latter note depending upon the existence of compensatory emphysema. The area of cardiac dullness may also vary with the character and degree of fibrous change present (retraction of the lung). Auscultation. — The breath-sounds are in no way characteristic. If fibrous bands connect a bronchus directly to the surface of the chest, the breathing will often be bronchial in character, although but shght actual PNEUMONOKONIOSIS. 115 consolidation may be present. If a bronchus is expanded, amphoric or even cavernous breathing may be elicited. As a rule, the breath-sounds at the base of the lungs posteriorly are feeble. A friction-sound is often detected, and may be present over a period of several days or weeks. Rdles are also present, but are of limited clinical significance. Summary of Diagnosis.— A diagnosis is attained, first, from a careful analysis of any preexisting disease of the lung and pleura. Next, the physical signs are of importance; thus deformity of the chest, marked re- traction of the affected side, and irregular expansile movements are among the most positive findings of chronic interstitial pneumonia. Cough and dyspnea with moderate emaciation are additional evidence of the existence of this disease. Clinical Course. — ^This is chronic throughout, the patient growing slightly, although progressively, worse for a period of three, five, or more years. A fatal termination seldom results directly from interstitial pneu- monia, but is due usually to an intercurrent malady. PNEUMONOKONIOSIS (ANTHRACOSISj CHALICOSISj SIDEROSIS). Pathologic Definition. — ^A variety of chronic interstitial pneumonia due tothe inhalation of small particles of a soUd substance, such as lime, stone, iron, or coal. The various forms of the disease derive their names from the character of the substance inhaled. Thus: (a) When interstitial change in the lung follows the inhalation of coal- dust, the disease is known as anthracosis. A macroscopic study of the lung shows it to be brown or black in color, its pleural surface presenting a mottled appearance. Upon incising the organ the knife encounters a gritty, stone-like resistance. Microscopically particles of black pigment are to be found within the pulmonary tissue, and there may also be an increase in the fibrous connective tissue, although in those suffering from the so-called miner's asthma undue distention of the air-cells may be apparent. (6) A similar pathologic condition presenting the same clinical symptoms is seen in stone-cutters. This is termed chalicosis. (c) Employees of factories and foundries in which the air is laden with metallic particles often develop sclerotic changes in the lungs, the condition being known as siderosis. Rincipal Complaint. — ^The symptoms develop somewhat insidi- ously, and within the course of a few months the patient complains of chronic bronchitis. This condition, however, does not exist until after several months or even years of more or less constant exposure to the irritating substances. After the symptoms of asthma (p. 97) have been present for weeks, months, or possibly years, the patient develops emphysema (see p. 124), which maybe either localized or general, and at this time the symp- toms he complains of are practically those of emphysema. Physical Signs. — ^These are not at all distinctive, nor are they con- stant in .any series of cases. Generally speaking, the physical signs of an- thracosis are the same as those of chronic interstitial pneumonia (q. v.), the exceptions to this general rule being that in selected cases emphysema develops early, and that instead of the chest being retracted, it is abnormally distended. I^aboratory Diagnosis. — This offers the most reliable clinical evi- dence. Regardless of the cause of the disease in question, the sputum is copious, and each paroxysm is followed by profuse expectoration. In an- 116 DISEASES OF THE BRONCHI, LUNGS, AND PLEURA. thracosis the sputum may be black or brownish in color, and when studied under a J or ^^ inch oil-immersion lens, small particles of coal will be seen to be present (Plate I). Not uncommonly leukocytes containing small black particles of dust are seen, and, indeed, dust is often apparently em- bedded within certain epithelial cells. The sputum of those suffering from stone-cutter's disease or of those who have been exposed to the inhalation of plaster-of-Paris or of Ume shows the presence of many small white or grayish particles of silica. The macroscopic appearance of such sputum, however, is in no way diagnostic. In siderosis, as in anthracosis, the sputum is characteristic, being rusty colored or red- dish, and upon microscopic study presenting fine particles of metallic sub- stance. The sputum of pneumonokoniosis always contains many degenerated epithelial cells, leukocytes, pus-cells, and a profusion of bacteria. The tubercle bacillus is a common finding. Summary of Diagnosis. — ^A history of exposure to coal, stone, iron, or metalUc dusts is of great importance, and should always suggest pneumo- nokoniosis. The symptoms of bronchitis, the physical signs of interstitial pneumonia, and the characteristic microscopic findings in the sputum leave no room for doubt as to the nature of the condition. Course and Duration. — ^This form of chronic fibroid pneumonia is of prolonged duration, the patient growing progressively worse from year to year, the condition, as a rule, terminating in pulmonary tuberculosis. PULMONARY TUBERCULOSIS. Pathologic Definition. — An infectious disease caused by the Bacillus tuberculosis. It may be acute or chronic in form, and is characterized by the formation of small tubercles in the lungs and in other portions of the body. When infection is localized to the lung, large areas of consolidation occur, which eventually break down and result in cavity formation. When general infection takes place, the so-called miliary tuberculosis results. In the latter condition microscopic tubercles may be found in the muscle tissue, choroid, and in practically all the viscera. (See Infectious Diseases, p. 803.) PNEUMORRHAGIA (Pulmonary Apoplexy). Pathologic Definition.— The escape of blood from the pulmonary vessels into the air-cells and connective tissue of the lung, either with or without appreciable laceration of the pulmonary tissue. Varieties. — There are three varieties — the circumscribed, the pneu- monic, and the diffuse. Predisposing and il^xciting Factors.— The most common cause of pulmonary apoplexy is rupture of a thoracic aneurism after it has become_ firmly adherent to the visceral pleura. The conditions that favor the accident are those that favor the rupture of thoracic aneurism — e. g., traumatism to the chest, heavy lifting, and morbid states that increase the heart's action. Sex is a predisposing factor, the majority of cases occurring in adult males. Clinical Features.— As a rule, the history and physical signs of aneurism are present prior to the development of pulmonary hemorrhage, and the general clinical picture is that described under thoracic aneurism (p. 312) , the most prominent characteristics of which are hemoptysis, dysp- PULMONARY EMBOLISM. 117 nea, cyanosis, subnormal temperature, and a tendency toward circulatory collapse. Physical Signs. — If the patient survives the initial hemorrhage, the physical signs of pulmonary consolidation may be eUcited in selected cases. I/aboratory Diagnosis.— The sputum is almost pure blood, is expelled with but slight coughing, and does not contain tubercle bacilli or fungi. PULMONARY EMBOLISM (Hemorrhagic Infarction, Embolism of the Lungs). Pathologic Definition.— A condition caused by thrombosis or by embolism of a branch of the pulmonary artery, resulting in a wedge-shaped infarct, the base of which is directed toward the pleura. The involved portion of the lung becomes firm, airless, and dark in color. This condi- tion may be single or multiple, the area of pulmonary tissue involved rarely exceeding the size of a walnut. Varieties and :Btiology.— (1) Non-septic embolism occasionally occurs during the course of chronic organic heart disease, and is said to follow mitral stenosis and, less often, mitral regurgitation. Thrombi may also be generated in the right auricle or in the large vessels^ and finally be- come lodged in the branches of the pulmonary artery. Venous stasis in- volving the pulmonary tissue also predisposes to pulmonary infarct. (2) Fat Emboli. — The pulmonary vessels are plugged with emboli of fat. There may be minute hemorrhages into the interstitial tissue sur- rounding the lesion, and the small arteries are filled Avith fat. Predisposing Factors. — Traumatism to the adipose tissue and fractures. Symptoms. — In this type of fat-embolus are seen extreme dyspnea, cardiac failure, and temperature ranging about 102° F. Symptoms usually progress from bad to worse. (3) Septic emboli are carried to the lung from septic processes else- where in the body, and may complicate gangrenous or suppurative condi- tions involving remote organs. Principal Complaint. — In non-septic cases both the history and the general clinical features are those of valvular heart disease. Following the pulmonary embolism acute symptoms develop — e. g., pain in the chest, dyspnea, expectoration of blood-streaked mucus, followed by syncope. Hemoptysis, while not a constant feature, is of clinical significance when it develops in a patient suffering from mitral disease, and when it is accom- panied by severe pain and cough, is still more significant of pulmonary embolism. Physical Signs. — ^Unless the area of lung involved is comparatively large, percussion and palpation are negative. If several emboli are lodged in different portions of the lungs, the character of the respiration is that of bronchopneumonia (p. 109). By palpation it is at times possible to detect areas in which the tactile fremitus is increased and the percussion-note impaired. Auscultation. — ^Moist rdles are audible over the, greater part of the affected lung, and the breath-sounds are intensified. When a large area of lung collapses as the result of an embolus, bronchial breathing may be audible. It must be borne in mind that the physical signs are in part, at least, the result of hyperemia of the surrounding pulmonary tissue, and, indeed, in many instances the actual condition is obscured by the emphysema which surrounds the diseased portions of the lung. 118 DISEASES OF THE BRONCHI, LUNGS, AND PLEUKA. I/aboratory Diagnosis. — The sputum is often bloody, the blood being equally distributed throughout. It is easily expectorated, is always frothy. Clinical Course. — Septic cases run a rapid febrile course, and the prognosis is that of pyemia. In non-septic emboli the course is also rapid, but the condition may exist for days or even weeks and recovery follow. PULMONARY GANGRENE. Pathologic Definition. — A condition produced by the action of the organisms of putrefaction upon a devitalized section of pulmonary tissue. The extent of the destructive changes in the lung tissue varies greatly in different cases. The gangrenous area is surrounded by a zone of congestion. Varieties. — (a) Diffuse gangrene is rarely seen complicating lobar pneumonia. In this condition there may be occlusion of the larger branches of a pulmonary artery. This process may be so extensive as to involve an entire lobe; cases have been reported in which an entire lung was destroyed. (b) Circumscribed gangrene may be unilateral or bilateral. Circum- scribed gangrene may follow embolus of an artery, or, as is more often the case, it may be the termination of an acute inflammatory process. Exciting and Predisposing Factors. — (l) Gangrene occurs when the pulmonary tissue, devitalized from any cause, is attacked by the organ- isms of putrefaction. Pathogenic bacteria may also be present, although the part played by this class of micro-organisms is questionable. The exact degree and nature of the changes in the pulmonary tissue necessary for the development of saprophytic bacteria (organisms producing gangrenous changes) have long been the subject of controversy; suffice it to state here that both saprophytic and parasitic bacteria are likely to be present in the sputum of pulmonary gangrene. (2) Acute inflammation of the lung, — e. g., lobar pneumonia, — ^broncho- pneumonia, tuberculous cavity with secondary infection, acute bronchitis, stab wounds and traumatism of the lung, contusions of the thorax, as well as inflammation resulting from perforation of the diaphragm or of the esophagus by carcinomatous or ulcerative processes, are all conditions that predispose to the development of pulmonary gangrene. In fact, it is by one or more of these processes that the vitality of the pulmonary tissue is lowered. (3) Pulmonary hemorrhagic infarction, emboli derived from gangrenous tissue elsewhere in the body and from purxilent tissue, with the production of pulmonary abscess, may at times be the exciting causes of gangrene. Pulmonary gangrene frequently develops from an embolus that probably originated in a suppurative process in the middle ear or the mastoid cells. (4) Foreign bodies — e. g., particles of food, metallic substances, etc. — entering the lung by way of the trachea are prominent exciting factors in pulmonary gangrene. (See Bronchopneumonia, p. 108.) (5) Thoracic tumor, either aneurismal or glandular, may, by continual pressure upon the lung, give rise to gangrene. (6) Those suffering from certain acute infectious maladies — e. g., noma — are especially likely to develop gangrene. In protracted febrile conditions pulmonary gangrene may occur as a comphcation, but seldom develops until convalescence sets in. (7) In such afebrile conditions as diabetes mellitus and chronic valvular (mitral) heart disease gangrene of the lung is not of infrequent occurrence. (See Pulmonary Embolism, p. 117.) PULMONARY GANGRENE. 119 Principal Complaint. — In those cases in which the area of gan- grenous involvement is small and in which secondary infection with pyogenic bacteria has not occurred, there are few, if any, constitutional symptoms, and the patient complains only of cough and the expectoration of fetid ma- terial. In this class of cases the physical signs are negative. In those suffering from more extensive pulmonary gangrene or gangrene following abscess-formation, pneumonia, the inspiration of foreign sub- stances, etc., there are progressive weakness and loss in weight. Anorexia develops early, and continues throughout the disease. The most annoying symptom is cough, which is paroxysmal. The patient may cough between the paroxysms, but, as a rule, a violent spell of coughing occurs every two to six hours, particularly after awaking from sleep. During each attack of coughing a large quantity of sputum may be expectorated and emit a characteristic gangrenous odor. (See Laboratory Diagnosis, p. 120.) In the majority of instances the patient's breath also gives off this offensive odor, although this is not a constant finding, having been absent in a case observed by one of us, in which the gangrenous process was found at autopsy to have no direct communication with a bronchus. Pam may be present, but is seldom an annoying symptom unless the areas of lung that are involved are superficially situated and an associated pleurisy is present. Vomiting may be an annoying symptom, and is prob- ably excited by the offensiveness of the material expectorated. The patient's general condition usually progresses from bad to worse, until finally he is unable to leave his bed. Pulmonary hemorrhage, although by no means a common symptom, may foUow ulceration of the pulmonary artery, and profuse hemorrhage may rarely cause a fatal termination. Thermic Features. — Early in pulmonary gangrene the fever becomes irregular, fluctuating between 99° and 102° F. In those cases in which sepsis becomes profound or gangrene develops secondarily to a suppurative process elsewhere, the temperature is governed largely by the preexisting condition, and is often of the continued type; an exception to this rule is seen in pulmonary gangrene complicating pulmonary tuberculosis with cavity formation, in which there is an evening rise in temperature followed by a morning remission. Physical Signs. — Inspection. — In cases showing constitutional symptoms there is extreme pallor, and later cyanosis of the mucous mem- brane, finger-tips, and feet develops. Swelling of the ankles may also occur late during the course of the process. Profound emaciation is always present in this class of cases. Palpation. — The pulse becomes weak, rapid, irregular, and often dicro- tic. These and other characteristics of the pulse are dependent on the degree of prostration. If gangrene follows pulmonary abscess or pulmonary tu- berculosis, the evidence obtained upon palpation will be the same as that obtained in these conditions. (See Tuberculosis, p. 803.) Generally speak- ing, the tactile fremitus will be found increased whenever there is an associated consolidation of the pulmonary tissue that extends to a point near the chest-wall. Gangrenous areas that are located centrally, however, manifest no definite physical signs. The chest movements are frequent, and may 'be jerking in character. Percussion gives negative results except in those cases in which there is consolidation, when resonance is impaired. A hyperresonant note may be obtained over the lung immediately surrounding the gangrenous process. Auscultation. — ^The heart-sounds are weak and rapid, and there is 120 DISEASES OF THE BRONCHI, LUNGS, AND PLEURA. often evidence of valvular disease, which is particularly common when pulmonary gangrene follows embolism. During the stage of consolidation the breath-sounds over the affected regions are harsh and may be bronchial in character. Both fine and coarse moist rdles are audible, and late in the disease the breathing may be that heard in the presence of pulmonary cavity. If the pulmonary inflammation extends to the surface of the lung and the visceral pleura becomes involved, a pleural friction murmur may be audible. (See Pleurisy, p. 139.) X-Ray Diagnosis. — ^It is possible not only to locate accurately the site of the gangrenous process, but this affection gives a fairly characteristic picture. The shadow will be found to vary greatly, depending upon the size and duration of the process. (See p. 74.) I^aboratory Diagnosis.^The blood changes are those of secondary anemia; at times leukocytosis may be present. Cultures from the venous blood are likely to give positive results when gangrene follows septic processes. The sputvun is of a greenish or bloody color, and is frequently said to be "prune juice" in character. When placed in a conic glass and permitted to stand for several hom-s, the sputum will be found to have separated into three quite distinct strata: (1) A superior layer, which is frothy, opalescent, and of a greenish yellow color; (2) a middle stratum, which has the appear- ance of water; and (3) an inferior layer, which is composed of a greenish or brown sediment, showing macroscopically many shreds of mucus and necrotic tissue; rarely this layer is bloody. Microscopically, many bacteria are present, and portions of degenerated lung tissue, fibers of elastic tissue (rare), pus-cells, fungi, and both red and white blood-cells are seen. Summary of Diag^nosis. — ^This is determined largely by the char- acteristic odor of the breath and of the sputum. The fact that the sputum separates into the characteristic layers when permitted to stand for several hours, and the detection, in the inferior layer, of lung tissue, go far toward confirming the diagnosis. Rapid emaciation and progressive prostration are prominent features in pulmonary gangrene. Differential Diagnosis. — Fetid Bronchitis. — In this condition the sputum, while highly offensive, does not have a gangrenous odor, and emaciation and prostration are often lacking and are never profound. Fever, which is common in pulmonary gangrene, is not marked in fetid bronchitis. Clinical Course. — ^This is dependent, first, upon the extent of the pathologic process, and, secondly, upon whether or not such devitaUzed tissue becomes infected with pyogenic organisms. In those cases showing marked constitutional symptoms — e. g., fever, prostration, etc. — the clinic^ course is rapid, extending over a period of weeks; or at most months. Re- peated hemorrhages from the lung render the prognosis less favorable. PULMONARY ATELECTASIS (Collapse of the Lungj Compression of the Lung). Pathologic Definition.— A condition in which a portion or the entire volume of air is removed from the air-cells of a portion of the lungs. Predisposing and i^xciting Factors.— (1) This condition is most commonly encountered in the new-born and in prematurely born infants. In either case it may be the result of feeble breathing power on the part of the child or of malformation of the respiratory tract. (2) Acquired atelec- tasis may follow inflammatory processes with the production of mucus in ABSCESS OF THE LUNG. 121 the smaller bronchial tubes. (3) Compression of the lung from whatever cause (pericardial effusion, pleural effusion, thoracic aneurism, new-growths of the thorax, and pneumothorax) may also give rise to atelectasis. (4) Enfeebled respiratory efforts markedly predispose to the development of atelectasis, and may result from cerebral hemorrhage, interference with the nerve supply to the lung, pressure upon the diaphragm from large abdominal tumors, peritoneal fluid, and tympanites. (5) Late during the course of bronchopneumonia and lobar pneumonia portions of the lung may become atelectatic, as has been shown by autopsy. Symptoms and Signs. — As this condition is practically always secondary, the symptoms and signs are those of the preexisting disease, appreciably inteiisified, however, by atelectasis. _ Inspection.— The movements of the chest are, as a rule, limited to the apices. Respiration is labored and unusually frequent. Course. — ^The patient rapidly approaches a state of collapse, the pulse becomes weak and rapid, the skin cold and clammy, vitality diminishes, and death soon follows. ABSCESS OF THE LUNG (Suppurative Pneumonitis). Pathologic Definition. — An acute localized infection in which de- struction of the pulmonary tissue and a circumscribed accumulation of pus within the lung occur. Surrounding an acute abscess there is an area of consolidation, and still further beyond the pulmonary tissue is congested for a considerable distance. The abscess may communicate with a bronchus or may rupture into the pleura. Exciting and Predisposing Factors.— (1) Bacteria.— Strep- tococci are commonly present, but are not the only direct excitant. The diplococcus of pneumonia and the bacillus of Friedlander are not infre- quently seen, as are also other pyogenic organisms — e. g., staphylococci, Bacillus pyocyaneus, Bacillus coli communis. (2) An acute localized inflammation of the lung, such as is seen in both lobar and lobular pneumonia, may terminate in abscess-formation; hence the conditions that predispose to these types of pneumonia also pre- dispose indirectl}'' to the formation of abscess. (3) Penetrating wounds of the lung from without, perforation of the lung from ulcer or carcinoma of the esophagus, abscess of the liver, gastric ulcer, etc., are also among the exciting causes of pulmonary abscess. (4) The aspiration of foreign substances that may carry with them pyogenic bacteria is also productive of abscess. (5) In pulmonary tuberculosis with cavity formation abscesses are common, and isolated abscesses may be found in different portions of the lung. (6) Metastatic abscess of the lung may develop during the~ course of septic processes elsewhere in the body and during septicopyemia. Septic emboli from whatever source frequently find a lodging-place within the pulmonary tissue and give rise to circumscribed abscess there. In this particular type of infection of the lung the abscess is usually situated near the pleural surface and is often egg-shaped. The history is of considerable importance in making the diagnosis. Trauma to the chest may be an exciting cause. The tendency to the develop- ment of pulmonary abscess is greatly increased while a patient is under 122 DISEASES OF THE BRONCHI, LUNGS, AND PLEURA. treatment for septic conditions elsewhere or for acute ulcerative endo- carditis. Principal Complaint. — Pain may be a prominent feature in those cases in which the abscess is situated near the surface of the lung, and con- sequently excites pleuritis. Cough may be an annoying symptom, and is usually accompanied by the free expectoration of purulent material. Chills, followed by an elevation in the temperature and later by profuse sweating, are a conspicuous feature in a fair proportion of all cases. Prostration is progressive, and there is also a steady loss of weight. As a rule, the patient becomes nervous and irritable, and delirium is to be expected when fever is a conspicuous factor. Thermic Features. — The temperature is somewhat influenced by the preexisting condition; however, an irregular fever, 101° to 104° F., is to be expected. Physical Signs. — Inspection. — Emaciation is well marked. The skin and mucous surfaces are unusually pale, and if the abscess is large, the lips and finger-tips may be cyanosed. The movements of the chest vary greatly, depending upon whether or not the pleura is involved; in any case the respirations are increased, and if the abscess is large, the two halves of the chest may expand unequally. Palpation shows an increase in the tactile fremitus over the consolidated areas. The heart's impulse is weak and rapid, and abnormal pulsation is often detected above the right clavicle. Unless the abscess cavity is large and superficial, palpation may be negative. Percussion. — ^A variable degree of impairment is elicited over the abscess, and surrounding it for some distance there may be hyperresonance, due to compensatory emphysema. Auscultation. — ^The breath-sounds may be those heard in the presence of a cavity, yet this finding is unreliable in many instances. Owing to the inflammatory changes and edematous condition of the lung, large and small moist rMes are heard in the region of the affected area. Bronchial breath- ing is not infrequent. X-Ray Diagnosis. — ^Here the clinical features of pulmonary abscess are comparatively clear, and its location is possible through this means of diagnosis (p. 74). I/aboratory Diagnosis. — ^This probably furnishes the most rehable data in the diagnosis of pulmonary abscess. The sputum is purulent, yellow, or frequently greenish or brownish-yellow, in color, and at times it may be streaked with blood. The odor of the sputum is, as a rule, offensive, but at times sweetish, being distinctly different from that emitted from the sputum of pulmonary gangrene and of putrid bronchitis. Microscopically, it will be found to contain particles of lung tissue (elastic fibers), pus, red blood-cells, and granular tissue debris. Summary of Diagnosis.— (a) A history of the existence of some condition or an accident that predisposes to the development of pulmonary abscess is of great importance. (6) Diagnostic value is to be attached to the examination of the sputum and the detection of great numbers of elastic fibers. (c) The physical signs of cavity-formation, when present, go far toward confirming the diagriosis, but it is impossible to base the diag- nosis upon the clinical history and the findings obtained by physical exam- ination. _ The x-ray is important in this connection. Clinical Course. — ^In abscesses following the development of pyemic processes elsewhere the course is rapid, and the general clinical picture is NEW-GBOWTHS OF THE LUNGS. 123 that of septicemia plus the characteristics of pulmonary abscess. Abscess arising as a sequel of lobar pneumonia may run a protracted course, ter- minating favorably in from six to twelve weeks. Complications. — If the abscess is situated near the visceral pleura, it is likely to perforate the pleura, giving rise to a purulent pleuritis (p! 150), empyema, or pyopneumothorax (p. 161). NEW-GROWTHS OF THE LUNGS. General Remarks. — ^The most common tumors of the lung are car- cinoma and sarcoma. In rare cases these growths may be primary, and when _ this is the case, a unilateral development is observed. In the majority of instances, however, malignancy of the lung is a secondary con- dition, and both lungs are involved, numerous foci being seen. Carcinoma of the Lungs. Pathologic Definition. — A carcinomatous growth, often secondary, involving the pulmonary tissue and resulting in consolidation of the organ. The carcinomatous process may extend by contiguity to the pleurae and other thoracic structures. Varieties. — (1) Primary pulmonary carcinoma; (2) carcinoma second- ary to carcinomatous growth involving remote portions of the body (head, rectum, or extremities) ; this is, as a rule, bilateral. (3) Secondary carcinoma resulting from direct extension of a carcinomatous process from the esophagus, stomach, liver, or mammary gland; this is frequently unilateral. Principal Complaint. — This will be found to vary in accordance with the location and extent of the lesion. Pain is an early symptom, and in those cases in which the pleurae are involved, is agonizing. The general symptoms of bronchitis — e. g., cough, expectoration, dyspnea — are quite constant. If the growth becomes large, symptoms referable to pressure upon the heart and upon the large thoracic vessels are also present. Late during the course of pulmonary carcinoma pressure upon the esophagus may give rise to dyspnea; and should the recurrent laryngeal nerve become involved, hoarseness and aphonia ensue. (See symptoms of aneurism, p. 313.) Pulmonary tumor may also exert sufficient pressure upon a bronchus to cause the signs and symptoms of bronchial stenosis. (See p. 103.) Physical Signs. — Inspection. — In those cases in which there may be a large new-growth in the lung the thorax will be somewhat prominent and fixed over the site of the tumor. Cases are recorded in which a car- cinomatous mass protruded through the chest-wall. The interspaces are, as a rule, widened, and the cutaneous veins are distended. The right supra- clavicular region is unusually prominent, and often shows decided pulsation as the result of intrathoracic pressure. Edema of the face, neck, and even of the thorax and arms is a late symptom in pulmonary carcinoma. The axillary and cervical lymph-nodes are generally enlarged. Palpation confirms inspection as to the movements of the chest, enlarge- ment of glands, and edema, and, in addition, reveals the fact that the tactile fremitus is altered and in many instances absent over certain portions of the lung, whereas at other points it may be normal or increased as the result of pleuritic adhesions or localized areas of consolidation. If the pleura is attacked by the carcinomatous process, an effusion into the pleura generally 124 DISEASES OF THE BRONCHI, LUNGS, AND PLEUEA. follows, in which case the physical signs of serofibrinous pleurisy (see p. 142) are present in addition to those of pulmonary carcinoma. Percussion. — The note is impaired over aU portions of the lung invaded by the tumor, and the degree of impairment varies with the degree of pul- monary consolidation present. Auscultation. — Where there is extensive carcinomatous involvement of both lungs, the respiratory murmur may be greatly diminished, a,nd indeed absent, over certain locaHzed sections; but in those cases in which the tumorous growth is locaUzed along the course of a large bronchus, bron- chial breathing is audible, and, indeed, the breath-sounds may resemble those heard when a pulmonary cavity is present. Numerous large and moist riles may be present over one portion of the chest, while at other portions the breath-sounds may be absent. So varied is the evidence obtained by auscultation that this method offers but little valuable data in the study of this disease. lyaboratory Diagrnosis. — Free expectoration is an almost constant symptom; at the same time, during the course of the disease, the sputum resembles currant-jelly, or again it may be bloody, or perhaps green in color, depending upon the character of the changes that have taken place in the carcinomatous tissue. The sputum commonly emits an offensive odor. Microscopically, pus-cells, leukocytes, red blood-cells, granular debris, and occasionally clusters of epithelial cells — the so-called " cancer clusters" — are found; too great an importance should not be attached to find- ing the last-named elements. Crystals of hematoidin are occasionally seen. The hemic changes are those of secondary anemia. (See a;-ray Diagnosis, p. 75.) Clinical Course. — Carcinoma of the lung progresses from bad to worse, terminating fatally within a few weeks or months. SARCOMA OF THE LUNG. Remarks. — Sarcomatous disease frequently invades the glandular tissue at the root of the lung, although secondary sarcoma of the lung proper may also be met. The diagnosis of sarcoma is based largely upon the clinical history and the preexistence of a sarcomatous growth elsewhere. The symptoms and signs closely resemble those of pulmonary cancer {q. v.). Two cases of pulmonary sarcoma have developed in patients under the care of one of us at the Philadelphia General Hospital, and both of these followed sarcoma of the knee. PULMONARY EMPHYSEKTA. Pathologic Definition. — This is a chronic disease, characterized by an abnormal thinning and loss of power of the pulmonary air-cells, with overdistention of such cells by air, and possibly escape of air into the interlobular connective tissue. The bronchial mucous membrane is usually the seat of a chronic inflammation. (See Remarks and Pathologic Char- acteristics, p. 125.) Compensatory emphysema, however, is not a pathologic process, but consists in physiologic dilatation of the air-cells secondary to pathologic processes in other portions of the lung. Varieties. — (1) Interlobular emphysema is a condition in which HYPEHTROPHIC EMPHYSEMA. 125 an air-cell has ruptured and a portion of its contained air has escaped into the surrounding connective tissue. (2) Vesicular emphysema is an abnormal dilatation of the alveoli and finer air-passages. There are three varieties: (a) Compensatory; (b) hypertrophic; and (c) atrophic. Interlobular Emphysema. Btiologic Factors.— These include: (a) Injury to the lung, pene- trating wounds made by fractured ribs, violence, etc. (6) Paroxysmal coughing, as, e. g.,m whooping-cough, and the inhalation of irritating gases; indeed, this condition may rarely follow violent muscular exercise, con- vulsions, and labor. This t5^e of emphysema selects by preference the upper lobes and anterior surface of the lung. Interlobular emphysema may rarely be found as an associated condition in advanced stages of vesicular emphysema. Vesicular Emphysema (Compensatory Emphysema). This variety is limited to certain localized pulmonary regions, and, as its name implies, occurs as the result of pathologic conditions in other portions of the viscus that prevent, or at least inhibit, lung expansion during the act of inspiration. Compensatory emphysema, therefore, is not a patho- logic condition, but a vicarious one, demonstrating the capability of the air- ceUs in one portion of the lung to expand sufficiently to do the additional work of a diseased part. Among the diseases in which compensatory emphysema occurs are pulmonary tuberculosis, lobar pneumonia, chronic tuberculosis with cirrhosis of the lung, and extensive disease of one lung. A good example of compensatory emphysema is seen in pleurisy with effusion, where one pleural sac is nearly filled -with flmd, and in pyopneu- mothorax. If the greater part of one limg is incapacitated by disease, as in lobar pneumonia, the remaining portions of the diseased organ and its fellow display general emphysema. It is, therefore, seen that compensatory emphysema, while probably a physiologic process, is nature's method of obtaining compensation for the loss of a portion of lung by any pathologic condition. Hypertrophic Emphysema. Remarks. — In this condition pathologic changes have resulted in a diminution in the retractility and elasticity of the lungs, as the result of overdistention of the individual air-cells, in consequence of which the lungs become permanently enlarged (air-cells expanded) . In those persons who develop true emphysema early in life it is fair to presume, at least, that the retractile lung energy was deficient, possibly as the result of a congenital condition. Pathologic Characteristics. — Macroscopically, large air-cells can be distinguished immediately beneath the pleurae, and air-sacs as large as a walnut, and even larger, may project above the lung's surface, a series of air-blebs being commonly seen at the anterior border. A microscopic study shows that the dilatation originates in the infundib- ular and alveolar passages. The septa are partially obliterated; the alveo- lar walls are thinned and finally perforated, and in consequence of these 126 DISEASES OF THE BRONCHI, LUNGS, AND PLEURA. changes the air-cells communicate with one another. The process is an atrophic one, the elastic fibers disappearing, whereas the larger ones become less conspicuous and often, rupture. Following atrophic changes the capilla- ries disappear, and the epithelium of the air-cells undergoes fatty degenera- tion. Ordinarily, the bronchial mucous membrane is the seat of a chronic inflammation. The diaphragm is appreciably lowered, and the liver and spleen are correspondingly depressed. Physiologic Pathology. — ^The right side of the heart shows well-marked changes: the cavities are dilated and the walls slightly hypertrophied, owing to obstruction in the pulmonary circulation. The pulmonary artery and its branches are enlarged and the seat of an atheromatous degeneration. Exciting: and Predisposing Factors. — (1) This affection is most often a secondary one, developing during the course of other diseases of the lungs, e. g., whooping-cough, chronic bronchitis, and asthma. When it develops under such conditions, emphysema is directly attributable to the mechanic influence and strain put upon the alveolar walls during the act of coughing. There is also interference mth the escape of air from the air-cells and smaller bronchi. Many of these primary affections result in an increase in the intra-alveolar air-pressure, and, as a consequence, the cell itself becomes permanently expanded. (2) In both whooping-cough and bronchial asthma the condition is at first that of a temporary emphysema, but numerous recurrences produce permanent overdistention of the lung. (3) That occupation is not without influence is seen in the case of musi- cians who play wind instruments, and who, not infrequently, present a variable degree of emphysema. Violent muscular exercise also tends to produce permanent dilatation of the air-cells, consequently emphysema is common in stevedores, stokers, athletes, and those who do heavy lifting. The disease is one of the working classes, and 7nales are more often affected than females. (4) Heredity plays quite a prominent part in the etiology of this disease, and many members of the same family may suffer from emphysema; indeed, it is occasionally seen to extend through several generations, affecting one or more in each. (5) Age. — ^After the age of fifty the elasticity of the lung tissue is dimin- ished, and in consequence a variable degree of emphysema develops. At the other extreme of life, as previously mentioned, congenital emphysema may be present. Organic heart disease and any other condition that causes a permanent congestion of the lungs markedly predispose to emphysema. Principal Complaint.— Emphysema develops insidiously, and the patient is, as a rule, unaware of his actual condition, complaining of the symptoms of chronic bronchitis, asthma, or whatever other pulmonary disease was originally present. In those cases in which emphysema occurs as the result of occupation the condition develops slowly, but in whooping- cough the lung becomes emphysematous in the course of a few days. In the former class the history shows that the patient has suffered from a gradual loss of strength and of flesh for some years, and in many cases he is conscious of the deformity of his chest (Fig. 36). The most marked symptom is dyspnea, together with paroxysmal cough, the severity of these symptoms varying in proportion to the degree of distention of the pulmonary air-cells. In this pulmonary condition mild HYPERTROPHIC EMPHYSEMA. 127 Fig. 36 — Emphysematous Chest (Dr. W. H. Smith, Massachusetts Geaeral Hospital). dyspnea is constant, but upon physical exertion it often attains an extreme degree. Late during the disease the patient's speech is somewhat characteristic, and his sentences are interrupted. As the disease advances the respiratory symptoms become more and more distressing, until, at length, as the result of increased blood tension in the lung, cardiac symptoms develop. Cough is believed to be due to the presence of an associated bronchitis, and is particularly annoying during cold weather. Indeed, there is a type of emphysema that appears in young adults and affects them most during the winter months, when they display all the characteristic features of this disease. Thermic Features.— Fever is absent throughout the entire course of imcomplicated cases of emphysema, and a subnormal temper- ature is by no means uncommon. Physical Signs. — Inspection. — In ad- vanced cases there is lividity of the skin and mucous surfaces. The contour of the chest is characteristic; it is often barrel-shaped, the an- teroposterior diameter being markedly increased; whereas the transverse diameter remains nearly normal (Fig. 37). The sternum is often de- cidedly bulging, the neck short, the back arched, and the head tilted forward. The infraclavicular and supracla- vicular regions are abnormally prominent, whereas the episternal notch is deepened. The clavicular and other accessory muscles of respiration stand out prominently, and this is responsible in part for the apparent shortening of the neck. The intercostal spaces are widened, and the ribs approach the horizontal plane more nearly than they do in health. It is not uncommon to find the external veins of the chest markedly dilated. The movements of the chest are vertical in direction, the chest moving en masse instead of displaying the normal expansile respiration, and during the act of inspiration there may be a retractile instead of an expansile movement of the base of the chest. Respiration may be more frequent than normal, although this is by no means an essential feature. The labored effort at respiration seeks to expel rather than to inspire air, whereas the rhythm is not only altered, but ia extreme cases is actually reversed, inspiration being short, while expiration is greatly prolonged. (See Auscultation, p. 128.) In extreme cases the apex-beat of the heart is not discernible. Epigastric pulsation is quite common, and pulsation at the second or third interspace, in the midclavicular line, may also be observed in selected cases, while venous pul- sation is commonly seen in the right carotid region. Palpation. — In addition to confirming the character and the degree of expansile movement of the chest, palpation reveals the fact that the tactile fremitus is markedly decreased. The apex-beat of the heart is al- ways feeble, and in extreme cases it may be imperceptible. The pulse, Fig. 37. — Transverse Sec- tion OF AN Emphysem- atous Thorax. 128 DISEASES OF THE BRONCHI, LUNGS, AND PLEURA. although normal at first, soon becomes weak and thready, but is not de- cidedly increased in frequency even late in the disease. As the result of overdistention of the right heart, which is caused by increased blood tension in the lung, a systolic shock is often detected in the region of the ensiform cartilage, and epigastric pulsation is the rule. Percussion yields somewhat characteristic findings, since everywhere over the surface of the lung hyperresonance is elicited. The character of the hyperresonant note is controlled by the degree of expansion of the air- cells. Indeed, in extreme cases of emphysema the note may give off a wooden tone. The area over which a hyperresonant note is obtained is larger than normal, and this feature is particularly conspicuous in the clavicular regions. In advanced cases the area of cardiac dullness is greatly diminished, and the heart is often covered by emphysematous lung; in the latter case cardiac dullness is absent. The diaphragm having been depressed by the greatly distended lungs, the area of liver dullness is, as a rule, situated some distance below the normal level. Auscultation. — The characteristics of the respiratory sounds of emphy- sema are that inspiration is short and feeble, whereas the expiratory murmur is appreciably lengthened, the normal ratio — inspiration, four; expiration, three — ^being disturbed — it may be one to one. Prolonged low-pitched expiration, accompanied by a wheezing sound, is probably the most valuable diagnostic sign of emphysema; at the same time the inspiratory murmur is often lower in pitch than the normal. In exceptional cases the respiratory murmurs are harsh, owing to the' extreme effort upon the part of the patient to expel air. As a rule, various riles are heard over practically the entire chest, and, indeed, the rales are not infrequently those heard in pulmonary asthma, chronic bronchitis, and pulmonary tuberculosis. A peculiar rubbing sound is occasionally detected, and is believed to result from friction of the large air-cells against the pleurse. In the interlobular variety a crumbling sound is occasionally audible, and is of doubtful significance. Laennec called attention to the presence of a sound that closely resembled the subcrepitant rale (see p. 70), but this is by no means a constant finding. Theoretically speaking, the voice-sounds should be poorly transmitted through the distended lung tissue; but as emphysema commonly develops as a secondary condition, the transmission of the voice-sounds is of but limited clinical value in certain cases. In advanced cases of emphysema the right heart at first hypertrophies and later dilates; when the latter occurs, a tricuspid regurgitant murmur is audible at the ensiform cartilage. Early in the disease accentuation of the second pulmonic sound is not infrequently heard. I/aboratory Diagnosis. — The sputum is practically the same as that found in chronic bronchitis. (See p. 93.) X-Ray Diagnosis. — ^In typical cases the most striking feature is the unusual degree of transparency that is universal through both lungs. (See p. 73.) Illustrative Case. — ^E. C, male, aged twenty-four years; stevedore by occupation. The patient has suffered from repeated attacks of bronchitis and of bronchial asthma since early adult Ufe. During the past ten years he has noticed that he suffers from extreme shortness of breath upon the slightest exertion, and that exertion also excites cough. He complains bitterly of violent attacks of coughing, and after moderate exer- tion dyspnea is so prominent a feature that speech is interrupted. The appetite has been good throughout his illness; in fact, his present condition developed so insidiously SENILE EMPHYSEMA. 129 that he is unable to fix the date on which he first experienced permanent difficulty in breathing. Moderate emaciation has occurred, but extreme weakness is not present. Local Examination. — ^The characteristic barrel-shaped chest is seen, the neck ap- pears to be short, and the supraclavicular and infraclavicular spaces are unduly promi- nent. There is distinct throbbing of the vessels at the right side of the neck, and marked pulsation occurs in the epigastrium, while the apex-beat of the heart is imper- ceptible. The lips and finger-tips are cyanosed. Tactile fremitus is greatly decreased, even over the upper portions of the chest, and is very feeble at the bases of the lungs. The note everywhere is hyperresonant to percussion, whereas auscultation reveals a short, feeble inspiration and a prolonged expiration, subcrepitant rS,les being present, particularly over the bases posteriorly. Stunmary of Diagnosis. — A history of the presence of conditions that markedly predispose to emphysema — e. g., asthma, whooping-cough, and violent exercise — goes far to support a diagnosis. The typical barrel- shaped chest is positive evidence of the existence of emphysema, except in those cases in which it is associated with disease of the spine. The gradual development and prolonged duration of the condition and the typical symptoms and signs are most characteristic of emphysema. Differential- Diagnosis. — Thoracic tumor (aneurism) may pro- duce a deformity of the chest that resembles in certain respects the deformity seen in emphysema. The distinguishing features, however, are that in aneurism the chest is not symmetrically enlarged, but an undue prominence occurs over some localized portion — most often the sternal or scapular regions. Again, aneurism gives a localized area of dullness, while surrounding this area, as the result of compensatory emphysema, a hyperresonant note is obtained. In aneurism there is likely to be a disturbance — an inequality — ^in the pulsations of the two radials, and a bruit, as well as a marked diastolic shock, may be present over the area of consolidation. Pneumothorax may cause an enlargement of the chest that is not unlike that seen in emphysema. The clinical features that distinguish pneumotho- rax from emphysema are: (a) Pneumothorax develops acutely, and with lancinating pain on one side of the chest; (6) immediately following the pain a condition of shock ensues, from which the patient raUies in from two to twelve hours; (c) the coin test is obtained over the affected side, and breath-sounds, if present over this half of the chest, are metallic in char- acter; (d) after sufficient time has elapsed for the effusion of fluid into the pleural sac to take place, the succussion splash is present; the temperature ranges between 101° and 104° F. and is septic in character. The signs and symptoms here outlined are unknown in emphysema. Clinical Course. — In those cases of emphysema resulting from whooping-cough recovery occurs in from three to six months. That type of the disease seen during adult and after middle life assumes a chronic course, extending over a period of several years, and showing no tendency toward improvement. After the pulmonary condition has sufficiently interfered with the circulation through the lung, cardiac embarrassment becomes evident, and the clinical picture is that of emphysema plus the symptoms of cardiac disease. Senile Emphysema. A condition in which, as the result of advanced years, the elasticity and retractility of the lung are diminished, and atrophy of the lung tissue has occurred — ^the so-called small-lunged emphysema. As a result of 130 DISEASES OF THE BBONCHI, LUNGS, AND PliEURA. the senile changes that have taken place in the wall of the alveolar cells, coalition of many of the air-cells occurs, with the production of rather large air-sacs. In senile emphysema the volume of air in the lung is seldom above the normal, and, indeed, as a rule, the total volume of air is found to be dimin- ished, a condition in striking contrast to that previously described under Hypertrophic Emphysema. FUNGOID DISEASE OF THE LUNG. Pulmonary Actinomycosis. Pathologic Definition. — A chronic infectious disease, common in bovines, and occasionally seen to attack man. It is excited by the ray fungus (actinomyces), which develops in the pulmonary or pleural tissues, resulting in consolidation and possibly, later, in ulceration. (See Infectious Diseases, p. 920.) Aspergillosis of the Lungs (Pseudotuberculosis). Pathologic Definition. — A primary or a secondary mycotic disease of the lung caused by the Aspergillus fumigatus, and characterized patho- logically by consolidation with cavity-formation. (See Infectious Diseases, p. 927.) Pulmonary Blastomycosis. Pathologic Definition. — A secondary disease caused by the blasto- myces, and characterized pathologically by the condition known as pneumo- mycosis (pulmonary consolidation). (See Infectious Diseases, p. 923.) Streptothricosis. Pathologic Definition. — A disease caused by the streptothrix, and characterized pathologically by pulmonary consolidation, caseation, and cavity-formation, with a tendency toward metastatic involvement of other viscera and of the lymph-nodes. (See Infectious Diseases, p. 923.) PARASITIC DISEASES OF THE LUNGS, EcHiNococcic Disease of the Lungs. Pathologic Definition.— A disease induced by infection with the dog tape-worm (Taenia echinococcus), and characterized pathologically by the presence of scolices, booklets, and shreds of cyst membrane in the sputum. (See Parasitic Diseases, p. 986.) Amebic Abscess. Pathologic Definition.— This condition is caused by the Entamceba histolytica, and is usually secondary to amebic abscess of the liver. It is characterized pathologically by destruction of the pulmonary tissue with cavity-formation. (See Parasitic Diseases, p. 988.) Endemic Hemoptysis. Pathologic Definition.— A disease caused by infection of the lung by Paragonimus Westermanii. The parasites make small cavities in the MOVEMENTS OF THE TWO HALVES OF THE CHEST. 131 lung tissue, and here, in a peculiar exudate, deposit their ova, which even- tually escape with the sputum. (See Parasitic Diseases, p. 988.) DISEASES OF THE PLEURAE. MOVEMENTS OF THE TWO HALVES OF THE CHEST. This clinical method was introduced in 1913 by Boston and Ulman, who gave a preliminary report after the study of 50 cases. A correlative study of the pneumograms from the two halves of the chest renders immediately apparent the fact that organic lesions of the lung and pleura and both liquid and air in the pleural cavity give im- mistakable evidences through this method. Fig. 38. — Recoeding Movements of the Two Halves of the Chest. (Boston and Ulman). Instrument in Operation Consideration. — Certain alterations in the pneumograms may result from either excessive or diminished muscular development, and also from unusual freedom of the respiratory movements; but these features do not, however, produce any difference in the writings of the two halves of the chest. This method of study has been found to be of inestimable value in all clinical forms of pleurisy, unilateral consolidations of the lung, pulmonary cavity, cardiac dilatation, cardiac hypertrophy, and diseases accompanied by increased abdominal tension. It likewise shows a distinct difference in the movements of the two halves of the chest where there is a unilateral loss in muscular tone, a feature best exemplified in hemiplegia. 132 DISEASES OF THE BRONCHI, LUNGS, AND PLEUEA. Technic employed by one of us (Boston) in collaboration with Dr. Ulman: The apparatus (Fig. 38) consists of (1) kymograph, (2) two Marcy tambours, (3) metal stand, (4) two clamps, and (5) two pneumographs (modified Elhs). The pneu- mograph consists of a rubber tube, 8 inches long, distended by a spiral wire spring. One end of the tube is closed, while the Other end has an opening attachment to connect Fig. 39.- -Apparattjs Showing Separate Parts (Boston and Ulman). (5) Pneumographs, (11) connecting chains. with rubber tubing (6) to the tambours. A bivalve (7) is interposed between each pneimiograph and tambour to prevent rupture of the rubber membrane of the tambour. Changes in the air pressure in the pneumograph is transmitted to the Marey tam- bours (2), which writes the respiratory movements upon the smoked paper on the drum of the kymograph (8), and produces the pneumograms (9). Fio. 40. — ^Bilateral Pneumogbam from a Patient Showing Large Plecrai, Effusion of the Left Side (Boston and Ulman). T, Time indicator, rate 60 per minute; L, curve shows limited movements of the left half of the chest. The pneumographs (5) are held in position upon the lateral parts of the chest by means of two small chams (11). One connects them across the back and the other across the front of the chest. Care must be taken not to have the chains too tight, as this will mhibit the respiratory movements of the chest. They are best appUed on a level with the sixth ribs, so that the anterior part of the pneumographs, which contain MOVEMENTS OF THE TWO HALVES OP THE CHEST. 133 the opening for connections to tlie tambours, is situated about the nipple hue. The distance separating the pneumographs over the back will vary greatly, depending upon the size of the chest. The apparatus can be appUed to the patient whether in the erect, sitting, or reclining posture. Have the small bivalves (7) open to prevent undue pressure on the tambours while adjusting the apparatus, preparatory to taking tracings. When ready to take Fig. 41. — Bilatehal Pnbumogham from a Male Aged Twenty-four, Showing the Physical Signs OF A Large Tuberculous Cavity Near the Apex op the Left Lung (Boston and Ulman). There were also present evidences of an old pleurisy of the left side. L, Curve shows lessened expansion of the left half of the chest. the tracings these bivalves are to be closed. White glazed paper, 6 inches wide, is placed on the drum (8) of the kymograph and smoked evenly, though not too heavily, by the flame from a coal-oU lamp or a gas burner. Be careful to bring the writing points of the two levers (10) of the tambours in the same vertical line, and with just sufficient pressure against the smoked paper, on the drum, to prevent binding. The distance between the two levers is not constant, but depends upon what type.of tracing you desire to take. Usually from 1 J to 2 inches apart Fig. 42. — ^Bilateral Pneumogham from a Case of Right Hemiplegia (Boston and Ulman). Note especially the marked irregularity in curve R; probably dependent upon lack of muscular tone of the paralyzed side. The extreme downward amplitude of the curves result from forced inspiration, curve R descending much further than does curve L, a feature probably also due to diminished muscular tone of the right half of the chest. will suffice. The tension of the rubber membranes of the tambours (2) must be equal. Should the patient cough (Case V), yawn, sneeze, or laugh during the taking of the record, these acts cause undue amplitude in the curves of the pneumogram. Figure 39 shows the separate parts of the apparatus. The time-marker can be placed at the base of the drum and this record may be made at the time the respiratory movements are recorded (Fig. 40). The time record may be 134 DISEASES OF THE BRONCHI, LUNGS, AND PLEUKA. iaken after the pneumogram, but in such cases care must be taken that the speed of the revolving drum is the same as it was when the pneumogram was made. The degree of pressure within the pneumographs is increased by inspiration (causmg the downward curve of the pneumogram), while expiration lessens this pressure and pprresponds to the upward curve of the pneumogram. The accompanying bilateral pneumograms will serve to show how disease causes variations in time and amplitude of the writing of one Fig. 43. — ^Bilaterai. Pneumoqeam from a Case of Extensive Chronic PLEnKisT or the Left Side; ALSO Small Pulmonary Cavity at the Left Apex (Boston and Ulman). Extreme downward amplitude of the curves resulted from the patient coughing. side of the chest. The upper tracing of the bilateral pneumogram repre- sents the movement of the right half of the chest, while the lower tracing is produced by the movements of the left side of the chest. In certain forms of pleurisy, pleural effusion, and pneumonic consolida- tion the movements of the affected side are greatly diminished, as com- FiG. 44. — Bilateral Pneumogram from a Case of Extreme Dyspnea — Respirations 60 per Minute (Boston and Ulman). In extreme dyspnea the two curves are likely to show such differences. pared with those of the unaffected side '(Figs. 40 and 41). Again, the movements may be widely different either at the upper portion or at the base of the chest, such variations depending upon the character and loca- tion of the lesion present. Unusual amplitude of both the right and left HYDROTHOHAX. 135 curves are rather characteristic of fluid in the abdominal cavity. The pneumograms are also affected by pneumonia, pulmonary cavity, chronic pleurisy, hemiplegia, and condition accompanied by dyspnea. (See Figs. 42, 43, and 44; also Mitral Regurgitation, Serofibrinous Pleurisy, Chronic Nephritis (Exudative), and Cheyne-Stokes Respiration.) HYDROTHORAX (Dropsy of the Pleurae). Pathologic Definition. — A secondary condition in which there is an accumulation of transudate in one or both pleural sacs, without the exis- tence of inflammatory changes in the pleurae. Usually the condition is bilateral. IBxciting and Predisposing Factors.— Hydrothorax is in real- ity not a disease, but merely a symptom of a pathologic change that is remotely situated; nevertheless it is necessary to describe the clinical fea- tures of this symptom. Varieties and Causes.— (1) Hemorrhagic Hydrothorax.— Under this heading are considered those conditions in which, as a result of impov- erishment of the blood, a blood-stained transudate accumulates in the pleura; among these are leukemia, pernicious anemia, amebic dysentery, malignant disease, malaria, scurvy, chronic suppuration, and syphilis. (2) Local pathologic changes may also give rise to the development of hydrothorax, and most of the unilateral cases belong to this class. Among the local exciting causes are: pressure upon the superior vena cava, pressure upon the thoracic duct, enlargement of the heart (dilated right auricle), thoracic aneurism, enlarged mediastinal glands, and carcinoma of the pleurae. (3) Renal Changes. — Renal disease is commonly concerned in the production of bilateral hydrothorax, and it will readily be understood that here there are two conditions that favor the accumulation of fluid within the pleura: (a) Increased work upon the part of the heart; and (6) impoverishment of the circulating blood. In hydrothorax of renal origui the diagnosis is confirmed either from a history of Bright's disease or from the laboratory diagnosis. (4) Cardiac disease is a frequent cause of bilateral hydrothorax, and in those cases in which there is cardiac enlargement, which in turn exerts pressure upon the thoracic vessels, unilateral hydrothorax may result. Cardiac hydrothorax is recognized by the detection of organic disease of the heart. Principal Complaint. — This is usually dependent on the pre- existing disease, of which hydrothorax is but an additional symptom. After the fluid has accumulated in the pleurae, there generally occurs a variable degree of aggravation of the original symptoms of the preexisting disease, and, in addition, the patient complains of other symptoms certain of which are more or less characteristic of hydrothorax: Dyspnea becomes more and more marked, depending upon the quantity of fluid present in the pleural sacs, and if severe, cyanosis is present; paroxysmal coughing and asthmatic seizures are common, and symptoms referable to enfeebled circulation are apparent — e. g., coldness of the extremities. Physical Signs. — In bilateral hydrothorax (Figs. 45, 46) the physical signs are identical with those seen in pleurisy with effusion {q. v.), unless there is a thickened pleura, when a variable degree of dullness is found by per- cussion above the level of the fluid. It is important that the examiner keep in mind the fact that bilateral pleural effusions are uncommon, whereas 136 DISEASES OF THE BRONCHI, LUNGS, AND PLEURA. bilateral hydrothorax is the general rule. The history of the patient will often enable one to interpret correctly the physical signs obtained m a case of hydrothorax. Previous Attacks.— One attack materially predisposes to subsequent seizures. Clinical Course.— This depends upon the exciting factors, the length of time a transudate has remained in the pleural sacs, and whether or not it is possible to institute judicious treatment. In those cases due to cardiac and renal disease a prognosis of the preexisting disease is readily made, but when hydrothorax is the result of hemic degeneration, selected cases may yield to treatment. Area of flat note in bilateral hydrothorax Dome of liver covered by pleural fluid Apex of heart ele- vated, but below upper level of transudate Fig. 45. — Bilateral Hydrothorax. PLEURISY (Pleuritis). Pathologic Definition. — ^A disease characterized by the presence of either a local or a general inflammatory process of the pleurae. (See Pathology of Special Varieties. Varieties. — ^These are: Acute plastic pleurisy, serofibrinous pleurisy (pleurisy with effusion), purulent pleurisy (empyema), tuberculous pleu- risy, subacute pleurisy, chronic adhesive pleurisy, diaphragmatic pleurisy, encysted pleurisy, intralobular pleurisy, cancerous pleurisy, and hemor- rhagic pleurisy. ACUTE PLASTIC PLEURISY. 137 The predisposing and exciting factors, as well as the clinical picture of each of the subclasses, will be described at length under their respective headings. Acute Plastic Pleurisy (Dry Fibrinous Pleurisy). Pathologic Definition.^An acute inflammation of the pleurae, characterized by congestion and the formation of a fibrinous exudate that covers the affected surface of the pleura. The pleura loses its normal luster, and the area involved is devoid of the normal glistening surface. Minute ecchymoses may be seen, and as the exudate accumulates upon the pleura a shaggy, roughened appearance results. Owing to the friction induced by the rubbing of the two layers of the pleura the exudate at times becomes greatly thickened, the involved surface of the pleura presenting a yellowish Hyperresonant areas Area where flat note obtained Fig. 46. — Bilateral Htdrothorax. or reddish-gray appearance. The disease may advance to the formation of pleural adhesions; in mild cases, however, they are absent, and the products of the exudate undergo fatty degeneration and are later ab- sorbed. Varieties.— (1) Primary plastic pleurisy is said to occur when, prior to the onset of the pleuritic condition, the patient enjoyed health. Aschoff, in a careful study of 200 cases of acute plastic pleurisy, found but 41 cases in which the disease developed in previously healthy individuals. (2) Secondary plastic pleurisy results from the extension of either an acute or a chronic inflammatory process to the pleura — e. g., the asso- ciated pleurisy of lobar pneumonia. 138 DISEASES OF THE BRONCHI, LUNGS, AND PLEURA. PRIMARY PLASTIC PLEURISY. l^xciting and Predisposing Factors.— Bacteria,— In both acute and chronic pleurisy the direct cause is a pathogenic micro-organism or the chemic product of such organism. Among the bacteria commonly- concerned in the production of plastic pleurisy should be mentioned the Bacillus tuberculosis, Streptococcus pyogenes, Staphylococcus pyogenes albus. Staphylococcus pyogenes aureus, pneumococcus, colon bacillus, and the Bacillus tjrphosus. These organisms may also be present after suppuration has taken place in the pleura, and any one of them may be the exciting cause of acute pleurisy. Other bacteria may enter the pleural cavity late in the course of dry pleurisy, or after a serous exudate has accumu- lated in the pleural sac. The ray fungus has been recovered from the pleura. Animal parasites — e. g., Entamoeba histolytica — ^have been known to cause acute inflammation of the pleura. Predisposing Factors. — Primary pleurisy not infrequently follows undue exposure to cold and wet. Sex. — ^The disease is slightly more common in men than in women, and is frequently seen to follow injury to the thorax. Age figures prominently as a predisposing factor, the majority of cases developing during early adult and middle life. Season is not without influence, the winter and spring months providing the greatest number of cases. Rheumatism. — ^Those afflicted with a rheumatic or gouty diathesis are most likely to be attacked, and persons showing a predisposition to the development of pulmonary disease, as, for example, tuberculosis, frequently develop acute pleurisy as the initial manifestation of infection. Every case of so-called idiopathic pleurisy should be studied carefully, having in mind that the great majority of such cases are either tuber- culous or rheumatic in origin. SECONDARY PLASTIC PLEURISY. General Remarks. — Secondary plastic pleurisy results from direct extension of the inflammation, hence it is associated with pulmonary abscess, pulmonary gangrene, superficial pulmonary cavity, lobar pneumonia, bronchopneumonia, hemorrhagic infarct, and hepatic, diaphragmatic, or mediastinal abscess. Plastic pleurisy may develop as a complication during the course of acute rheumatism. Conditions characterized by mal- nutrition — e. g., chronic nephritis — are also likely to develop acute pleurisy as a complication. The pleura may be attacked secondarily by a similar inflammatory process involving other serous membranes — e. g., synovial sacs, the meninges, or the pericardium. Principal Complaint.— As a rule, the symptoms are well marked, although there are exceptional cases in which they are so mild as to be disregarded by the patient. Pain Referable to the Chest. — ^The patient is suddenly seized with a sharp, stitch-like pain, generally near the nipple. This pain is increased on deep inspiration, and on movement of the arm of the affected side. Cough is troublesome, and is accompanied by a lancinating pain. Among the general complaints is that of chill or a series of chilly sensar tions, which may have been slight or so severe as to constitute a distinct rigor. The patient declares that he was feverish at the onset, and that he sweat profusely. SECONDARY PLASTIC PLEURISY. 139 The appetite is poor, thirst somewhat increased, and constipation obsti- nate. Headache, while by no means constant, may be an annoying symptom. Thermic Features. — In the average case the temperature ranges between 100° and 103° F., whereas in severe types of infection it may reach 104° or even 106° F. Nervous Symptoms. — ^Mild cases may run their course without develop- ing any nervous manifestations other than those that have been previously mentioned. Physical Signs. — Inspection. — Attitude. — In sitting, the patient in- clines toward the affected side, his arm being clasped tightly against the chest. He may also stoop slightly forward, and there is drooping of the shoulder. Within a few hours after the initial pain the face becomes flushed. The movements of the chest are limited, the respirations are rapid and jerky in character, but on the affected side there is an absence of movement. The tongue becomes coated within the first thirty-six hours, and the lips are dry. Palpation. — Palpation confirms inspection with reference to the limited movements of the chest. A friction fremitus can be felt in a small per- centage of cases. Percussion. — ^Throughout the entire stage of acute plastic pleurisy the percussion-note is normal over both the affected and the healthy side. The exception to this rule is that, if the plastic exudate is extensive, moder- ate impairment of resonance will be detected. Percussion frequently is quite painful, however. After a patient has suffered from repeated attacks of acute pleurisy, the pleura may be appreciably affected, and impairment of the ordinary resonance obtained by percussion will follow. Auscultation. — A friction murmur is heard over a limited area on the affected side of the chest. This murmur is audible both by the direct and by the indirect method of auscultation. It consists of a peculiar grazing or grating sound, which is most distinct at the end of inspiration. The point of greatest intensity of the friction murmur depends entirely upon the area of pleura involved, and the murmur may be detected over any por- tion of the lung. With the appearance of a fibrinous exudate upon the pleura the friction-sound becomes somewhat less distinct and appears to be masked by numerous, fine, crackling riles that are heard during both in- spiration and expiration. After the fibrinous exudate has accumulated a distinct friction-rub is usually audible when the patient is directed to inspire deeply. If the plastic exudate is extensive, as rarely occurs, the lung is somewhat compressed, and the breath-sounds become somewhat bron- chial in character, thus making the differential diagnosis between adhesive pleurisy and pneumonia rather difficult. I/aboratory Diagnosis. — In those cases that display high fever, the urine is lessened in quantity and may contain a trace of albumin. In severe inflammation of the pleura the number of leukoc3d;es will be above the normal. Illustrative Case of Pleurisy. — James D., a cigar-maker, aged twenty-seven years. Height, 5 feet lOJ inches; weight, 152 pounds. Family History. — Parents and three younger sisters living, one of whom suffered from an attack of pleurisy at the age of seventeen years, and now, at the age of nineteen, her physician has directed her to live in a mountainous district. She is reported as having a severe cough, and although there is no positive evidence that she is afflicted with tuberculosis, yet the patient's description of her condition suggests strongly the existence of this disease. Previous History. — Had measles at the age of nine, but does not recall having had 140 DISEASES OF THE BRONCHI, LTJNGS, AND PLEURA. the other diseases of childhood. At the age of twenty-one he suffered from an a,ttack of pneumonia, and states that he was confined to bed for a period of six weeks and was unable to return to his work for several months. Before this attack he was unus- ually robust, but since he has never regained his original weight. For the past three years he has suffered from periodic attacks of tonsillitis. Social History.— The patient is married, and has two children Uving, both appar- ently healthy. He is a mechanic, employed in a cutlery factory, and the room m which he works is not well ventilated; there is also a large amount of dust. Present Illness.— Two days before consulting a physician he was seized with what he believed to be a severe cold, and when seen soon after, he stated that during the night he had had repeated attacks of chilliness, following which he felt feverish. Anorexia and constipation were also present. There was some cough the evening before definite symptoms developed, and during the night the cough became more severe, harsh, short, and was not accom- panied by expectoration. The cough further caused intense lancinating pain in the region of the left nipple; this symptom became so severe that the patient was com- pelled to restrain his coughing in order to obviate the pain. Headache was present, and there was also some soreness of the muscles of the back and limbs, although the patient's chief complaint was of pain in the chest. Both pain and cough were re- lieved when the patient assumed a certain position— i. e., when he inclined toward the affected side and held the chest firmly with the hand. Relief also followed strapping of the left side of the chest. By the end of the first week the pain had subsided markedly, and by the third week it suddenly disappeared. (See Serofibrinous Pleurisy, p. 142.) Soon after the initial symptoms appeared fever developed, and was of an irregular type, fluctuating between 99° and 101.4° F. for a period of two weeks, when it gradually fell to near the normal. Physical Examination. — General. — When first seen, the patient was sitting with his body inclined well toward the affected side, and grasping the left side of the chest with the hand. The skin was bathed in perspiration. Local Examination. — Movements of the chest were much diminished and the affected half appeared almost motionless. The head was inclined to one side and speech was interrupted. Slight movement of the body was followed by an expression of pain. The mucous surface of the throat was reddened. The face was flushed, the conjunctivEe reddened, and the expression was that of pain. Palpation. — Tactile fremitus was decreased over the base of the left lung in the anterior axillary region. The movements of the same side of the chest were decidedly restricted. Percussion. — There was a moderate degree of impairment of the percussion-note over an area about two to three inches in diameter, and the center of this area corres- ponded to the point where the friction murmur was heard with greatest intensity. Auscultation. — During the acts of respiration a distinct to-and-fro, harsh, respira- tory (friction) murmur was audible over a small area immediately below and outside the left nipple. Few crackling riles were also heard over this area. By the third day of the illness the friction murmur had disappeared, but riles were still audible. Laboratory Findings. — The urine was sUghtly decreased in quantity, from 20 to 35 ounces being usually voided during the twenty-four hours; it was high colored, but contained neither albumin nor sugar, and a microscopic examination was negative. Diagnosis by Induction from Clinical Data. — The history of suspected tuberculosis in another member of the family and the previous attack of pneumonia, following which he never recovered his usual weight, were factors that gave rise to the suspicion that the pleural condition was tuberculous in nature. Occupation was also regarded as a possible predisposing factor, and the fact that the disease began as a severe cold, during the course of which there was chiUiness, followed by fever, cough, and a lancinating pain in the region of the nipple, was considered highly sugges- tive of pleurisy. Other evidences of the existence of acute pleurisy were that pain was intensified by deep respiration, and that the patient inclined toward the affected side and held his hand firmly over the site of the pain. The fact that the pain disappeared suddenly further supported the original view that the patient had been suffering from acute vkistic pleurisy, and at this time effusion was probably accumulating in the pleural sac. Fever, which was not extremely high at any time, was decidedly irregular, a fact that strongly suggested the existence of pleurisy. Among the physical signs detected during the early stage of the iUness and considered pathognomonic was a to-and-fro friction murmur, synchronous with respiration. Differential Diagnosis. — At the onset the pain suggested the possible exis- tence of intercostal neuralgia, from which the existing condition was differentiated by the following facts: (o) There was no distinct soreness upon palpation over the afiected SEROFIBRINOUS PLEURISY. 14^ Bide of the chest; (6) pain was not distributed along the course of the intercostal nerves- and (c) a pleural friction murmur was present. (See Differential Table, p 151) ' Course of the Disease.— At the end of the first week the fever had fallen con- siderably, registering 100° F. during the evening hours. Pain had disappeared and the appetite was somewhat improved. During the second week the patient was per- mitted to sit up in bed and was allowed dry foods— an attempt being made to restrict the taking of Hqmds. Three weeks later dyspnea developed quite acutely, and within forty-eight hours following its appearance the physical signs of effusion into the left pleura were present. Fluid continued to accumulate in the pleura until its upper level was found at the superior border of the third rib anteriorly, and the fluid remained at this level for two weeks, when it was deemed advisable to remove at least a portion of it by aspu-ation. Following the removal of about twenty ounces of serous fluid (see Serofibrinous Pleurisy), the patient's general condition continued to improve until the seventh week, when he was permitted to leave the house. Summary of Diagnosis.— A history of exposure to cold and wet, or of a tendency toward the development of pulmonary disorders, is of great value in formulating a diagnosis of acute pleurisy. The occurrence of a chill, followed by moderate fever, and acute lancinating pain in the chest are among the most valuable symptoms detailed by the patient. A moder- ate increase in the frequency of the pulse, together with immobility of the chestj further strengthens the diagnosis. The one positive sign of acute pleurisy, however, is the occurrence of a friction murmur, which develops early and remains, though sUghtly modified, until an effusion is poured into the pleural sacs. Average Duration. — ^The milder types of the disease tend toward a favorable termination in from four days to three weeks. Severe types — e. g., those ushered in by a rigor and high fever — may terminate fatally. After repeated attacks there is a tendency for the pleurae to become markedly thickened and for adhesions to form. In the' latter event the patient may suffer from pleuritic pains for an indefinite period. Acute plastic pleurisy occurring during either an acute or a chronic disease shows less tendency to terminate favorably than when it attacks those in apparent health. Acute pleurisy developing during the course of pulmonary tuberculosis assumes a protracted course. It is to be remembered that in a large percentage of all cases an accumulation of serum in the pleural sacs (serofibrinous pleurisy) takes place. Serofibrinous Pleurisy (Pleurisy with Effusion? Subacute PLEtniiSY). This condition is merely the second stage of an acute pleurisy, in which a serous or a serofibrinous exudate has escaped into the pleural sac. Serofibrinous pleurisy, hke acute pleurisy, may be either primary or secondary in nature. Varieties. — ^Among the special varieties encountered are encysted pleurisy, partial pleurisy, and encapsulated pleurisy. Predisposing- and Exciting Factors.— The etiology of the disease is the same as that of acute plastic pleurisy (g. v.), since, as pre- viously stated, serofibrinous pleurisy is but a second stage of the disease in its severer forms. Infection with the tubercle bacillus is said to be the exciting factor in 75 per cent, of cases, and the general belief is that the tubercle bacillus attacks primarily the pleura; this subject, however, is still unsettled. That tubercle bacilli invade the pleurae secondarily to a similar involvement of the lung cannot be doubted. 142 DISEASES OF THE BRONCHI, LUNGS, AND PLEURA. Rheumatism. — ^An accumulation of fluid in the pleural sac not unusually occurs as a complication of acute articular rheumatism. A similar condi- tion may follow typhoid fever, scarlet fever, and epidemic meningitis. In lobar pneumonia the pleura of the affected side may be the seat of a serous effusion. Bacterial Infection. — ^A bacteriologic study of the fluid obtained from the pleurse is often negative, although many instances have been reported in which different bacteria have been recovered. A most satisfactory method of ascertaining which pathogenic organism is present is to inocu- late an animal with a portion of the fluid; this method is almost essential in order to detect tubercle bacilU in the pleural exudate. Principal Complaint. — ^The history and symptomatology are the same as those previously outlined under Dry Pleurisy. (See p. 139.) After the patient has suffered from an acute lancinating pain in the side for several days, the character of the pain becomes gradually altered. Pain. — After a copious effusion has been emptied into the pleural sac, the pain becomes of a dragging or tearing character. Its intensity is not dependent on the quantity of fluid that is present, for not infrequently we find a pleura nearly filled with fluid where a moderate amount of pain is present. When the pleura is well filled, the pain ceases to be local- ized, and may be absent; more or less soreness, however, is always present over the entire half of the chest. Pain along the margin of the ribs or in the midsternal region may be distressing, and is likely to mislead the physi- cian. In those cases in which a copious pleural effusion is present and pain is not a prominent symptom, it may be excited by directing the patient to cough, to bend from side to side, or to inspire deeply. To avoid error we repeat that the acute pain of dry pleurisy diminishes with the appeari ance of the effusion, but that the pain may be continuous even though the pleura is well filled with fluid; conversely, this symptom is seldom, if ever, absent throughout the entire course of the serofibrinous stage of pleurisy. Cough may continue from the dry stage throughout the greater part of the course of an attack of serofibrinous pleurisy. The character of the cough changes as the effusion accumulates, and the harsh cough, which may have been accompanied by slight expectoration, now becomes less racking and expectoration is more free. When serofibrinous pleurisy ter- minates in recovery, expectoration is more profuse during the stage of absorption, and the cough, which may continue for some weeks, is either dependent upon an associated catarrhal bronchitis or upon the irritation resulting from the reexpansion of the lung. Dyspnea, as previously stated under Dry Pleurisy, is present, and the respirations are shallow and jerking or irregular. Inspiration is often made up of a series of short inspiratory efforts, and the act may be interrupted at any time. Whenever there is a copious effusion in one pleura, or when both pleural sacs are half filled with fluid, dyspnea becomes pronounced, and the patient may be unable to rest in the recumbent posture; cyanosis is usually well marked. In those cases in which the effusion has accumulated rapidly dyspnea is more intense than in those in which a much longer time was consumed in collecting an equally large quantity of fluid. It is not uncommon to find a patient with one pleural cavity two-thirds filled, the fluid having accumulated slowly, display Uttle evidence of embarrassed respiration. SEROFIBRINOUS PLEURISY. 143 Gastrointestinal Symptoms. — Anorexia, while mild during the dry stage of pleurisy, becomes well marked whenever the amoimt of effusion is large. Nausea and vomiting may occur at any time during the disease, and constipation is an almost constant symptom during all stages of pleurisy. Thermic Features. — ^Fever is present throughout the greater portion of an attack of serofibrinous pleurisy, the temperature ranging between 100° and 103° F. Near the end of the second or third week there is generally an appreciable decline in the temperature, and by the fourth week it has often reached the normal. Not infrequently, in the more severe cases, a continued type of fever (101° to 104° F.) runs through the second and third weeks of the disease. On the other hand, there are mild types of pleurisy in which the temperature never exceeds 101° F. A hectic temperature, with evening exacerbations and morning remissions, is suggestive of infection of the pleural fluid with some pus-producing organism, but it is to be remembered that this is by no means a positive sign. The axillary temperature of the affected side may be from one-half to two degrees higher than that of the opposite side, but this peculiarity of the temperature is not a constant finding, and its clinical significance is questionable. Apex of heart Area of flatness in large left pleural exudate Fig. 47.— Large Pleubal Exudate Illustrative op Displacement of the Heart. Cardiac Symptoms.— These form so prominent a group of symptoms occurring during the course of serofibrinous pleurisy that they have been considered under a separate heading, and out of the regular order employed for their description. As soon as fluid begins to accumulate in the pleura the heart-beats increase in frequency, and as the accumulation proceeds the pulse-rate may show a corresponding increase, ranging between 100 and 130 beats a minute. If the accumulation of fluid is large and the heart is greatly 144 DISEASES OP THE BRONCHI, LUNGS, AND PLEURA. displaced to one or the other side of the chest, ]the pulse becomes irregular both in rhythm and in volume. There is some controversy as to whether this irregularity in the pulse is the result of pressure of a pleural effusion upon the heart or of pressure upon the great vessels in the thorax. In the judgment of certain observers pressure upon both the heart and the vessels is responsible for this irregularity of the pulse. Owing to embarrassment of the heart and to torsion of the great vessels at the base of the organ (large left pleural effusion, Fig. 47) , cyanosis de- velops and often becomes extreme. Dyspnea, as previously mentioned, may result in part from embarrassed circulation following pressure upon the heart. Physical Signs. — These are directly dependent upon the quantity of exudate present in one or in both pleural sacs. The three factors that figure most prominently among the physical signs of serofibrinous pleurisy are: (a) The signs present when the effusion is at its height; (6) displacement of thoracic and abdominal viscera; and (c) the signs present during the stage of absorption. Stage of Effusion. — Inspection. — If one pleural sac is only partially filled, say to the fourth rib, inspection reveals but slight bulging at the base of the chest on the affected side, and, indeed, in muscular and obese individ- uals no alteration in the contour of the chest may be perceptible. If one pleural sac is filled to the third rib, a distinct bulging of the affected side is apparent, and the chest movements over such a large effusion are limited, and often confined entirely to the apex. The abdominal type of respiration becomes more and more prominent as the quantity of fluid in the pleural sacs increases, and where the effusion is large, the respirations are rapid and often shallow (Fig. 48) . There may be but little difference apparent in Fig. 48. — Bilatebal Pnbumogbam fbom a Case of Right Pleural Effusion. Respirations, 48 per minute. Curve R represents movements of the right half of the chest. Curve L represents movements of the left half of the chest. Note irregularity in the general course of curve L. Case studied at the Philadelphia General Hospital. (See Bilateral Movements of Chest, p. 131.) the two sides of the chest, even though one pleura is practically filled with fluid, this condition being due to compensatory emphysema of the lung of the unaffected side. The apex-beat of the heart is always displaced when a large pleural effusion is present. If the effusion occupies the left pleura, the heart's impulse may be seen to the right of the median fine, and in extreme cases it may be observed at the fourth and fifth interspace, in the right axillary region. In right-sided effusion the heart is displaced to the left. Whenever there is but a moderate effusion in the left pleura (the sac being half filled), the apex-beat of the heart is elevated, and a distinct pulsation may be seen about the third or fourth interspace inside the left nipple-line. Absence of the apex-beat may be dependent upon the fact that the apex of the heart is lodged behind the sternum (Fig. 47), the result of pressure SEROFIBBINOUS PLEURISY. 145 from a left-sided pleural effusion; it may hot, however, indicate the position of the apex of the heart, since, because of cardiac embarrassment, there is frequently undue pulsation of the right auricle. On inspection of the base of the chest anteriorly there is noticed undue fullness at the margin of the ribs on the affected side; the epigastrium is also seen to be prominent. In the case of a large pleural effusion the prominence of the epigastrium may extend from the affected side beyond the median line. In thin subjects it is often possible to observe the outline of the lower margin of the liver when it is decidedly displaced by a large right-sided effusion. Mensuration. — When a large unilateral effusion is present, the measure- ments of the affected side of the chest are increased, and its contour is altered most at its base. Inequality in the measurements of the two sides of the chest may be found during health, and in right-handed individuals the right side is slightly larger than the left; consequently, a moderate effusion into the left pleura of such an individual would not be detected by mensuration. The degree of expansion of the healthy side during the act of inspiration gives positive evidence of the existence of pleural effusion, since expansion is absent at the base of the chest on the affected side. The horizontal measurements of the chest are also altered by fluid in one pleural sac, the distance from the clavicle to the margin of the ribs being greater on the affected side. Palpation. — By pressing the two hands upon the chest and directing the patient to inspire deeply, the limited range of expansion of both sides of the chest may readily be appreciated. The chest-wall over a large pleural effusion is practically fixed, whereas the opposite side is observed to move more rapidly than in health. The intercostal spaces are found to be prominent over a large effusion. Rarely, indeed, the tissue of the chest-wall may pit upon pressure, and fluctuation is said to occur. Tactile fremitus is absent over an effusion, the exceptions to this rule being in the case of an infant — e. g., a child crying — and when pleural adhesions were present prior to the accumulation of the fluid, such adhesions still anchoring the compressed lung to the chest-wall. Absence of tactile fremitus is of less cUnical significance in women than it is in men, and, owing to the character of the female voice, these patients should be instructed to pronounce distinctly and to assume a masculine tone of voice during chest examinations. The impulse of the apex-beat of the heart is always displaced in large pleural effusions, and where such displacement is sufficiently great to em- barrass the circulation, pulsation of the right auricle may be palpable. Pul- sation at the right side of the neck and in the sternal notch may also be detected. When pushed down by a pleural effusion, the liver is felt below the costal margin (Fig. 50), and the spleen is Ukewise displaced down- ward when the left sac is well filled. Whenever either the spleen or the liver is palpable below the costal margin, it is necessary to determine, by both percussion and auscultatory percussion, whether or not the viscus in question is actually enlarged. Percusdon. — As soon as the effusion begins to accumulate in the pleura the percussion-note is impaired beneath the angle of the scapula, and with the increase in the quantity of fluid exuded, this impairment changes to dullness, and eventually to flatness, which is present over the ^entire base of the chest upon the affected side when the patient is standing or sitting. 10 146 DISEASES OF THE BRONCHI, LUNGS, AND PLEURA. When the pleura is more than half filled with fluid, the area of flatness ex- tends across the median line (paravertebral area of dullness), giving a pecu- liar arched-hke line of flatness, extending from the upper level of the fluid to the base of the pleura, and for from one and one-half to two and one-half inches beyond the median line (Fig. 49). The paravertebral angle is altered by the position of the patient (Fig. 49). Second in importance is the sensation offered to the pleximeter finger, such resistance being augmented over a large effusion and where a flat note' is obtained. The note obtained over the fluid is always flat, and there is a variable degree of impairment for some distance above the fluid if the pleura is half filled. One of the characteristics of pleural fluid is the change of level of the fluid (Fig. 49) with the change in position of the patient. In extensive pleural adhesions movable dullness is not present. Lower margin of lung Paravertebral angle lessened by positioD of patient H ^3 9 mi ' ''^^eI r \ e^ l..^''^>-^ ■1 /.^I^Hj T I A ^^p^m^i y A\ pi ill ^ijiM 1 ' 'r mtSr^fl^^'^ '^^9H ' /\ ! 1 ffinl^HiAV i'^^JB?fe?'/jBj^Bi'Jfi^'' ' ' 'J^H xm WL flBHj ' -- — --■- _ ~Y ■ ' ^ ^i^^^''^'y^*?f ■ ^1 ■ ^^^^1 _._ 1 mig Area of flatness due to pleural effusion Fig. 49. — ^Effect of Position of the Patient on a Large Pleural Effusion. In those cases in which the exudate fills one pleura to the level of the third rib the note obtained by percussion over the apex and above the, third rib is h5rperresonant (skodaic resonance) and often tympanitic in character. Modified skodaic tympany is also found above an effusion that almost fills the pleura to the fourth rib, and a hyperresonant note is elicited above the level of the fluid when both pleura are partially filled. In the case of a large effusion, in which the pleurae is practically filled with fluid, firm percussion may eUcit the so-called "cracked-pot sound"; to obtain this, however, certain conditions must exist: (a) The compressed lung and its bronchus must be forced against the chest-wall anteriorly; (6) the chest-waU must be thin and relaxed; (c) the patient must breathe with the mouth open; (d) firm percussion is required. The upper Hmit of pleural fluid or the line of flatness is not horizontal when the patient is sitting or standing, but is slightly higher near the spine, and becomes gradually lower as the anterior surface of the chest is approached. If the quantity of fluid present is moderate, a reverse condition is found, and SEROFIBRINOUS PLEURISY. 147 the lower level of the fluid, as indicated by the level of the note of flatness, is found posteriorly, rising highest in the axiUary region, and descending slightly as we pass anteriorly. This curved line of flatness has been re- ferred to by Garland and others as the S-line. It is only by careful percussion and by a keen appreciation of the sensation offered to the finger (pleximeter), as well as by a careful analysis of the note produced, that the distinction between the lower border of the pleural fluid and the upper margin of the liver can be made. Again, it must be borne in mind that, owing to the anatomic relation of the pleura to the top of the liver (Fig. 50), a certain portion of the latter must be overlapped by Edge of liver on deep palpation Fig. 50. — ^Ahea of Flatness in Large Right Pleural Effusion. the distended pleural sac, which makes it necessary to employ deep percus- sion, and even then the height to which the top (dome) of the liver rises is difficult to determine. A large accumulation of fluid in the left pleural sac causes an obliteration of Traube's semilunar space, and produces an alteration in the percussion- note obtained over this area. . . Amadtatary Percussion. — In order to insure accuracy in determimng the level at which the flatness of pleural effusion and that of hepatic dullness unite, auscultatory percussion is invaluable. This method of combined auscultation and percussion is also of service in determining the position of the spleen when there is an effusion into the left pleura. 148 DISEASES OF THE BKONCHI, LUNGS, AND PLEURA. Auscultation. — Whenever sufficient fluid has accumulated in a pleural sac to cause a separation of the parietal and visceral pleurae, the friction murmur described under acute pleurisy (p. 139) disappears, and the breath-sounds become weak and distant over the fluid. After the pleura is at least half filled with fluid, the breath-sounds over the affected side above the fluid may acquire a bronchial quahty. Breath-sounds are absent over the pleural fluid except in those cases in which the patient has suffered from previous attacks of pleurisy, in consequence of which pleural adhesions are present which convey the sound from the visceral to the parietal layers of the pleura. Again, when an enormous quantity of fluid is present in the pleura and the lung is compressed tightly beneath the clavicle, distinct bronchial breathing is audible over this compressed lung. Seldom, indeed, the bronchial quality of the breathing is heard over the entire chest on the affected side. The breath-sounds may display an amphoric quality, and, indeed, the breathing at times resembles that heard in pulmonary cavity. Rales are also pres- ent over the affected side, and in children their presence is of but limited diagnostic value. When one pleural sac is only partially filled, bronchovesicular breathing is audible above the fluid and over the unaffected lung, and in proportion to the quantity of fluid in the pleura the breath-sounds are exaggerated over the unaffected side. Vocal resonance is absent over a pleural effusion, and, owing to compensa- tory emphysema of the healthy lung, it is also diminished over the unaffected side and above the level of the fluid. If firm pleural adhesions exist below the upper level of the fluid, breath-sounds may be altered or even exaggerated over an area where a flat note is obtained by percussion. In those cases in which there is a large effusion into the pleural sac and compression of the lung occurs, the voice-sounds may be exaggerated and simulate closely the sounds heard over a superficial tuberculous cavity. Egophony. — By placing the ear at a point level with the junction of the fluid with the lung the voice-sounds resemble the bleating of a goat when the patient speaks (egophony). In small pleural effusions egophony is most likely to be heard over the scapular region. X-Ray Diagnosis. — WiUiams states that, given a large pleural effusion, the rays do not readily pass through it, and, as a consequence, the outline of the diaphragm, ribs, and solid viscera is obliterated on the affected side. By means of fluoroscopic examination it is possible to detect displacement of the heart, and Bergoine and Carrie, by a fluoroscopic study, observed the changes in the pleural fluid resulting from the position of the patient and also from the action of the diaphragm. Fluoroscopy is a method of great diagnos- tic value, since the heart may be markedly displaced, and yet, owing to the fact that the organ is covered by emphysematous lung (compensatory), such displacement may be undetectable by percussion. (See x-ray findings, p. 77.) Paracentesis. — Aspiration of the pleural sac is of inestimable value in determining both the type of fluid contained in the sac and the variety of bacteria that may serve as etiologic factors. The operation is, com- paratively speaking, free from danger if done under antiseptic precau- tions. Caution. — Always test the aspirator by removing fluid from a cup or bottle, through it, before inserting the needle into the pleura. Tec/imc— The accompanying illustration (Fig. 51) will show the posi- SEROFIBBINOUS PLEURISY. 149 tion in which the patient is preferably placed. Those cases where it is impossible to sit the patient erect are aspirated with decided difficulty, since it is impossible to get far below the level of the fluid. In any event the hand of the affected side should be placed on the opposite shoulder in order to widen the interspaces. The points of election are just below the angle of the scapula and in the mid-axillary line. Insert the needle in the sixth interspace on the right, and in the seventh interspace when aspirating the left pleura. In selected cases the needle may be inserted one interspace lower. Estimate approximately the thickness of the patient's chest-wall and grasp the needle firmly at a point allowing just sufficient of it to reach the pleura. Insert the needle immediately above, and hug closely to the superior surface of the rib to avoid wounding the intercostal Fig. 51. — ^Aspiration of the Right Plehsa artery. Immediately upon having entered the pleura elevate the outer portion of the needle in order to direct its point downward and from the lung. Stage of Resorption. — Inspection. — ^The abnormalities observed when the disease was at its height gradually disappear with the resorption of the fluid, and when a large pleural effusion has become almost completely ab- sorbed, the chest and respiratory movements are approximately normal. After repeated attacks of pleurisy, and, indeed, rarely after a single attack, permanent retraction of the affected side may follow. During the stage of absorption the widened intercostal spaces become narrowed, the elevated shoulder of the affected side assumes its normal level or droops slightly, and slight curving of the spine toward the affected side may rarely be detected. For weeks or even months after an attack of serofibrinous pleurisy the scap- ula of the affected side may project further from the chest than does its fellow. Permanent shrinking of the thorax may follow serofibrinous pleurisy^ but 150 DISEASES OF THE BBONCHI, LUNGS, AND PLEURA. such deformity is usually compensated for by abnormal expansion of other portions of the thorax. Chest deformities occurring as the result of pleurisy are discussed at length under Empyema (p. 127). Palpation. — Tactile fremitus, which was absent over the fluid, is now discernible, and is situated at a lower and lower level from time to time as the fluid is being absorbed. There are few exceptions to this general rule, and these are dependent upon the formation of pleural adhesions and extreme thickness of the pleura. As the fluid disappears the expansion of the affected side more and more closely approximates that of the normal, although after the process of absorption is completed, the expansile move- ment of the affected side of the chest may show moderate restriction. Mensuration. — Some months after an attack of serofibrinous pleurisy a limited expansion of the affected side of the chest generally occurs, and when at rest, the measurements of this half of the chest are slightly below those of the opposite side. Percussion. — With the absorption of the pleural fluid the flat note grad- ually disappears, giving place to normal percussion resonance, which pro- gresses from above downward. Normal percussion resonance is not obtained for weeks and often months after an attack of serofibrinous pleurisy. With the absorption of the fiuid areas of dullness, due to displacement of the heart, liver, and spleen, gradually disappear, to reappear at their normal sites. Auscultation. — During the process of absorption of a large effusion breath-sounds that were formerly heard only at the apex of the lung are now heard at a lower and lower level from time to time until the fluid has been completely absorbed, when they become audible at the base. As the fluid disappears the breath-sounds, which at first were extremely weak and •distant (at the base), gradually assume their normal tone. The friction-sound, described under Acute Pleurisy (p. 139), may re- appear when the fluid is almost completely absorbed, and occasionally it persists for days, weeks, or even months after the patient has apparently recovered and is free from pain. In rare instances the lung does not expand sufficiently to follow the upper surface of the fluid during the process of absorption, in which case breath-sounds are heard only over the upper por- tion of the pleura. The heart-sounds, which were rapid and may have been greatly altered by the presence of a large effusion, return to normal with the disappearance of the pleural exudate. X-Ray Diagnosis. — ^The best results are to be obtained by placing the patient in the erect postiu'e for the plate posteriorly. This means of diagnosis is of great assistance in determining the localized areas of con- solidation due to encysted pleurisy. (See a>ray diagnosis, p. 77.) I^aboratory Diagnosis. — ^While the quantity of fluid in the pleural sac, is increasing, the urine becomes scanty, of high color and high specific gravity, and may contain albumin. During the stage of resorption the flow of urine is increased, and it becomes pale and of low specific gravity unless the patient is placed upon a dry diet. Fluid obtained from the pleural sac is serous in character, has a specific gravity of 1.018 to 1.030, and is rich in albumin. Microscopically endo- thelial cells, leukocytes, and, rarely, bacteria (tubercle bacilli) are present. An examination of the sediment obtained by centrifugation of a pleural fluid shows a preponderance of lymphocytes if the process is tuberculous. SEROFIBRINOUS PLEURISY. 151 of polymorphonuclear cells if it is septic. In order to determine whether or not a pleurisy is tuberculous in character, a healthy guineas-pig should be injected with a small quantity of the pleural exudate, when, if tuberculosis is the causal factor, the animal will develop tuberculosis in from four to eight weete. Cultures from pleural effusions seldom show the presence of the bacillus of tuberculosis unless a large amount of fluid is used, and, indeed, such cultures usually remain free from bacteria. Summary of Diagnosis. — In serofibrinous pleurisy there is a history of preceding dry (acute) pleurisy, except where malignancy extends to the pleurae. The diagnosis is strengthened by the presence of movable flatness, the absence of breath-sounds over the affected area, and increased res- piratory murmurs over the compressed lung and over the unaffected side of the chest. Cyanosis and limited movements of the affected side further confirm the diagnosis, whereas aspiration of the pleura makes the diagnosis positive, and serves as the distinguishing feature between serofibrinous pleurisy and empyema. The x-ray findings are also of great value. Differential Diagnosis. — In those cases in which the patient has been seen during the attack of acute dry pleurisy, differentiation is easy, and is based largely upon the preexisting condition. Pleural effusion is to be distinguished from other pathologic conditions in which the lung is consoli- dated, retracted, or compressed; and from new-growths of the thorax, -pericardial effusion, acute cardiac dilatation, hydr other ax, and lobar pneumonia. General Tuberculous Infiltration of the Lung. — When a large portion of one lung is involved by an acute tuberculous process that has spread rapidly from an initial pulmonary focus, the associated pleurisy resulting from such inflammatory process may point toward the existence of sero- fibrinous pleurisy. These two conditions may, however, be differentiated by the physical signs, since over a consolidated lung dullness is obtained, and not flatness, and the resistance offered to the pleximeter finger is less intense than it is over a pleural effusion. Bronchial breathing is heard over a lung consolidated from any cause, but is usually absent over fluid; the breath-sounds are also intensified over consolidation or even over a partially consolidated lung, whereas over fluid they are usually diminished or absent. Movable dullness is characteristic only of pleural effusion. The adjacent viscera — ^the heart and Uver — are not displaced by pulmonary consolidation as they are by pleural fluid. The detection of tubercle baciUi in the sputum goes far to support a diagnosis of tuberculous inflltration. New-growths of the pleura may compress the lung, and when this occurs, the signs of pulmonary consohdation are present; but here again the adjacent viscera are not displaced, and the measurements of the affected side of the chest are seldom, if ever, greater than those of the unaffected side. The accompanying table, ampUfied from Anders, shows the leading differ- ential points between acute croupous (lobar) pneumonia and pleurisy with effusion. Pletjrisy with Effusion. Primary Lobar Pneumonia Symptoms. 1. Onset marked by chilliness persisting 1. Onset acute, with rigor, lasting one for a few days. hour or longer. 2. The pain is sharp, "stitch-like," and 2. Acute pain (similar), but soreness more strictly localized. diffuse. 152 DISEASES OF THE BRONCHI, LUNGS, AND PLEURA. Pleurisy with Effusion. — (Continued.) 3. Cough is irritating; no expectoration, or, if present, catarrhal in character. 4. Sputum negative; tubercle bacilli rare. 5. Moderate fever of continuous tjrpe; decline by lysis. 6. Prostration moderate. 7. Herpes does not appear. 8. Leukocytosis absent or moderate. Primary Lobar Pneumonia. — (Continued.) 3. Cough more marked, and accompanied by rusty or bloody, tenacious expec- toration. 4. Dense aggregations of pneumococci present. 5. Fever, 102° to 104° F., falls by crisis. 6. Prostration extreme. 7. Herpes labialis quite common. 8. Leukocytes number 15,000 to 40,000 per c.rftm. 9. Unilateral distention of the thorax. 10. Countenance pale and anxious. 11. Limited expansion at base of chest on the affected side. 12. Patient, when in bed, rests upon or inchnes toward the affected side. Physical Signs. Inspection. 9. Absent. 10. Mahogany-colored flush of cheeks. 11. Degree of expansion slightly, if at all, inhibited. 12. Most hkely to rest upon the back. Palpation. 13. Tactile fremitus diminished or absent. 14. Expansion limited on the affected sidjB. 15. Interspaces bulging at base of chest. 16. Traube's semilunar space is usually prominent. 13. Increased over area of consolidation. 14. Not detectable. 15. Absent. 16. Absent. Percussion. 17. Flatness, with great resistance to the pleximeter finger. 18. Shows displacement of adjacent vis- cera. 19. If the sac is partially filled, the line of flatness changes with the position of the patient. 20. Upper level of flatness extends from the sternum to the spine (patient sitting or standing). 17. Dullness with less resistance, sometimes a tympanitic note. 18. Absent in uncomplicated cases. and 19. Absent. 20. Outline of dullness usually limited. irregular and Auscultation. 21. 22. 23. 21. Diminished or absent breath-sounds over effusion the rule. Respiratory murmur diffuse, distant, and gener- ally unaccompanied by r41es. Bron- chial breathing may be present over the entire affected side of the chest. Vocal resonance diminished or ab- 22. sent; egophony heard at junction of lung and upper level of fluid. Friction-sound heard in early and late stages. Harsh bronchial breathing and pres- ence of rales in fu-st and third stages, unless a bronchus is plugged. Bronchophony (loud), unless a bron- chus is occluded. 23. No friction murmur; riles present. Aspiration. 24. Serum is recovered from pleura by 24. Negative or yields a few drops of aspiration. thick blood. Cysts of the liver or of the lung, or even abscess of the liver, may push the diaphragm and lower border of the pleura to a sufficient height to give rise to physical signs that may be confused with those of pleural effusion. The clinical history of hepatic disease differs widely from that obtained in SEROFIBRINOUS PLEURISY. 153 pleurisy. In the former dullness may be extreme, and may even simulate the flatness of pleural effusion; but movable dullness is absent in hepatic disease, whereas it is constant in pleural effusion. An exploratory puncture will furnish decisive evidence in distinguishing between pleural effusion and disease of the liver. Hydrothorax.— The physical signs presented by unilateral hydrothorax are identical with those seen in pleural effusion, except that in the former the friction murmur is absent. As a rule, however, hydrothorax is bilateral, which fact serves to distinguish it, in the majority of instances, from acute pleural effusion. Bilateral accumulation of fluid in pleurisy, while un- common, may occasionally be found. In hydrothorax there is no history of acute pleurisy, but, on the contrary, one of cardiac, hemic, hepatic, or renal disease is the rule. Aspiration of the pleura serves as a valuable distin- guishing point, since a transuded pleural effusion (the fluid of hydrothorax) is of low specific gravity, — ^never above 1.015, — whereas a pleural exudate the result of acute pleurisy has a higher specific gravity. Pericardial Effusion. — A large pericardial effusion may be mistaken for fluid in the left pleura. In pericardial effusion dyspnea is a more prominent symptom than in pleural effusion. In the former the heart is not displaced to the right (Fig. 47), as in pleural effusion. In pericardial effusion per- cussion shows the area of flatness to be circumscribed, and to be most marked in the axillary region. Along the posterior margin of the left pleura normal pulmonary resonance is obtained, whereas in pleural effusion a flat note is elicited over this region. In pericardial effusion the heart-sounds are dis- tant, feeble, or muffled, while in pleural effusion the quality of the heart- sounds is unaltered. Dilatation of the Heart. — In acute cardiac dilatation the area of cardiac dullness may be sufficiently great to occupy the greater portion of the anter- ior and axillary surfaces of the chest, as lugh as the fourth rib. A circum- scribed area of dullness the size of a silver dollar is often found near the angle of the scapula. On deep percussion normal pulmonary resonance is obtained on a level with the base of the pleura and near the spinal column, and rela- tive dullness (over the portion of the dilated heart overlapped by lung) is detected anteriorly and in the axiUary region. Marked pulsation of the epi- gastrium is a prominent sign in acute dilatation, and is but feebly mani- fest or absent in pleural and in pericardial effusions. The sounds of the heart are weak, rapid, irregular, and lacking in muscular element in cardiac dilatation. Clinical Course and Duration. — These are dependent entirely upon the exciting cause. The prognosis, regardless of the causal factors, is guardedly favorable. The course is divided into two stages — ^the febrile stage, which corresponds to the time when the exudate is accumulating, and the afebrile, which corresponds more or less closely to the stage of resorption. Generally speaking, the febrile period continues for from seven to twenty- one days, whereas the afebrile period varies greatly in duration and is de- pendent upon the presence or absence of complications. In selected cases the pleural exudate appears to accumulate rapidly, and in these same in- dividuals rapid absorption often takes place. Certain mechanic hindrances may delay absorption of the fluid, in which case the final course of serofibrinous pleurisy becomes subacute. A fatal termination may result from extreme pressure upon the heart and upon the great vessels. Complications and Sequelae. — The prognosis is far less favorable 154 DISEASES OF THE BRONCHI, LUNGS, AND PLEURA. in those cases in which the serous fluid becomes infected with pyogenic organisnas (streptococci and staphylococci). Infection with other bacteria — e. g., the typhoid bacillus, the pneumococcus, the colon bacillus, etc. — also tend to make the prognosis more grave, and will be considered at length under Empyema (p. 158). Chronic adhesive pleurisy may follow an attack of the acute serofibrinous variety, and is a complication that results in perma- nent lessening of the air-space of the lung on the affected side. Empyema and chronic bronchitis may be a sequel of serofibrinous pleurisy. (See p. 156.) SPECIAL CLINICAL FORMS OF PLEURISY. Carcinomatous Pleurisy. — This clinical form of pleural irrita- tion usually results from direct extension of malignant disease from adjacent structures — e. g., the esophagus and lung. The symptoms are quite similar to those of acute dry pleurisy, except that they continue for a longer period. A serous or bloody effusion is Ukely to result where carcinoma involves the pleura. Hemorrhagic Pleurisy. — Under this heading are included all types of pleurisy in which, in addition to an exudate of serum, blood-corpus- cles and hemoglobin are also present in the pleural fluid. The depth of color of a pleural exudate is entirely dependent upon the quantity of blood that has extravasated with the serum. Etiology. — Among the conditions capable of exciting a hemorrhagic pleural exudate are: traumatism and fracture of the ribs, carcinoma of the pleura, tuberculous pleurisy (either circumscribed or general), superficial pulmonary cavity, chronic interstitial nephritis, secondary infection of the pleura in acute infectious conditions (pneumonia, anthrax), and a right- sided hemorrhagic pleural exudate may follow atrophic hepatic cirrhosis; it is also rarely seen during the course of hepatic hypertrophy. The general arterial sclerosis characteristic of old age and alcoholism is also accepted as a possible cause for the accumulation of bloody fluid in the pleura. Hemothorax. — This is an accumulation of bloody fluid in the pleura, with or without disease of the pleura itself. The etiologic factors in this con- dition are practically identical with those described in hemorrhagic pleurisy. Tuberculous Pleurisy. — Acute serofibrinous pleurisy may be of tuberculous origin, but the majority of such cases doubtless develop during the course of pulmonary tuberculosis, and are the result of direct extension from a superficial pulmonary cavity or consolidation. When tuberculous pleurisy follows tuberculosis of the lung, its development is less acute than is that of acute plastic pleurisy, and there is a tendency toward chronicity. Chronic adhesive pleurisy results in more or less obliteration of the pleural sac by a thickening of the pleura and by adhesive bands. Owing to adhesions and to consequent retraction of the lung on the affected side, certain physical signs are observed over the affected pleura; these include retraction of the interspaces, limited expansion, abnormal tactile fremitus, and impairment of percussion. The unaffected side of the chest is unusually prominent, and may display compensatory emphysema. It is occasionally found that both sides of the chest have been affected by chronic adhesive pleurisy, in which case there are localized areas of retrac- tion on both sides, whereas other portions of the chest are unduly prominent. Tuberculosis of the pleura, when primary, and, indeed, occasionally when secondary, is followed by tuberculosis of the pericardium. Tuberculous peritonitis is also often found as a complication. SPECIAL CLINICAL FORMS. 155 Acute tuberculosis of the pleura is one of the common causes for the ac- cumulation of bloody pleural exudate. (See Hemorrhagic Pleurisy, p. 154.) Tuberculosis of the pleura may terminate in recovery, although a large proportion of all cases is followed by the development of pulmonary tuberculosis. If the condition assumes the chronic adhesive form, the patient may live for many years, although he is never restored to perfect health. Encapsulated Pleurisy. — This is a variety of pleurisy in which the pleural exudate is held in one position by firm adhesions (Fig. 52). Ana- tomically, it is not infrequent to find more than one small sac of fluid that is practically isolated from the general pleural sac. Encapsulated pleural effusion may be foimd over any portion of the lung, and in this event the ^rea of dullness. Encapsulated right interlobar pleural effusion Fig. 52. — Encapsulated Pleural Exudate. physical signs are those of consoUdation, although these are often so modified that the diagnosis of encysted pleurisy is made only with difficulty. Interlobar Pleurisy. — This is a special variety of serofibrinous pleurisy in which the exudate is more or less completely encapsulated. It is due to the presence of recent or of old pleural adhesions, the pleural fluid being retained between the pulmonary lobes. Interlobar pleurisy is more common upon the right than upon the left side, and the encapsulated fluid is oftenest found near the root of the lung, and between the superior and middle lobes. Although it usually follows acute and chronic pleurisy, interlobar pleurisy may also develop as a com- plication of lobar pneumonia. The encapsulated exudate may rarely become infected with pyogenic organisms, and instances are recorded in which such 156 DISEASES OF THE BRONCHI, LUNGS, AND PLEURA. purulent material has gained access to a bronchus and been ejected with the sputum. The quantity of fluid in the capsule is usually small — ^not exceeding a few drams of, at most, a few ounces. Upon inspection the physical signs common to the presence of a large pleural effusion are lacking, and, on the contrary, the interspaces of the af- fected side are either normal or deepened, the quantity of fluid being too small to cause bulging. It is extremely difficult to obtain a sufficiently clear history and to elicit the satisfactory physical signs necessary to make a positive diagnosis of interlobar pleurisy. In patients in whom the chest-wall is thin, a diagnosis is more readily attained. Diaphragmatic Pleurisy. — When the inflammatory process first attacks that portion of the pleura covering the diaphragm, and if the in- flammation is localized, the condition is referred to as diaphragmatic pleu- risy. Pam is a most constant feature, and extends along the tenth rib and across the upper portion of the epigastrium to the articulation of the sternum with the xiphoid cartilage. In severe cases the pain may be reflected slightly over the abdomen. Deep inspiration and movements of the chest and ab- domen increase the pain. When an effusion collects at the base of the pleura, the pain diminishes and finally disappears. Nausea, paroxysmal coughing, and vomiting are occasionally seen, and the symptoms of peri- tonitis may be present. Fever is always present, and is slightly higher than in the ordinary type of serofibrinous pleurisy. The effusion in diaphragmatic pleurisy is said to be more likely to become infected with pyogenic bacteria than that resulting from other forms of pleural irritation. (See Empyema, p. 158.) The physical signs, with the exception of the friction murmur, which may per- sist during the initial stage, are negative, unless the accumulation of fluid is large. Chronic Pleurisy (Adhesive Pleurisy). Pathologic Definition. — ^A chronic inflammation of the surface of the pleura, with or without effusion. Chronic Pleurisy with BflEiision.— This commonly follows sero- fibrinous pleiu'isy (see p. 154), although it may develop insidiously. After a moderate amount of effusion has collected the physical signs are practi- cally those of acute serofibrinous pleurisy (p. 144). This type of pleurisy differs markedly in certain particulars from the acute form, e. g.: (a) Dysp- nea is but slight, owing to the slow accumulation of the fluid in the pleura; (b) fever is generally absent, and, indeed, a subnormal temperature is not unusual; (c) the accumulated fluid shows little or no tendency to disappear, and may remain for weeks, months, or even years. Chronic pleurisy with effusion becomes more serious when it is found in those under ten years of age, for there is a special tendency for such exudate to become infected with pyogenic bacteria. (See Empyema, p. 158.) DRY chronic (ADHESIVE) PLEURISY (THICKENED PLEURA). Remarks. — ^Reference has already been made to pleural adhesions above, and the rule is that this type of pleurisy follows the serofibrinous variety of the disease after the exudate has been absorbed. Owing to the DRY CHRONIC PLEXTRISY. 157 slow absorption of the serofibrinous exudate, the fibrinous constituents of the fluid become further organized into layers of connective tissue. Fur- ther changes take place, and both the visceral and parietal'layers of the pleura become coated mth the fibrinous elements of the exudate, and, probably owing to irritation of the pleura, an actual proliferation of the pleural covering occurs. In all events the pleura becomes markedly thickened. Adhesions and even thickening of the pleura are likely to be most pronounced at the base of the chest, although they may extend over the entire pleura and materially incapacitate the lung. This condition may follow empyema, and instances are reported in which the pleural exudate has undergone cal- careous degeneration. Principal Complaint.^A history of one or more attacks of acute pleurisy and of serofibrinous pleurisy is usual, although many cases follow a chronic course from the onset; the latter are nearly always tuberculous in origin. There are vague and sometimes acute pains over the affected pleura, the patient becomes dyspneic and exhausted upon slight exertion, but there are never any definite, rational symptoms that point conclusively to the existence of this form of pleurisy. Physical Signs. — Inspection. — ^The patient is usually emaciated, the chest movements are restricted, and depression of the interspaces is common. Mensuration shows that there is atrophy of the affected side. The apex- beat is often displaced as the result of pleural adhesions, and may even be seen to the right of the median line. "Wben there are many dense adhesions and the pleura has become markedly thickened, certain vasomotor symptoms, due to pressure upon the sympathetic nerves, are observed — e. g., unilateral sweating (usually limited to the head and chest), unilateral flushing of the face, and inequality of the pupils. Palpation. — ^Tactile fremitus is, as a rule, markedly decreased over the affected pleura, and most commonly at the base of the chest; but in the event of the presence of dense pleural adhesions extending from the parietal pleura to the lung, localized areas in which the fremitus is increased may be found. Percussion may be negative, although in those cases in which there is decided thickening of the pleura the percussion resonance is greatly impaired, and a firm stroke is necessary to obtain a note suggestive of underlying lung tissue. The area of cardiac dullness may also be altered. When there are marked thickening of the pleura at its base and many adhesions, it is custom- ary to obtain a hyperresonant note over the apex of the same lung, and if the disease is unilateral, a hyperresonant note is ehcited over the imaffected side. Auscultation. — ^The breath-sounds are diminished, feeble, andin some instances indistinct. A friction murmur, although not constant, is by no means uncommon; the breath-sounds may be accentuated over the apex of the lung, both as the result of exaggerated breathing and of dense pleural adhesions connecting the parietal with the visceral pleura. X-Ray Diag^UOSiS. — A thickened pleura may be encountered both in this disease and in pulmonary tuberculosis, and is placarded by a uniform shadow of moderate density, which density is controlled entirely by the de- gree of pleural thickening, and an accurate interpretation of a plate made from a case of thickening of the. pleura requires one thoroughly skilled, and, as put by Pfahler, "here experience alone will serve as a guide." Both an anterior and a posterior plate should be made see (x-ray diagnosis, p. 76). 158 DISEASES OF THE BEONCHI, LUNGS, AND PLEURA. Di£ferential Diagnosis.— Chronic adhesive pleurisy with thick- ening of the pleura may be confused with serofibrinous pleurisy. The fol- lowing table gives the prominent distinguishing features between the two conditions: Thickened Pleuba with Adhesions. Pleural Effusion. 1. History of long standing. 1. Acute, of three to eight weeks' dura- tion. 2. Interspaces depressed. 2. Interspaces bulging. 3. Dullness over case of pleura. 3. Flatness over base, with skodaic reso- nance immediately above the level of the fluid. 4. Area of duUness unaltered by posture. 4. Area of flat note changed by posture. 5. Measurements of affected side less than 5. Measurements increased on affected those of the opposite half of the chest. side. 6. Breath-sounds diminished over area 6. Breath-sounds absent over fluid, ex- where a dull note is obtained. cept when the quantity is large and the lung firmly compressed or when there are pleural adhesions. Clinical Course and Duration.— The prognosis is favorable as to life, the majority of patients living for years. There is no known method by which the lung may be restored to its normal function. Sequelae. — Many of these cases terminate in cirrhosis of the lung and in cardiac disease resulting from increased pulmonary tension. EMPYEMA (Purulent Pleuritis). Pathologic Definition. — ^An acute or subacute purulent infiammar tion of the pleura. The pleura will be found to contain a variable quantity of purulent or seropurulent liquid. The degree of inflammation of the pleu- ral surface is, as a rule, more extensive and more intense than in serofibrin- ous pleurisy. The pleura may be greatly thickened and the entire surface distinctly granular, whereas in selected cases the parietal pleura may show perforation. Varieties. — (1) The ordinary type. (2) Traumatic empyema. (3) Empyema necessitatis (that form in which the pus escapes through the chest-wall and forms a tumor). (4) Pulsating empyema, characterized by distinct pulsation at the base of the affected side of the chest. Predisposing and Bxciting Factors. — Bacterial Infection. — A number of varieties of bacteria have been recovered from the purulent exudate obtained from the pleura; among these are: the pneumococcus (Micrococcus lanceolatus). Streptococcus pyogenes, Staphylococcus pyo- genes albus. Staphylococcus pyogenes aureus, Bacillus coli communis, Bacillus typhosus. Bacillus of Friedlander, Bacillus aerogenes capsulatus, and Streptothrix pulmonalis. Fungi may also be present in the purulent pleural exudate, actinomyces having been found in quite a large number of cases. Empyema frequently develops as a sequel of acute serofibrinous pleu- risy, in which case the pleural fluid has become infected with pyogenic micro- organisms. In children, pleurisy is especially likely to terminate in empyema. A pleural effusion frequently becomes purulent following acute in- fectious diseases — e. g., miliary tuberculosis, pneumonia, typhoid fever, whooping-cough, scarlet fever, dysentery, and pyemia. EMPYEMA. 159 Malignant conditions of the lung may form a fistulous communication between a bronchus and the pleura, causing empyema, with or without pneumothorax. The extension of carcinoma from the esophagus, even if the pleura is not perforated, may be the exciting cause of empyema. Tuberculosis of the spine or of the ribs is an occasional cause. Trau- matism to the chest with fracture of the ribs is quite a common exciting factor among men. Rarely, empyema follows an acute purulent endo- carditis and also tuberculosis of the mediastinal glands. Principal Complaint.— As a rule, there is a history of acute pleu- risy, followed by serofibrinous exudate, although such history may be ob- scure. The symptoms vary greatly according to the type of the case. In those cases in which empyema follows acute infections the onset may be sudden, beginning with a chill, after which the temperature rises abruptly and prostration becomes pronounced. Pain is nearly always a prominent symptom, and is aggravated by movements of the chest. In severe cases the typhoid state may be simulated, marked by continued fever, a rapid pulse, coated tongue, and delirium. Gangrenous changes in the pleura may take place, and when they occur, are always followed by the so-called typhoid state. Chronic empyema is a type of this form of infection in which the symp- toms develop insidiously, and the patient, in spite of the fact that he is much reduced in vitality and has a large purulent pleural exudate, still walks about. It is in these chronic cases that the diagnosis becomes es- pecially difficult and aspiration of the pleura may be necessary to establish a diagnosis. Complaint Referable to the Chest. — ^The pain is seldom severe in character, although more or less constant. The cough, which is more or less continuous, aggravates the pain, and is often accompanied by free ex- pectoration, but neither the pain nor the cough is so distressing in empyema as in acute pleurisy. Again, there are certain cases in which both pain and cough are absent. When there is a virulent type of infection, profuse sweat- ing is a prominent symptom, and, owing to the pressure of the exudate upon the sympathetics, there may be unilateral sweating. Thermic F'eatures. — In those cases ushered in by a rigor the fever rises rapidly to from 102° to 104° F., and may remain high, although an irregular temperature is the rule. In mild cases that have developed in- sidiously the temperature is irregular and may not exceed 102° F. After chronic pleurisy has existed for some weeks or even months fever may be absent. Physical Signs. — Empyema displays all the physical signs detailed imder Serofibrinous Pleurisy (p. 144), and to these are added certain signs distinctive only of this affection. Inspection. — In addition to the bulging of the affected side of the chest, there are usually indentations and markings on the skin made by clothing, especially when the patient has been lying upon the affected side. Anemia and emaciation are apparent. Palpation. — ^Upon making firm pressure on the chest overlying a puru- lent exudate pitting of the skin is common, and especially is this true in children. Long-standing empyema may perforate through the chest-wall, when a fluctuating mass will be displayed. By placing the hand over a large purulent effusion, the chest-wall may be felt to pulsate (pulsating em- pyema). The causes of this pulsation are doubtful, although the following factors are said to favor its production: (a) A copious effusion; (jb) forcible 160 DISEASES OF THE BRONCHI, LUNGS, AND PLEURA. heart action; (c) relaxation of the chest-wall, with possible paresis of the intercostal muscles; and (d) possible association of a thoracic aneurism. Pulsating empyema differs in no way from the ordinary tj^je described, ex- cept that pulsation is an added sign. Expansion is lessened at the base of the chest on the affected side. Percussion. — ^The upper level of the area of flatness changes less readily with the position of the patient than it does in serofibrinous pleurisy (p. 145). Auscultation. — Spoken-voice sounds are seldom heard over a large purulent exudate, and Baccelli's sign, transmission of the whispered voice sounds, is absent, although where there is a small collection of purulent exu- date in the pleura, Baccelli's sign may be audible. I^aboratory Diag^nosis. — Microscopically, fluid obtained from the pleura is seen to contain pus, and may show granules of blood-pigment. Stained specimens of this pus contain pyogenic bacteria. Cultures made from the pleural exudate invariably develop colonies of pyogenic organ- isms, cocci, and baciUi. Blood. — ^Leukocytosis of 12,000 to 30,000 per c.mm. is present in all acute cases, but may be absent after the pus has been retained in the pleural sac for a long period and has become surrounded by a dense capsule of fibrous tissue. A differential leukocyte count shows the polymorpho- nuclear cells to be markedly increased — ^from 80 to 95 per cent. The number of red cells per c.mm. and the hemoglobin are reduced. Urine. — ^The quantity of urine excreted dm-ing the twenty-four hours is approximately normal, unless there is an associated septic nephritis or a persistent high temperature, when the quantity will be diminished. The urine displays a high color, a high specific gravity, and is rich in peptone and indican. When nephritis occurs as a complication, a high grade of albuminuria and casts are present. Summary of DiagfUOSis. — ^A history of preexisting pleurisy or of traumatism to the chest, high irregular fever, marked prostration, emacia- tion, leukocytosis, and the recovery of pus from the pleural sac constitute the cardinal symptoms of this affection. An x-ray study may offer valuable assistance (see page 74). Differential Diagnosis.— The only reUable method of distinguish- ing between a large pleural effusion and pus in the pleural cavity is by making an exploratory puncture into the pleura and recovering the fluid. This is best accomplished by employing a needle of unusually large caUber, which may be attached to an ordinary hypodermic sjo-inge. Aneurism. — Pulsating empyema may simulate thoracic aneurism, but a distinction is usually made from the fact that in aneurism pathologic changes (hardening) are present in the radials and other arteries. The radial pulses may be unequal, and the presence of bruit and thrill is charac- teristic of aneurism. Clinical Course and Duration. — Enipyema should be regarded as a serious disease, although the special etiologic factors present materially modify its clinical course. Rarely, spontaneous absorption of the pus takes place, but even in this event convalescence is protracted and the patient may never return to perfect health. Rupture into the bronchus, one of nature's methods of sending relief, may be followed by recovery, as may also those cases in which pus escapes through the chest-wall or burrows along the re- troperitoneal tissue. In certain cases recovery follows aspiration and re- moval of the greater portion of the purulent material, whereas in others a purulent discharge continues for months or even years. Surgical inter- PNEUMOTHORAX. 161 vention. becomes necessary in quite a large percentage of all cases, and more recoveries would doubtless follow if this condition were regarded as a surgical one, whenever the diagnosis is attained. Bilateral empyema has been reported, and is an extremely grave condition. In children the out- look is more favorable than in adults, though even here recovery is fol- lowed by, at least, partial obliteration of the pleural sac, with appreciable retraction of the thorax. The variety due to the pneumococcus often pur- sues a favorable course. Complications. — Pneumothorax may result from perforation of the lung tissue, and perforation of the pericardium has been recorded. Pneumothorax may also follow infection of pus by gas-producing bacteria (colon bacillus. Bacillus aerogenes capsulatus). PNEUMOTHORAX (Seropneumothorax , Pyopneumothorax). Pathologic Definition. — A secondary condition in which air es- capes into one pleural cavity. Rarely, pneumothorax may follow infection of a pleural exudate with gas-producing bacteria. (See Special Varieties, below.) Varieties. — (1) Seropneximothorax, a condition in which serum and air fill the pleura. (2) Pyopnetmiothorax, a variety in which the serous exudate has become infected with pyogenic bacteria. (3) Traumatic pneumothorax, a form resulting from stab wounds and fracture of the ribs, with rupture of the lung. (4) An additional variety is made up of those cases in which pulmonary cavity, pulmonary abscess, pulmonary gangrene, and pulmonary carcinoma have formed a fistulous communication between the lung and the pleura. (5) Carcinoma or abscess of the esophagus may extend to and perforate the pleura, allowing air to enter. (6) Subdiaphragmatic pneumothorax is a variety resulting from perforation of the diaphragm and pleura by gastric or duodenal ulcer, or from a subphrenic abscess rupturing into the pleura. (7) Pneumothorax may follow infection of a serous pleural exudate by gas-producing bacteria — e. g., Bacillus aerogenes capsulatus and Bacillus coli communis. (8) Abscess of the liver that has ruptured into the pleura may give rise to pneumothorax. Predisposing and Bxciting Factors. — (1) Age. — Pneumothorax is extremely uncommon before the tenth year, and is most frequently seen during early adult and middle life. (2) Sex. — ^The condition develops among males more often than among females, and is probably influenced by strenuous exercise. (3) The commonest exciting cause (70 per cent, of all cases) appears to be pulmonary tuberculosis with cavity-formation, such cavity rupturing into the pleura. The left pleura seems to be affected in about 66f per cent, of all cases. A cavity that has become partially encapsulated and undergone caseous change is also likely to rupture into the pleura. Among the other diseases of the lung that are to be considered in the etiology of pneumothorax are bronchopneumonia, pulmonary gangrene, pulmonary abscess, a sup- purating echinococcus cyst, and abscess of a bronchial gland. Heavy lifting, and the like, has been known to result in rupture of the air-cells, with the production of pneumothorax; paroxysmal coughing, as in whoop- ing-cough, and a bronchiectatic cavity, when situated near the periphery of the lung, may rupture into the pleural space and cause pneumothorax. Thoracic aneurism, by pressure upon the root of the lung and upon the esophagus, may produce ulceration of the latter, which may communicate 11 162 DISEASES OF THE BRONCHI, LUNGS, AND PLEURA. with the pleura. Esophageal carcinoma and esophageal abscess are also un- common causes. Empyema of long standing may produce an erosion, with subsequent perforation of the visceral pleura. (See Empyema, p. 161). Stab wounds of the chest, gunshot wounds, and fracture of the ribs, whenever these penetrate the pleural space from without, give rise to external pneumo- thorax; if the lung itself is ruptured sufficiently to communicate with the pleural space, the condition is known as internal pneumothorax. The physical signs of pneumothorax may be prominent even when the pleura does not communicate either with the lung or with the external sur- face of the body; this is the result of infection of the pleural effusion with gas-producing bacteria. The gas recovered from such pleural sacs will be found to contain elements not present in the air — e. g., hydrogen, hydrogen disulphid, or marsh-gas. Subdiaphragmatic pneumothorax may follow a number of pathologic conditions, among which are hepatic abscess, infected echinococcus cyst of the liver, abscess between the layers of the diaphragm, ulcer or carcinoma of the stomach, ulcer or carcinoma of the duodenum, carcinoma of the pan- creas, carcinoma of the liver, and, rarely, carcinoma of the colon, all of which may perforate the diaphragm. Principal Complaint. — ^This will be found to vary greatly accord- ing to the exciting cause in the individual case. In those cases in which perforation of the pleura from the lung is the result of pulmonary disease or is due to traumatism from without, stab woimds, etc., the onset is sudden and extreme pain is one of the prominent symptoms. There is also a history of pronounced dyspnea, weakness, nausea, and a tendency to faint within the first few hours after air enters the pleura. The severity of these initial symp- toms is in direct proportion to the volume of air that gains entrance to the pleura — the greater the volume, the more intense are the symptoms, and the more hkely is collapse to ensue. The patient complains of weakness, is unable to move about the room, and has no desire for food. Within a few days symptoms referable to general sepsis arise — e. g., intense heat during the afternoon hours, profuse sweating, headache, and other nervous mani- festations. Constipation is Hkely to occur except in those cases in which some form of enteritis existed prior to the onset of pneumothorax. Thermic Features. — Immediately following rupture of the pleura the temperature is found at normal, or even subnormal — 97° or 96° F.; it is likely to remain below the normal for a period of from one-half to two hours. As a rule, within the course of from forty-eight to seventy-two hours the pleural fluid becomes infected, and the temperature rises to 100° to 101° F. As the condition progresses the fever becomes hectic in type, and an evening temperature of 103° or 104° F., with a morning decline to near the normal, is observed. The more profound the septic condition, the more continuous is the type of fever, and the patient may present the typhoid state. In that small proportion of cases in which recovery takes place the fever begins to decline in from the third to the sixth week, although convar lescence is usually protracted. Physical Signs. — Inspection. — When seen early, the face is dusky, the lips and extremities are cyanosed, the skin is covered with beads of per- spiration, and the apex pulsation may be diffuse, displaced, and often absent. The neck appears to be unusually short and thick, and there is throbbing of the vessels. The patient inchnes slightly toward the affected side, and the clavicle of this side is elevated; the respirations are rapid and shallow, and one side of the chest does not expand. The upper quadrant of the ab- PNEUMOTHORAX. 163 domen (Fig. 160 on p. 418), joining the affected pleura, is usually promi- nent. Inequality of the pupils, the result of undue pressure upon the spinal sympathetics, is quite common. Palpation. — ^The skin at first is cold and clammy, but later it may be hot and at times dry; after sleep, however, as a rule, it is bathed in perspira- tion. Palpation further confirms inspection with reference to the move- ments of the two sides of the chest and displacement of cardiac pulsation. In right-sided pneumothorax the liver is readily felt below the costal margin, Fig. 53.-1, Air in the pleural sac; 2, fluid exudate at base of pleural sac; 3, compressed' portion of lung; 4, displaced heart; 5, depressed spleen; 6, mediastinum pushed toward the right (Anders' Practice). whereas when the left side is affected, the spleen is likewise pushed below the margin of the ribs (Fig. 53). Firm pressure over the affected side may elicit pain, although this is by no means constant. Percussion. — Tympany is obtained over the affected side, except at the base of the chest, where, owing to the collection of fluid (pus) (Fig. 53), a flat note is elicited. At the apex of the lung skodaic resonance is elicited. As a result of the high tension under which air is held in the pleura a wooden or almost flat note is occasionally obtained between the lower border of the 164 DISEASES OF THE BRONCHI, LUNGS, AND PLEURA. lung and the upper margin of the fluid. The normal area of cardiac dullness is displaced regardless of which pleura is involved. Both hepatic and splenic dullness extend to a lower level when the pleura of their respective side of the body is involved (Fig. 53) . Owing to the fact that one lung is almost completely incapacitated, the opposite lung becomes hyperresonant. Occasionally a small area of cardiac dullness may be outlined, but it is commonly absent. A point of much clinical importance is that the adjacent viscera are dis- placed to a greater degree by pneumothorax than by a large pleural effusion. Wintrich's Change of Note. — If the air in the pleura communicates directly with a bronchus, the "cracked-pot" sound is elicited by firm per- cussion over the affected side of the chest, and Wintrich's sign — change of pitch in the percussion-note when the patient is directed to hold the mouth open and then to keep it closed — is also present. Combined Percussion and Auscultation. — By placing a metallic substance, e. g., a coin, over that portion of the pleura con- taining air, and the ear over a different area of the chest, a peculiar metallic, bell-like note is audible when the coin is tapped with a metal substance (Fig. 54). This is known as bell tympany, and is generally conceded to be one of the path- ognomonic signs of pneumo- thorax; some writers, however, claim that it exists where there is a large superficial pulmonary cavity without the 'presence of free air in the pleura. Auscultatory percussion (p. 59) is a method of value in separating the lower level of the fluid from the superior surface of the liver. It is like- wise serviceable in outlining the lower margin of the compressed lung, and in determining the exact outline of the heart. Auscultation. — When heard over the affected side, the breath-sounds display a metallic quality. Bronchial breathing may be heard over the compressed lung, while over the fluid collected at the base of the pleura the breath-sounds are decidedly lessened or even absent. If the ear is placed at a level between the upper border of the fluid and the lower margin of the lung and the patient is shaken vigorously, the liquid is heard to splash against the pleura; this is known as the Hippocratic succussion splash (Fig. 55; also p. 72, Causes of Thoracic Splashing Sounds). If, immediately after obtaining the succussion splash, the ear is held against the chest- wall, a peculiar dropping sound (metaUic tinkle) will be heard; this was formerly believed to be produced by the dropping of the liquid from the surface of the lung into the fluid below; a later theory, however, maintains that small bubbles are produced upon the surface of the fluid, and that the metallic tinkle is the sound generated by the bursting of each bubble. Another theory is that this sound may be the reechoing of Fig. 54. — Method of Tapping to Elicit Coin-test IN Case of Pneumothorax. The ear of the chnician is placed at a level corre- sponding to that of the coins, and on the anterior surface of the chest, while the assistant taps the coin. PNEUMOTHORAX. 165 vibrations of moist bronchial TM.es that are communicated to the free air in the pleura. If pleural exudate is placed in a bottle that is not tightly corked, it is possible to produce the metallic tinkle artificially. The breath-sounds are exaggerated over the unaffected side, but may become weak, owing to extreme compensatory emphysema. The heart- sounds are rapid, and late in the disease they become weakened and irregular. Accentuation of the second pulmonic sound is present throughout the course of this disease. X-Ray Diagnosis.— See Z-Ray Diagnosis (p. 77). I p a a ^ ™ 1 jt ^ o -t in >n «rt Ji 9 U1 a "~ " ^ ^ 149 148 147 146 ~ ~ ~ ■■ ^ B- - . ■^ ^ —■ "* 144 143 t42 141 140 ^ , - "^ . ^ C \\ G . ^ J ^ — — " i\l ^ — ' 139 138 137 136 las 134 133 132 131 inn « -- " , ^ — ^ 129 128 127 126 ^ ^ _ _ _ _ _ _ _ _ _ _ _ _ _ -: 1 _ L _ _ _ _ _ _ _ _ L _ = " ~ ~ - - - R\ E R* G E ~ ^f- L :s A T; n r " AL .- A 31 £ ~ r - ~ - - - - - r - £, 124 123 122 121 •- ', t Ell' ^ ^ ^^ ^ -ft* . ^ f19 lie 117 lie ^\ f pf TiF F V)^ L Ff \T 1 rj ^ ^ -" ^ 114 113 112 111 ^ - ^ ' , .^ ' ■ ■ ^ > <^ 109 108 107 106 ^ ^ ' ^ > ^ -f V , -- \\ P i,0»- 104 103 102 101 -' ^ ^ p ^ L. ^ _ _ .;. wm _ _ _ n _ . _ _ _ _ _ _ « _ _ _ ^ . . » Fig. 79.- -Wolet's Chart Showing Effect of Age on Blood-prebsuke, Giving Mean, High, and Low Average. PALPATOHT-AsciLiiATORT Method (Jour. Amer. Med. Assoc). Sex. — Blood-pressure is said to be lower in women. Brunton estimates it to be from 10 to 15 mm. Hg. below that of men. Posture is of some importance, since blood-pressure is lower when the patient is standing erect and highest when the head is lowered. Important in comparative readings. Age has a decided effect on blood-pressure. It is lowest in childhood, and increases progressively with years. Thayer, in a series of observations upon 276 healthy individuals, found the systolic blood-pressure average for the different decades to be- BLOOD-PRESSUBE. 203 1-10 years 104.6 mm. average pressure 10-20 " 128.7 " 20-30 " 136.9 " 30-40 " 140.8 " 40-50 " 142.2 " 50-60 " 154.8 " 60-70 " 180.0 " Brunton found the systolic pressure for children eight to fourteen years of age to be about 90 mm. Hg., and subjects fifteen to twenty-one years were found to give a reading between 100 and 120 mm. Hg. Time of day has a slight effect on blood-pressure, but this is of little clinical significance. Digestion. — During digestion dilatation of the blood-vessels of the abdominal region takes place, which would naturally cause a fall in blood- pressure, but the heart increases the output to not only compensating for the fall, but also actually increasing arterial pressure. Altitude. — Recent clinical studies would seem to show that change from low to high altitude causes a rise in blood-pressure in normal individuals, which becomes less marked as the subject becomes accustomed to the change, while in the tuberculous with a subnormal pressure high altitude affects a usually permanent rise. Exercise. — Physical exertion in the normal healthy individual causes a sharp rise of from 5 to 30 mm., which persists for a while after the cessa- tion of the exercise. This rise is less marked as the individual becomes accustomed to the exertion. This factor demonstrates the benefit on the circulation of graduated systematic exercises; extreme exertion, resulting in fatigue, is usually followed by a fall of pressure, which may be so marked, as after a boat race or marathon, as to be a sign of great danger, often of acute cardiac dilatation. Emotion, Excitement, Etc. — The effect of these depends upon the temperament of the individual, and is an indication of the stability of the vasomotor system. The change in pressure may be extreme, and may in cases detract from the value of the observation. Obesity. — Under ordinary circumstances this state does not materially affect the readings. The extremely obese may show subnormal pressures. Pathologic Variations in Blood-pressure. — For convenience of clinical study we have considered pathologic blood-pressure under the following subheadings: 1. Those conditions showing high blood-pressure — hypertension. 2. Conditions accompanied by low blood-pressure — hypotension. 3. Those conditions displaying a primary rise and a secondary fall of blood-pressure. 4. Maladies in which there is an instability of blood-pressure. Hypertension is frequently found in — 1. Nephritis. — In chronic interstitial nephritis the blood-pressure is always high except during the last few hours before death. Here a routine study of blood-pressure is of great clinical importance. An approaching uremic crisis can often be foretold before it becomes evident through any other clinical method. In the chronic parenchymatous form high tension may or may not be present. In amyloid and in the hemorrhagic forms of nephritis normal or subnormal blood-pressure is frequently encountered. 2. Arteriosclerosis. — Blood-pressure will be found high in proportion as the general arterial tree is involved, and will be highest in general 204 DISEASES OF THE PEKICAHDTUM, HEART, AND BLOOD-VESSELS. arteriosclerosis involving the splanchnic area. It should be remembered that local arteriosclerosis as in the radials may not be accompanied by high pressure. 3. Cardiac Disease: (a) Aortic regurgitation; (6) angina pectoris. In aortic regurgitation, hypertension combined with a large pulse pressure (60 mm. or more) is a most characteristic sign of this disease. This reaction is purely physical, and is due to the fact that the heart at each systole is required to force into the aorta not only suflB.cient blood to maintain the circulation, but also an additional volume to allow for the regurgitation into the left ventricle. (See also p. 265.) 4. Puerperal Eclampsia. — The importance of a high and rising blood- pressure as an early diagnostic evidence of toxemia in the latter half of pregnancy can hardly be overestimated. For nearly two years the blood- pressure of every patient in the University of Pennsylvania Maternity, and also those cases in the private practice of Dr. John C. Hirst, has been taken from these observations. The following conclusions have been war- ranted: (a) A high blood-pressure (average, about 190 mm. Hg., highest over 300 mm. Hg.) is noted in every case of actual eclampsia. (6) A high blood-pressure, constantly rising, is noticed as an invariable, and very often the earliest, sign of toxemia in the latter half of pregnancy. In one private case it antedated albuminuria by three weeks, and in another by two weeks. (c) As far as any diagnostic rule can be laid down, a blood-pressure of under 120 mm. can be disregarded; from 120 to 150 carefully watched, and over 150 usually means danger. (d) When the membranes rupture in labor or are artificially ruptured in a patient who is toxemic, there is an immediate fall of blood-pressure of from 60 to 90 mm., followed by a prompt rebound to nearly the original height with, however, a marked amehoration in the subjective symp- toms. (e) There is a second fall of blood-pressure following the birth of the child, with a second rebound to near the original height, and then a gradual but steady fall until the normal is reached — three to seven days after dehvery. (/) Cases terminating fatally do not return to normal pressure. 5. Toxic agents (poisons from): (a) Lead; (6) nicotin. 6. Metallic Toxemia. — (a) Lithemia; (6) gout — here an unusually, high pressure may persist for an indefinite period. (7) Cerebral and ocular hemorrhage also causes a rise in blood-pressure. B. Hypotension is a feature seen in: (1) Shock. (2) Exhaustion. (3) Cachexia and anemia. (4) Certain infectious fevers, especially typhoid and tuberculosis. In typhoid fever observations of blood-pressure is of clinical value. The pressure falls gradually with each week of the disease, and this is very well shown in 115 cases studied by Crile, who found: First week = 115 mm. Second week = 106 " Third week = 102 " Fourth week = 96 " Fifth week = 98 " BLOOD-PKESSUBE. 205 A rapid fall of blood-pressure should suggest hemorrhage. Crile and Briggs have found a sharp rise marking the onset of peritonitis following intestinal perforation. All authorities agree that hypotension is the rule in tuberculosis, and this pressure falls correlatively with the loss in general bodily vigor. (5) Venesection, temporary. (6) Excessive hemorrhage. (7) Copious Diaphoresis. — Both the hot-pack and the hot-air bath reduce the blood-pressure by free diaphoresis. (8) Diarrhea. (9) Following aspiration of fluid from the pleural and abdominal cavities the pressure is temporarily lowered. (10) Cholera asiatica. (11) Cerebral embolism. (12) Cardiac Conditions. — (a) Myocarditis; (6) tachycardia. C. A primary rise and a secondary fall of blood-pressure are seen in severe types of: 1. Pneumonia. 2. Scarlet fever. 3. Peritonitis. D. Instability of blood-pressure is often seen in very nervous persons, in exophthalmic goiter, neurasthenia, and during the menopause. , Faught's Blood-pressure Indicator. — The Faught indicator, as shown by the accompanying illustration (Fig. 80), is unusually easy of opera- tion, and does not require any special skill in order to obtain accurate, as well as constant, readings with this instrument. Another advantage worthy of special mention is that the Faught pocket indicator is light, and can, there- fore, be readily brought to the bedside. Application. — (1) Raise the lid, which carries the manometer until it locks in a vertical position. Apply the cuff to the arm just above the elbow (Fig. 80). The armlet and cuff are applied together, the ends of the rubber being smoothly overlapped. (2) The straps are now buckled, when the cuff fits neatly, but without compression. (3) Whether applied to the calf of the leg or to the forearm, if the limb is very conic, there will be a tendency to slip, and the rubber must be_ placed somewhat diagonally, otherwise the pressure will be exerted chiefly on the portion surrounding the larger portion of the limb, and the result will be the same as though a narrow cuff had been employed. (4) If the mercury has become separated, gentle jarring up and down will cause it to reunite. Then set the scale (G), which is adjustable, so that zero is at the mercury level. (5) Connections are made as follows : Attach the pump P by means of the expansile tubing to the nipple F, having the stopcock M. Connect the arm-band to the nipple D. Close the needle valve N and turn both mer- cury guard-cocks K and L in the vertical or open position (Fig. 80). (6) Locate the pulse, with the left hand, on the same member to which the arm-band is attached, and do not change the position of the fingers dur- ing the test. Operate the pump with the right hand. (7) Action of the pump will now force air into the closed system, dis- tending the rubber armlet, and with the same degree of force driving the mercury up in one limb of the "U" tube H. 206 DISEASES OF THE PEHICARDIUM, HEART, AND BLOOD-VESSELS. P— > Fig. 80. — Faught's Standard or Mercury Sphygmomanometer. (8) When the pulse disappears, the valve M is closed by turning to right angle to the nipple F. (9) Turning the needle valve N slightly in a contra-clockwise direction, or until the mercury gradually falls about 2 mm. per pulse-beat, and the pressure indicated on the scale when the pulse reappears at the wrist is the systolic pressure; disregard all motion of the mercury up to this time. (10) As the mercury column falls, oscilla- tions of the mercury will follow the pulse, and will increase in magnitude until they reach a maximum and then quite suddenly decrease and finally disappear. The base Une of the greatest oscillation (the line from which it starts) is the diastolic pressure. (11) Patients presenting little or no oscil- lation may have the diastolic pressure meas- ured by noting the mercury level on the scale, at the moment that the first full forci- ble impulse is felt at the wrist. (12) After having determined the sys- toHc and diastohc pressures disconnect one tube and allow all air to escape, then repeat the tests to verify the findings. Cautions. — (1) Uniform Method. — It is wise to adopt a method by which all pressures are taken. This diminishes the time required and eliminates error. The muscles of the arm should always be relaxed; conse- quently if the patient is sitting the elbow and forearm should be sup- ported, as muscular contractions show themselves on the mercury column. Preferably, the pressure should be taken with the patient in the recumbent posture. It is easier for most observers to take pressure from the left arm, as the necessary manipulations of the manometer are more easily per- formed with the right hand. In nearly all cases the first estimation will be found to be from 10 to 20 mm. higher than subsequent esti- mations; this is probably due to excitement. Several estimations should be made, until the level nor- mal to the individual is obtained. (2) Rapid Pulse. — There is no pulse so rapid that the mercury instrument may not be used; actual experiment has shown that 200 beats per minute will be shown by syn- chronous oscillation of the mercury. (3) Slow Pulse. — With a very slow, strong pulse the oscillations may be so large that it is difficult to record the largest ones. In these cases, by Fig. 81. — Stanton's Sphtgmomanometeh. BLOOD-PRESSUBE. 207 leaving the valve A open, a part of the oscillation is absorbed by the elastic rubber bulb and the reading becomes easier. Faught's JNIercury Apparatus in Use. (4) High Pressure. — In those showing threatened circulatory failure, especially in case of high pressure, it will be found almost impossible to ascertain definitely either the high or the low pressure. Despite repeated estimations, the high pressure will vary from 5 to 15 mm. These cases may at times show a condi- tion in which an occasional beat reaches a much higher level than that at which all the beats can be detected, a feature possibly influenced by res- piration. In event of high pressure, the pocket instrument is most satisfactory. Pocket Sphygmomanometers. — The pocket, or so-called aneroid sphygmomanometers, have recently attracted great attention, and are rapidly being adopted for clinical purposes. Their chief advantage is their portability. A number of them are now made of such a size that they are all contained in a leather carrying case of pocket size. The Faught pocket sphj^gmomanometer is made in two sizes, one (Fig. 83) has a dial of 3^ inches in diameter and records pressure up to 300 in mm. Hg. The method of use does not differ from the mercury instruments, excepting that if anything they are easier of application. The graduated standardized dial takes the place of the mercury column, while the cuff, to reduce its size, if of the bandage type, contains a, compression bag of Fig. 83. — Faught's Pocket In- dicator. Actual Size. 208 DISEASES OF THE PERICAHDIUM, HEART, AND BLOOD-VESSELS. standard size, 5 by 9 inches. This is retained on the arm Ijy placing the rubber portion over the vessel and then wrapping the long fabric cufif over this until it is used up, finally tucking the end under the preceding turn, where it is held by the air pressure within the bag. The rubber portion of the arm-band is easily removable from the fabric portion, which may then be easily washed or sterilized. The authors have grown to use this instrument exclusively. Ausculatory method for determining the systolic and_ diastolic pressure is shown by the accompanying illustration (Fig. 84). Karotkow, of St. Petersburg, contributed the first paper on this method in 190.5. Gittings, of Philadelphia, gave an admirable review of the subject, to- FiG. 84. — Auscultatory Method. Faught's Pocket Indicator In Use. gether with a report of his observations. The authors employ this method in all their clinical work. The maximum and minimum pressure can be more readily and more accurately determined by the auscultatory method than by any other, and its use is attended with no difficulties. (1) Before placing the cuff around the arm over the brachial artery the bowl of the stethoscope is placed immediately below the elbow and over the bifurcation of the artery. If it is possible to hear the sound of the artery, the auscultatory method cannot be employed in such a case. It is to be emphasized that in certain selected cases, especially those of aortic regurgitation, the so-called pistol-shot sounds are heard over the larger arteries, and in a case of this kind the auscultatory method is not appli- cable, except for the determination of high pressure. Again, it is essential that the radial artery be readily palpable. (2) After placing the cuff around the arm, one must be especially careful that the second portion of the cuff surrounding the arm (that part of the canvas not containing the rubber bag) extends to both edges of the rubber bag and continues for one or two laps. The tip of the canvas is then BLOOD-PRESSURE. 209 tucked underneath the bag. When the cuff is properly apphed it should fit the arm sufficiently tightly, so that one can rotate the cuff without its slipping toward the elbow. It is well to place the center of the rubber bag across the brachial artery. (3) Place the stethoscope over the artery below the elbow and, while listening, inflate the bag slowly, observing that no portion of the bag creeps from under the second lap of canvas while the inflation is taking place. (4) Record the first sound that is heard over the artery (Fig. 85, 5). Continue to inflate the bag until the instrument registers ten to twenty points above where the first sound was obtained, and then permit the air to escape from the bag gradually until one ascertains at what point the sound disappears (Fig. 85, 5). This point must register identically with the reading at where the sound was first heard, and represents the (generally accepted) diastolic pressure. In normal pressure the disappearance of sound is noted 2 to 4 mm. below the true chastolic pressure. In event of unusually high pressure, 160 to 220, add from 8 to 15 to this reading. FiQ. 85. — Fast Drtim. Sudden Decrease in Size of Pulse-wave at 4, Marking the Change from Clear, Sharp Tone to Dull Tone (Warfield, in Jour. Amer. Med. Assoc, Oct. 4, 1913). (5) Continue inflating the bag until a point is reached at which all sound over the artery disappears (Fig. 85, 1). Continue to inflate the bag until the instrument registers ten to twenty points above this reading, and then, as in the case of determining the diastolic pressure, permit the air to gradually escape from the bag until the first sound over the artery is heard. This reading and that for which the sound disappeared should be practically the same, and represent the systolic or high pressure (Fig. 85, 1). Cautions.~(l) The cuff must be properly applied (see Fig. 84) ; (2) the muscles must be relaxed; (3) the patient dare not move the arm or hand during the procedure; (4) in aortic regurgitation the pistol-shot sound rarely present renders an accurate study difficult. Character of Sounds Heard Over the Artery Below the Cuff (Fig. 84).— Ettinger, in a systematic study of 235 cases, found that the cycle began with the passage of the first waves of blood under the cuff. This usually produces a clear, tapping sound, and is designated the first phase. The second phase quickly follows the first, and is heard as a more or less distinct murmur, the duration of which is variable (this murmur may accompany the first sound, but rapidly replaces it). The third phase includes that period when the murmur is audible. The fourth phase occupies that por- tion of the cycle where as the mercury falls the clear sound becomes dull (this change is not distinct in all cases, although in health it is readily recognized). Ettinger holds that the beginning of this fourth phase (where the clear sound becomes dull) represents the true diastole. This 14 210 DISEASES OF THE PERICARDIUM, HEART, AND BLOOD-VESSELS. point, however, remains open for discussion. The fifth phase occupies the remaining portion until the disappearance of the dull sound. Krylow claims that where there is extensive arteriosclerosis the aus- cultatory phenomena are apt to be unusually pronounced. Among the conditions to be taken into consideration are : (a) Degree of narrowing of the vessel. (6) The elasticity of the vessel. (c) The size of the puLse-wave. (d) The rapichty of transmission of pulse-wave. Ettinger has called special attention to the fact that the rapidity of the pulse increases the auscultatory phenomenon. In aortic regurgitation with marked dicrotism Fig. 86. — Detehmining Blood-pressure (Auscultation Method). Apparatus in Use.) (Kearcher's Blood-pressurb a double sound may be heard, and there may be a persistence of the second sound. Both Krylow and Gittings have suggested that alteration in aus- cultatory phenomenon points conclusively to insufficiency of heart muscle, and the latter observer has reported an interesting series of 63 cases where such alterations were conspicuous. By employing the auscultatory method the maximum pressure is detected at a higher, and the minimum pressure at a lower, reading than are they when the previously described method (p. 205) is employed. It consequently follows that the mean and pulse pressure will be found higher where the auscultatory method is employed. Ettinger found this difference to be 13.2 mm. Per.sonal experience has caused us to regard the systolic reading by this method approximately 5 mm. above that obtained by palpation. BLOOD-PKESSURE. 211 Fig. 87.- — The Dudgeon Sphygmograph in Position. THE SPHYGMOGRAPH. The sphygmograph is an instrument for recording graphically the fre- quency, volume, force, and tension of the pulse, together with other general characteristics. The sphygmograph was devised by Jlarey, and since its introduction many valuable modifica- tions have been added to it, until, at present, Dudgeon has produced a clinical de- vice that serves fairly well, although it is by no means without objectionable fea- tures. Irrespective of what instrument may be used, the actual value of the trac- ing or record depends greatly upon the personal skill of the operator; consequently the sphygmograph occupies a place widely different from that of many other clinical instruments, and records obtained through its use will, in the hands of skilled individuals, prove to be practically constant and reUable. The clinician learns to recognize practically all the peculiarities of the human pulse by palpation of the radial artery, but despite this fact he is forced to be more careful by comparing the pulse with its written record. Again, the sphygmographic record may be preserved in conjunction with the clinical history, and in this way serve as a valuable datum. Technic. — By careful observation of the sphygmograph we find that it consists, first, of clockwork, carrying a narrow strip of smoked paper; second, of a writing needle; and third, of a support or canvas by the use of which it is held in position over the artery. (a) The clockwork is first wound by turning a special button. (b) The patient is directed to place his forearm and hand in a comfortable position, expose the wrist at the site of the radial artery, flex the fingers gently, and allow the muscles of the forearm and hand to be relaxed. ^ (c) To apply the sphygmograph slip the band or support over the patient's wrist, when the free end of the band is then passed through a special retaining clamp (Fig. 87). The metallic box of the instrument should be directed away from the hand. (d) The next step is to adjust the sphygmograph so that the bulging button, which connects the levers, is directly over the radial artery, and, while the instrument is now held in position by the operator's left hand, the band that holds it to the wrist is drawn through the clamp until the instru- ment is sufficiently tight so that the writing needle plays easily with each pulsation of the artery. Whenever the last-named result is obtained, fasten the clamp, and the instrument is ready for use. (e) Place a strip of smoked paper (Fig. 87) between the rollers of the instrument and directly underneath the needle. (/) There is a special thumb-screw for the purpose of gaging the pressure, and this must be adjusted to effect the best possible amplitude of vibration. (g) Steady the patient's hand gently, start the clockwork, and permit 212 DISEASES OF THE PERICARDIUM, HEART, AND BLOOD-VESSELS. it to continue until the smoked paper has entirely passed through the rollers; then stop the instrument. In Dudgeon's instrument the machinery is so regulated that a five-inch slip of smoked paper will pass in ten seconds, and by a simple matter of calculation the pulse-rate a minute is attained. Preparation of Paper. — Smoked paper is usually employed in the making of sphygmographic trac- ings, and some writers rec- ommend that this paper be glazed upon one side and rough upon the other. The paper must first be cut in strips, approximately I of an inch in width, and six or seven inches in length. Fig. 88.— Normal Pulse Tracing. The glazed SUrfaCe of ab Up-stroke or percussion stroke; bg, descending or ^J^g reCOrd paper is black- catacrotic limb; abc, percussion wave; cde, predicrotic or r^ l ^ ^ tidal wave; efg, dicrotic or recoil wave; bed, protidal notch; ened by holduig it OVCr the def, aortic notch. rj i i i i • name produced by burning a small piece of gum cam- phor. \'arious devices may be employed for the purpose of keeping the paper exposed to the smoke, but the method most often employed is that of a strip of tin so bent upon itself as to catch and hold the narrow strip of paper at each end. Care should be taken not to blacken the paper too deeply, lest the lines of the tracing will be irregular and often indistinct. Preservation of Record. — Write upon the record with a broken pen or a needle, or upon the unsmoked portion, with pen and ink, the patient's name, important features connected with the case, the date, and the name of the artery from which the tracing was made. The record is preserved by dipping the smoked paper into a solution of shellac or into a solution of benzoin. The method is as follows: Grasp one end of the sphygmographic record by a pair of forceps and draw slowly, record side up, through the solution, and permit it to dry in the air. When records are likely to he handled or are to be preserved for a long period, it is well to give two or more coats of shellac. Interpretation of Tracing. — Normal Pulse Tracing. — As the result of each contraction of the left ventricle a volume of blood is forced first into the aorta, which is appreciably distended, and the distended impulse is further transmitted by a characteristic wave-like motion to the remote portions of the arterial system. The distending impulse elevates the Isutton of the lever, causing the so- called percussion stroke (a, b) (up-stroke). The distending impulse has been exaggerated by the sphygmographic system of levers, and has been thrown too high; therefore, the lever falls by its own weight to a point too low; consequently it is again caught and elevated by the tidal blood to form the writing of the tidal wave (c, d, e). Further descent is again interrupted at e, forming the so-called dicrotic wave (e, /, g), which is dependent upon the recoil of blood from the closure of the aortic leaflets. The normal pulse tracing (Fig. 88) will display the following character- istics: (a) The percussion stroke, which is nearly vertical and of moderate amplitude. BLOOD-PBESSUKE. 213 (6) The apex or summit, which is fairly acute. (c) Gradual descent. (d) A small tidal wave. (e) A distinct dicrotic wave (Fig. 88). Features of the Sphygmographic Record to be Observed with Refer- ence to its Clinical Significance. — (1) The characteristics of the percussion stroke, particularly its height, and whether or not it is vertical or inclined. (2) Is the apex pointed, rounded, or unusually broad? (3) Is the tidal wave conspicuous, scarcely per- ceptible, or absent? Also observe the same character- istics with reference to the Fig. 89. — Pulse Tracing in a Case of Aortic Regurgita- ,. ,. TiON (William Hoffman). dicrotic wave. (4) Do the successive strokes occur regularly, irregularly, or do they intermit? Is the line of descent regular? (.5) Is the character of the base line or line connecting the bases of the different beats straight, curved, or irregular? Clinical Significance of Variations in the Pulse Tracing. — Percussion (Up- stroke). — (a) A long upstroke is observed when a large volume is ]Dresent, and is also significant of a sudden quick systole or of a relaxed condition of the arteries. It is a feature of low tension and of aortic regurgitation. (See Fig. 89.) (b) A short upstroke corresponds to a small volume, and is indicative of those conditions in which but a small volume of blood is capable of escaping into the aorta — e. g., aortic stenosis, mitral regurgitation, thoracic aneurism, and conditions causing obstruction to the peripheral circulation. If the up-stroke is vertical, it signifies a quick systole, regardless of whether or not the cardiac muscle is weak or strong or an abnormally large volume of blood is propelled into the aorta at such systole. A vertical up-stroke is frequently seen in association with the unusually low-tension pulse of aortic regurgita- tion. (c) An oblique upstroke may be obtained where the radial ai-tery is covered with a thick layer of fat. It is also seen where the arterial system fills slowly — e.g., in aortic stenosis, thoracic aneurism, marked arterioscle- rosis with high tension, mitral regurgitation, and, rarely, it is a feature of myocardial change of the left ventricle. The Apex. — (a) A pointed apex signifies that there is no obstruction to the peripheral circulation, that the tension is low, or that we are dealing with aortic regurgitation (Fig. 89). (6) A broad apex signifies that the muscle action of the heart is forcible, but that high tension in the peripheral circulation, arteriosclerosis, aneu- rism, or aortic stenosis is present (Fig. 90). A broad apex may also result where the sphygmograph is not correctly adjusted, or where the spring exerts too great pressure. ^ The Tidal Wave.— (a) If the tidal wave (Fig. 88) (c, d, e) is exaggerated, it indicates that there is high tension due to obstruction in the peripheral circulation (arteriosclerosis), or to aortic stenosis. 214 DISEASES OF THE PERICARDIUM, HEART, AND BLOOD-VESSELS. (6) If the tidal wave is feeble or absent, the heart muscle is usually weak, or possibly there is moderate or low arterial tension in conjunction with mitral or aortic regurgitation. Dicrotic Wave. — (a) When the dicrotic wave is prolonged, the heart is weak or of but moderate strength, and there is low tension in the peripheral Fig. 90. — Pulse in Advanced Arteriosclerosis. Slow ascent and descent of the wave; anacrotism — only 32 beats to the minute. circulation. A conspicuous dicrotic wave is less often seen in cases of high tension with cardiac failure. (6) If the dicrotic wave is small or absent, obstruction to the peripheral circulation exists; but, despite the high tension, the heart is still strong — a feature of arteriosclerosis, aortic stenosis, aneurism of the great vessels, and, rarely, aortic incompetency. Fig. 91. — Jaquet Sphygmocardiograph. Line of Descent. — The line of descent in both mitral stenosis and regurgi- tation is made conspicuous by its irregularity. Base Line. — The base line will be found to be irregular, and at times to BLOOD-PRESSURE. 215 show some change, corresponding more or less closely to the acts of respira- tion in those suffering from cardiac disease who also display dyspnea. This last phenomenon may result from involvement of the cerebral center. The degree of regularity or irregularity displayed by any given sphyg- mographic record is immediately apparent when other peculiarities that are present are analyzed. Sphygmocardiograph.— The most reliable apparatus now to be had for obtaining tracings from the various parts of the circulatory system is Fig. 92. — Tracing Produced by the Sphygmoc.\rdiogr.\ph. that known as the sphygmocardiograph of Jaquet. With this apparatus (Fig. 91) it is possible to take tracings of the circulatory system from three points at the same time. It is provided with a time marker, which registers every two-fifths of a second. This method of clinical investigation was introduced by Mackenzie. The advantages of this instrument are, first, the method by which the apparatus is fastened to the arm. This is effected by means of a metal Fig. 93. — Poltghaphic, Venous, and R.adi.\l Curves (Mackenzie). V illustrates the auricular type of venous curve with prolongation of the a-c intervals; R displays the ventricular type of curve where great irregularity is present; T, time record, I sec. plate so perforated as to permit the spring to come in contact with the artery. It has the additional advantage of being easily adjusted to almost any wrist, and the width of the attachment is sufficiently great to support the instru- ment without the aid of the hand. The sphygmocardiograph is anchored and retained in place by a screw. The apparatus itself consists of a case containing the clockwork necessary to furnish the motive power of the machine, as well as the machinery that runs the time-marker. The power that drives the paper through the apparatus consists of a straight rod with four] small wheels driven by clockwork. This may be run at either a slow or a fast rate of speed, the fast one being five times as quick as the slow one. The breadth of this driving surface is so great that the paper, once started, will pass through without catching or binding on tlie sides. 216 DISEASES OF THE PERICARDIUM, HEART, AND BLOOD-VESSELS. The writing apparatus consists of a spring and a lever of the type of the old Dudgeon insti-ument, and takes the tracing from the radial artery. The other two tracings are talven from the small air-capsules covered by rubber, which operate the two levers in the center. The pulsations are transmitted to these capsules by air through rubber tubes. The fourth writing point is the time-marker. The rubber capsules are so constructed that the rubber is very easily applied, and the adjustment of the levers is readily accomplished. The tracing from the heart is made by means of a special apparatus called the cardiograph. It is adjustable to any shape or form of chest, and can readily be held in position. Pulsations from the jugular veins or from the liver are taken 1iy means of small cone-shaped receivers, similar to those advocated by j\IcKenzie. Although the apparatus is apparently complicated, Fig. 94. — Jaquet's Instrument in Operation to Record Writing of Impulse over Heart, Right Carotid, and Right Radial Arteries. it may be thoroughly understood with but little study, and it can be oper- ated by any one after a Uttle practice. (See Fig. 94.) The advantages of the sphygmocardiograph are: (!) The size of the tracing, which is 70 mm. broad and about 30 inches long. (Fig. 92.) (2) The aljility to get the tracings from the various points of the circu- lation at the same time (Fig. 94) and on the same sheet of paper (Fig. 92). (3) The mechanical advantage of a firm fixation to the arm, which permits of it being operated successively by one man. (4) A two-speed drive, permitting the stretching out, as it were, of the pulse-curve, so that the individual characteristics can be studied. (5) The time-marker, which enables one to figure out in time the various phases of the curves obtained. The method of using the apparatus is well shown in the accompanying illustration (Fig. 94). ELECTROCARDIOGRAM. 217 ELECTROCARDIOGRAM. Through this system of study one is able to record changes in potential of the heart muscle that accompany its activity, thus giving a favorable view-point of the normal and abnormal heart action. It has been possible Fig. 95. — Apparatus Complete, Containing Einthoven Thread Galvanometer as Employed by Edelman. L, Arc lamp; W, cooling bath; G, Einthoven thread galvanometer; M, projection microscope; K, camera containing sensitized paper on which the cardiogram is made; Si S2 S3 Si, switches controlling the normal element, resistance, and condensers for determining the sensibility of the galvanometer and tor compensation of the skin currents. through this course of study to obtain new light upon that complex problem presented by the pathologic changes of the heart. Rapid strides in the development of electrocardiography have been observed during the past five years. In this volume it has Jseen deemed advisable to consider only certain of the more practical phases in con- 218 DISEASES OF THE PERICARDIUM, HEART, AND BLOOD-VESSELS. nection with this chnical method. The authors are indebted to Dr. Thomas A. Cope for the illustrations in connection with this subject. The electrocardiogram is a graphic record of the feeble action currents of the cardiac muscle (Fig. 96), and it is obtained by leading these currents to an hypersensitive galvanometer; the circuits of the moving parts of which are recorded by a shadow that is made permanently upon a moving strip of film (Figs. 101 and 102). Certain established physiologic facts are essential to a full appreciation of electrocardiography. First, every muscle contraction has associated Fig. 96. — Lines of Diffusion of the Cardiac Action Current {after Waller). with it definite changes of electric potential; for example, a piece of mus- cle becomes in reality a feeble galvanic cell, in which the active portion of the muscle corresponds to the zinc plate and the passive to the copper, and when these two are connected the current which passes is designated the action current of the muscle. Again, the surface of that portion of muscle which is for the time active is negative to all the remaining muscle surface, which is at the same time positive (Fig. 97). The electrocardiogram in health is a curve displaying general char- acteristics, although it is subject to certain variations. The cardiogram varies within rather wide limitations in pathologic conditions of the heart, and this is of great interest to the clinician when it placards definite anatomic changes and abnormalities in function. In referring to the ELECTROCARDIOGRAM . 219 factors, which in turn cause changes in the form of the electric curve, it is to be remembered that this curve is solely the expression of changes in the electric conditions of the heart, and is due to muscular action. Movement of the blood-stream and mechanical disturbances of the cardiac Fig. 97. — Scheme to Illustrate the Action Current of a Simple Muscular Contraction (James and Wilson, in Amer. .Jour. IMed. Sci., Sept., lUlOj. valves do not exercise any direct effect upon this record. Another factor is that the character of the curve varies in accordance with the points of the body surface from which the current is led off. Likewise variations in the position of the heart will cause rather marked changes in the electrocardio- cs rom laetern B B ^ C m iM^- fl^fiw^; tm ~/i-. Fig. 98, — Scheme of Connection Employed in Galvanometric Work for Clinical Use. GS, Galvanometer atring; K, key; R, resistance; C, commutator; A, accumulator; B, bath; W, W, compensator high-resiatance wire. gram. Decided changes in the shape of the muscle mass also affect the curve, as do those contractions which originate in abnormal locahties and pursue an unusual course through the muscle. 220 DISEASES OF THE PERICARDIUM, HEART, AND BLOOD-VESSELS. Leads. — The electrocardiographic curve is obtained by leading off from various points of the body, and for clinical purposes Einthoven recognizes three leads taken in pairs: (1) Leading off from the right arm and left arm. (2) Leading off from the right arm and left leg. (3) Leading off from the left arm and left leg. Ventricular extrasy stole. Normal P-wave. Auricular extrasystole. Normal P-wave. Auricular extrasystole. ■ 1 Fig. 99. — Electrocardiogram, Showing Auricular Extrasystole. The Curve also Shows Ven- tricular Extrasystole. Patient Philadelphia General Hospital (Cope). Physiologic Mammalian Electrocardiogram. — The fact that no two in- dividuals present during health exactly similar curves renders this problem one of considerable difficulty, but when we come to consider the lead 1 (from the right arm and left arm), certain features are common to the Ventricular complex. Fig. 100. — Electrocardiogram from a Patient Showing Complete Heart-block (patient studied by Dr. T. A. Cope). The P-wave, representing the auricular action, is independent of the ventricular contraction. electrocardiogram. Again, the electrocardiogram of the normal subject consists of two parts: (a) auricular; (b) ventricular complex. Auricular Complex. — The auricular complex is composed of a primary deviation in the "base negative" or upward direction. In the terminology of Einthoven, which is generally adopted, it is termed the summit P (Fig. 100). This summit P may be either rounded or pointed and is sue- ELECTROCARDIOGRAM. ceeded by a horizontal line (iso-electric period) , or by a somewhat less spicuous deviation in the opposite, "base positive," or downward direc 221 con- as ^BB^a^B&i Fig. 101. Ventricular Vibration of extraaystole. fibrillating auricle. -Electroc.\rdiogr.\m, Showing Auricul-\r Fibrill.vtion. Private patient) (Cope). Note entire absence of P-wave, but instead a continued slight vibration. Ventricular Complex. — This is, as a rule, triphasic, and is composed of the variations R, S, and T (Fig. 101), of which the R and the T are deflected upward, while the S-curve is directed downward (Fig. 102). R is ordinarily Q s Fig. 102. — Electrocardiogram from a Case of Mitral Stenosis. University Hospital (Cope). Note unusually high P-wave (high as T-wave), denoting hypertrophic auricle. found to be the most conspicuous summit in the curve; its duration is ap- preciably short (approximately .03 second). R may be preceded by a small and short deviation in the opposite direction, the summit Q (Fig. 102). 222 DISEASES OF THE PERICARDIUM, HEART, AND BLOOD-VESSELS. R is followed by a short downward deviation (S), which varies consider- ably in amplitude, often being scarcely perceptible, although it may be conspicuous. It is immediately apparent that the opening phase of the electrocardio- gram consists of summit P, which is associated with auricular contraction; summits Q, R, and S, which are associated with the initial events of ven- tricular systole. It is to be seen (Figs. 101 and 103) that the preceding group of variations is followed by a horizontal line of varied length, during which the contacts are iso-electric (contacts with the patient when no cur- rent is passing through the string), and the curve continues ending in broad and somewhat prolonged variation (T). P R T T T Fig. 103. — Electrocardiogram from a Case of Hypertrophied Left Ventricle, Accompanied bt High Blood-pressure (Cope). Note the high T-wave, denoting strong action current. Time Relationship. — The electrocardiogram may be taken simul- taneously with records from the auricular and ventricular musculature, as well as the sphygmographic curve, the intraventricular pressure curve, and the heart-sounds (Fig. 103). Through a correlative study of these records it has been possible to determine that P stands in direct relationship to the auricular systole, and that the upstroke P antedates by .012 to .017 second the stroke R (a phase known in the normal human electrocardiogram as the P-R interval). The upstroke R ordinarily precedes the beginning of ventricular contraction by .03 second, an interval referred to as "a measure of the latency of contraction" (Lewis). Summit T occurs during the systole of the ventricle and subsides abruptly .03 second before the occur- rence of the second or the auricular sound. Pathologic alterations in the electrocardiogram are seen when dis- sociation of the auricular and ventricular rhythm obtains, at which time summit P appears at uniform intervals in the curve (Figs. 101-103), but does not bear a constant relationship to the ventricular complex, which is also present. Difficulty in interpreting the events upon which the physiologic type depends are very great, and at present we have but a superficial grasp of the factors determining its component parts. These difficulties are: (a) AUSCULTATION. 223 the complexity of the path by which the contraction wave enters the ventricle, and (6) the variations in the course of fibers in the wall of the ventricle. Similar difficulties are likewise encountered in the study of electrocardiograms from patients presenting various types of arrythmia, yet definite changes in the electric record are rightly asso- ciated with certain pathologic entities, as is shown by the accompanying illustrations. The reader is referred for complete technic, etc., to special works devoted to the subject.* MENSURATION OF CHEST IN CARDIAC DISEASE. By this clinical method it is possible to ascertain the circumference of the chest at different levels, e. gr., at the ensiform cartilage, the nipple, and the axilla. It is also possible to determine the measurements of but one side of the chest, as well as the amount of unilateral expansion during the act of respiration. PERCUSSION. Percussion serves, in great measure, to confirm the findings secured by inspection and palpation. With reference to cardiac conditions, percussion serves, first, to distinguish between cardiac enlargement, the result of either hypertrophy or dilatation, and pericardial effusion. In pericardial effusion the lower portion of the posterior lobe of the left lung becomes airless, as the result of pressure exerted by the effusion; hence dullness below the angle of the left scapula is a conspicuous sign of pericardial effusion. In performing percussion for the purpose of detecting diseases of the heart and pericardium, it is almost always necessary to distinguish between diseases of these organs and diseases of the lung and pleura. It shall, therefore, be our aim to em- phasize, under each particular disease, the advantages of percussion; and here we wish again to call the reader's attention to the great advantages to be gained by the use of auscultatory percussion (p. 59) in differen- tiating between both diseased and healthy viscera that are in close prox- imity. (See Percussion of the Lung, p. 55.) AUSCULTATION. This method of physical diagnosis provides a means of obtaining the most valuable data with reference to diseases of the heart. In auscultating the clinician should first place his ear over the various areas at which the cardiac lesions are best heard — e. g., the right and left second intercostal areas, the apex, and at the ensiform cartilage. The skilled observer can detect with the ear the character of both the first and second soimds of the heart, and determine accurately the condition of the cardiac muscle, weakness of which is also further placarded by arhythmia. In order to recognize certain abnormal sounds heard over the precor- dium, or, as is often the case, exclude other sounds, the stethoscope serves as a valuable means of diagnosis. It is also possible, by the aid of the stethoscope (Figs. 104 and 105), to trace certain murmurs throughout their * T. Lewis, "Mechanism of the Heart-Beat," 1911. 224 DISEASES OF THE PERICARDIUM, HEART, AND BLOOD-VESSELS. various areas of distribution, as well as to determine their points of greatest intensity. The stethoscope enables the clinician to obtain valuable data regarding endocardial, pericardial, and pleuropericardial murmurs. (See Auscultation of the Lung, p. 63.) Fig. 104. — Bowles' Stethoscope. Regular pattern. Fig. 105. — Bowles' Stethoscope. Flat iron pattern. Normal Heart-sounds. When the stethoscope is applied over the heart in the third and fourth interspaces, within and in the left parasternal line, there is heard a rhythmic alternation of sounds and pauses. These sounds may be distinctly audible over all the precordium, and for some distance beyond it. The predominant sound is synchronous with the apex-beat and carotid pulse, and hence is called the systolic or first sound, because it coincides with the systole or the ventricular contraction of the heart. A short pause follows, which is in turn followed by a different sound — the second or diastolic sound. The second sound occurs at the beginning of a longer pause, corresponding to the diastole. The two sounds of the heart are often represented by the respective monosyl- lables, lub-dub. The first sound and short pause, together with the second sound and long pause, constitute the cycle. This rhythm of sounds and silences is not clear in infants. AUSCULTATION. 225 First Sound. — Here the quality of the systolic sound is a dull, booming "lub," and its intensity is marked, while the pitch is relatively low and the duration long. Second Sound. — The quality of the second sound is sharp and clicking. Its intensity is less loud than that of the first sound; while the pitch is distinctly higher. The duration is decidedly short. The first and second heart-sounds may be heard over the whole precordium ; their accent varies at different points, but the rhythm is maintained. The first sound corresponds to the ventricular systole, and its accentuation is heard at a point where the ventricular conduction of sound is clearest at or near the apex of the heart. The second sound is accentuated at the base of the heart. Causes of Sounds. — The first sound is produced by the synchronous closure of both the mitral and tricuspid valves, and the synchronous con- tractions of the ventricles. The second sound is undoubtedly caused by short closure of the pul- monary and aortic valves. Both sounds are caused practically by valvular action, although the char- acter of the sound may be appre- ciably altered in affections influ- encing the vigor of the muscular contractions. The Cardiac Cycle.— The two heart-sounds and their pro- duction will be understood by re- viewing the physiologic movement of the blood through the heart: "The blood flows from the body through the cavse into the right auricle, whence, during the ven- tricular diastole, it passes through the right auriculoventricular open- ing, the tricuspid valve, into the right ventricle, being urged for- ward toward the end of the dias- tole by the weak muscular con- traction of the right auricle. The systole which immediately follows drives the blood out of the ventricle, the tricuspid valve being at the same time closed, through the open pulmonary semilunar valve, into the pulmonary artery. The blood, prevented from flowing Vjack into the ventricle during the diastole, which immediately follows, by the closure of the pulmonary semilunar valve, passes through the lungs, and from them flows through the left auriculoventricular opening, the mitral valve, into the left ventricle, whither it is again assisted at the end of the diastole by the contraction of the auricle. The left ventricle discharges its contents during the systole (mitral valve being closed) into the commencement of the aorta, through the open aortic semilunar vah'c, whence it is prevented from returning to the ventricle when the pressure from the ventricle ceases and the diastole begins, by the closure of the aortic semilunar valve. The blood then flows from the conus aortse into the body" (Vierordt). (See also Fig. 106.) In the second place the blood enters the aorta and pulmonary artery at the same time by the synchronous contractions of the two ventricles. With 15 3. 106. — Diagrammatic Representation of the Movements and Sounds of the Heart — the Cardiac Cycle. (After Sharpey.) 226 DISEASES OF THE PERICARDIUM, HEART, AND BLOOD-VESSELS. the completion of systole relaxation of the ventricle begins, and at once the recoil of the arterial walls forces the columns of blood against the semilunar valves, which close with the snap of sudden tension at the commencement of the ventricular diastole. The four sounds that are created, one at each valve orifice, are normally audible as two sounds, because of the simultaneous closure of each homologous pair. The accompanying illustration, after Sharpey, serves to illustrate the cardiac cycle (Fig. 106). The systolic sound, as stated, is partly valvular and partly muscular. It is to be remembered that the valves at the two orifices act simultaneously, consequently it becomes the part of physical diagnosis to determine whether the right or the left heart is the seat of any alteration in sound that may be audible. In health the condition of the cardiac muscle is not greatly con- cerned with reference to rhythm. (See Pathologic Conditions of Heart.) Valve Areas. — A superficial area of half an inch square will include a portion of all four sets of cardiac valves (Fig. 60) , so that stethoscopic ex- amination here fails to detect the valve affected. Special valve areas are selected for auscultating the heart, and represent the points to which the vibrations from the corresponding valves are best conducted; consequently we have the mitral, the tricuspid, the aortic, and the pulmonary areas. Maximum Intensity. — The areas of greatest intensity of the first, systolic or ventricular sound is near the apex; and the second diastolic sound is at the base of the heart. (1) Mitral Area. — The sound produced by the closure of the mitral valve (at systole) is most clearly heard at the apex, within an area about 1 inch in diameter. (2) Aortic Area. — The second right intercostal space near the border of the sternum is the point of maximum sound caused by the closure of the aortic leaflets. (3) Tricuspid Area. — The point of election for auscultating the tricuspid element of the first sound of the heart is at the lower part of the sternum, especially near the left border, opposite the fourth and fifth interspaces. (4) Pulmonic Area. — The closure of the piilmonary valve is heard best at the second left interspace, near the sternal border, or at the sternal end of the third left costal cartilage, a point directly over the valve. The points of election just given are used to locate the seat of production of organic valvular murmurs, as well as for the purpose of differentiating the separate sounds themselves. The physiologic events causing the first and second heart-sounds as heard at the four valve areas have been summarized by Vierordt as follows : "Apex of the heart (mitral orifice): " First sound : Closure of the mitral valves and ventricular contraction. "Second sound: Prolonged aortic second sound (closure of aortic valve). " Under the sternum (tricuspid orifice) : " First sound : Closure of the tricuspid valves and ventricular contraction. " Second sound : Prolonged pulmonary second sound. " Second intercostal space, right or left (aorta, pulmonary artery) : "First sound: Sudden filling of the beginning of the aorta, of the pul- monary artery, and continuation of the first ventricular sound. "Second sound: Closure of the semilunar valves of the aorta, or of the pulmonary artery." Physiologic Variations. — The heart may vary in loudness, and both sounds together are relatively increased or diminished in intensity. The condition is often temporary, such increase of intensity depending upon AUSCULTATION. 227 stimulation, diet, exertion, or mental excitement. More or less persistent loudness may depend upon thinness of the chest, as well as the flexibility and delicacy of the bony thorax in children. On the other hand, in those with thick chest-walls, especially women with large mammary glands, both sounds — the first usually more than the second — are relatively weak- ened. The heart-sounds also are less distinctly heard in an individual when he is lying on the back than when in upright posture, owing to the heart's swinging back from the precordial region. "Thus it is apparent that the loudness of the cardiac sounds depends upon the nature and the thickness of the media through which they pass, the degree of blood-pressure within the heart and arteries, and the distance of the vibrating valve orifices and ventricular muscle from the front surface of the chest" (H. S. Anders). The individual valve sounds vary with age, temperament, vigor, nervous- ness, and occupation. Variations in such normal qualities as pitch, duration, and rhythm are frequently observed. In childhood the valvular element of the first sound predominates and has a high-pitched, shorter character. In the vigorous and robust the first sound is often of a loud, prolonged nature, whereas in the fat and indolent it is distant and indistinct. The component elements of the second sound differ in relative intensity, and in childhood the pulmonic sound is the stronger of the two, while in middle life these sounds are about equal. In old age the aortic sound pre- dominates over the pulmonic. The rhythm of the first sound may be physiologically disturbed; to produce the so-called doublmg, the sound is divided, but without any inter- val, such as exists between the first and the second sounds. Reduplication of the second sound, while it may occur normally, is usually pathologic. It is rarely heard at the end of deep inspiration. Heart-sounds of Pathologic Significance. Murmurs. — These include aU adventitious sounds heard over the precordium or any portion of the vascular system. The normal heart-sounds may be appreciably modified and at times replaced by these superadded sounds (murmurs). Murmurs are clinically considered as: 1. Endocardial, j^" g^S^P^ . „ (0. Hemic (functional). 2. Extracardial. 3. Vascular. jArterial. / Venous. Here may be the opportune place to call attention to alterations in the normal cardiac sounds the result of pathologic changes in the myocardium. Myocardial degeneration has been considered at length under Myocarditis (p. 297) and is given special mention here because cardiac murmurs are materially influenced by the force and tone of the cardiac muscle. (See Fatty Degeneration, p. 299.) Organic endocardial murmurs result from structural defects in the cardiac orifices or their leaflets. Functional murmurs are believed to result from myocardial enfeeblement, together with alterations in the circulating blood. Extracardial murmurs include the friction murmur of pericarditis; the splashing sound of pneumopericardium (p. 251) ; and the so-called " car- 228 DISEASES OF THE PERICARDIUM, HEART, AND BLOOD-VESSELS. diopulmonary murmur," or whiff. There are also fine rales audible synchron- ously with the heart's impulse (cardiopulmonic rMes), a sign of question- able clinical importance. A pleuropericardial murmur is also audible in selected cases. Vascular Murmurs. — The vascular murmurs heard over the arteries are best described by the bruit of aneurism, and the chucking and pistol-shot sounds, audible over the femoral artery in aortic regurgitation (p. 270). A venous murmur, "venous hum," deserves mention, and organic heart murmurs may also be heard over the veins of the right side of the neck. (See Tricuspid Regurgitation, p. 289.) Significance of Murmurs.— The chief physical alterations produc- tive of organic endocardial murmurs are as follows : (a) Insufficiency, or incompetency, causing regurgitation of blood when the valves fail to close at the appointed physiologic time. (6) Stenosis, obstruction at the orifices, interfering with the free flow of blood at the time when the valve should normally be open. (c) Relative insufficiency at a valve (especially the mitral or tricuspid) orifice, because of dilatation of the heart chamber (weakening of the myo- cardium) containing it, the simultaneous dilatation of the orifice causing incomplete closure of the leaflets. Murmurs may occur at non-valvular orifices: e. g., open foramen ovale or at a perforated ventricular septum. A patulous ductus arteriosus may be responsible for a murmur. " It will be seen that murmurs may be of several varieties : they may vary in causation, in combination, and in general and specific characteristics. There may be but one murmur present, with distinctive or obscure features, or two or three at different orifices, perhaps two at one orifice (double lesion) " (H. S. Anders). Points to be Observed. — The observations to be taken regarding every murmur are : 1. Its location or area of greatest intensity. 2. Its time, place it occurs in the cardiac cycle. 3. Area of distribution and of transmission. 4. Acoustic attributes, volume, intensity, pitch, and duration. 5. Relation the murmur bears to the normal heart-sounds. 1. Localization. — Point of Maximum Intensity. — The first step in the diagnosis of a murmur is to localize it, and thus determine the valve or orifice affected (seat of the lesion). To recapitulate, the points of greatest loud- ness usually correspond to the areas where the respective valve sounds are best heard; e. g., mitral valve murmurs are most distinctly audible at or near the apex; aortic murmurs, at the right second intercostal space, near the sternum; tricuspid murmurs, over the lower part of the sternum; and pulmonary valve murmurs, at the left second intercostal space, at the sternal border. Any murmur whose maximum intensity does not coincide with one of these areas is probably not valvular in origin. 2. Rhythm (Time). — The majority of organic valvular murmurs may be diagnosticated, that is, the lesions producing them may be rather posi- tively inferred upon the basis of the facts of the area of greatest intensity and of the time. Determination of the area of maximum loudness de- termines the valve or orifice affected, and the time a murmur is heard during the heart's cycle indicates what the normal condition of function should be at that orifice at that given time, and dictates whether the lesion is obstruc- tive or regurgitant. THE PERICARDIUM. 229 Two subvarieties of organic murmurs must needs be studied correlatively : 1. Murmurs of regurgitation (insufficiency) are heard at that time during the heart's cycle when the affected valves ought normally to be closed, e. g., they are heard at a systole when the auriculoventricular or venous (mitral and tricuspid) valves leak, and during diastole when the arterial (pulmonic and aortic) valves are diseased. 2. Murmurs of obstruction or stenosis occur at that time in the cardiac cycle when normally blood is passing through the orifices affected; conse- quently, they are heard during the systole, with disease at the arterial open- ings, and during diastole, when the auriculoventricular regions are affected. Time of Murmurs. — The mitral regurgitant murmur is always systolic; the aortic regurgitant, diastolic; the aortic obstructive (stenotic) murmur, systolic; the mitral stenotic, diastolic (presystolic), because it is best heard near the end of diastole or just before systole. With similar lesions on the right side of the heart, tricuspid and pulmon- ary valve murmurs have the same times. The mode of reasoning in the timing of a murmur may be put forth as follows: a murmur that is best heard at or near the apex (the mitral area) and is systolic in rhythm, when normally the mitral valve should be closed. The valve must leak (insufficiency) in order to cause a murmur at this time. Murmurs are timed by requesting the patient to hold the breath, so as to exclude the occasional intervention of the respiratory murmur. Placing a finger over the carotid or the subclavian arteries, which pulsate synchro- nous with the first or systolic sound of the heart. The characteristic features of the murmurs present in aortic regurgitation, mitral regurgitation, and tricuspid regurgitation, as well as those of aortic and mitral stenosis, have been discussed at length in this chapter, and the reader is especially referred to the mechanism of the lesion under each respective heading. An endocardial murmur may be so loud as to obscure a portion of the normal heart-sound, and it is indeed common to meet with cases where these murmurs are so loud as to make it impossible to hear either the first or second sounds of the heart. In myocarditis accompanying endocardial lesions the cardiac rhythm may be so irregular as to cause great confusion with reference to the time and characteristics of a given murmur. The loudness of the heart's sound (muscular element) may also vary at dif- ferent impulses, and this causes decided confusion in the study of organic murmurs. Extracardial murmurs have been described in connection with pericard- itis, aortic regurgitation (pistol-shot sounds), and aneurism. X-RAY EVIDENCE IN DISEASES OF THE PERICARDIUM, HEART, AND BLOOD-VESSELS. By George E. Pfahler, M.D. THE PERICARDIUM, Dry pericarditis gives no characteristic appearances by the x-ray, but may increase the heart's action, which can be observed fluoroscopically. . Exudative pericarditis gives a characteristic appearance, depend- ing on the amount of exudate. 1. The cardiac shadow is much increased. 2. The outline of this shadow is less clearly marked than where the heart 230 DISEASES OF THE PERICABDIUM, HEART, AND BLOOD-VESSELS. muscle is observed. This is due to the lesser density of the fluid than of the heart muscle. 3. The complementary spaces are filled up. The cardiohepatic angle becomes a right or obtuse angle, instead of acute. The curve of the apex of the heart is lost (this is best observed when the tube is placed low or on a level with the lower border of the heart). The dome of the left side of the diaphragm is likely to be somewhat flattened (Brauer). This alters the shape of the usual cardiac shadow, and gives it more of a triangular appearance. 4. The movements differ from the usual cardiac pulsation, and this change may be recognized as an early sign, or in this early stage pulsation may be confined to the ventricle. In large effusions there may be only a general pulsatory movement, instead of a sectional wave of contraction, as is seen in the heart normally. Obliterative pericarditis gives no characteristic appearance. iBxternal mediastinal pericarditis gives, on the other hand, definite signs. If the patient holds his breath, distinct tugging movements of the surrounding tissues may be observed. This appearance is made more evident by deep inspiration or by bending sidewise, which will depend upon the location of the adhesions. If they are on the under surface, when the patient inspires deeply, the heart will be elongated more than usual, and the cardiodiaphragmatic angles will be modified. If they are anteriorly, adhesions to the sternum may at times be seen by oblique illumination (Brauer). THE HEART. General Remarks. — Exact measurements of the heart can be made orthodiagraphically (outlined by the central ray, which strikes the screen perpendicularly). This procedure, unfortunately, involves considerable exposure of the operator, and, like most fluoroscopic work, is extremely dangerous. An outline of the heart which is probably as accurate is obtained by long-distance roentgenography (plate 2 meters from the target of the tube — Kohler). The outline of the heart is modified normally by a number of factors, but probably most of all by the respiration. During deep in- spiration it is decreased transversely and increased vertically. This is probably due to the rotation of the heart upon its axis. The shadow, as a whole, seems to take a more central position in the chest instead of extending greatly to the left. This modification in the general shape of the cardiac shadow is permitted because of an elongation of the chest cavity, and, there- fore, will occur in any condition which permits of this elongation, such as visceroptosis, the phthisical chest, etc. As a result of this elongation and narrowing of the heart shadow, one would get the impression of a smaller heart. (Percussion would, of course, be affected by these same modifica- tions.) During forced expiration, on the other hand, the heart is thrown more transversely, and, therefore, tends to give an impression of a wider heart shadow. Similarly, any condition which crowds the diaphragm up- ward will give a more transverse position to the heart, and therefore a false impression as to its size. The size of the heart is affected by age, stature, weight, sex, and posture. These latter modifications have beeii carefully tabulated, and these tables of averages published by Dietlen and Groedel.* After an accurate record of the size of a heart has been, made, it should be compared with carefully * Groedel, Atlas und Grundriss der Rontgen-diagnostik in der inneren Medizin, Lehmann's Verlag, Miinchen, 1909. THE HEART. 231 prepared tables of this kind, or it is not of great value. Moritz has shomi that in standing the cardiac shadow is narrower, whOe the length is not affected. However, in the ordinary chest plate one can recognize gross enlargements and variations in shape. Such a record is of decided value in making com- parisons in any particular case with subsequent plates made under like conditions, as well as in making an accurate diagnosis. The modifications in the shape and position of the heart are of far greater diagnostic importance, than the determination of its actual sizes. This information can be obtained by the ordinary methods of Roentgen examina- tion of the chest. Stereoscopic methods are adding much to our accuracy. Fia, 107 — Cardiac Dilatation (Pfahler). Due to mitral and aortic disease. Notice the enlargement of the left ventricle, the left auricle, the ptilmonary artery, and the right auricle. Before studying the pathologic shape.s of the heart, one must he familiar with the normal curves. On the right side, the lower curve indicates the outline of the right auricle, and above this is the curve of the ascending portion of the arch of the aorta. The right ventricle rests upon the dia- phragm, and is only occasionally visible, when the upper part of the stomach IS distended with gas. The left border of the cardiac shadow is made up of the curve of the left ventricle below, and alcove this is the curve of the pulmonary artery. Be- tween these two there is a lighter area of cardiac shadow, due to the left auricle. Normally, this does not stand out as a curve, but in dilatation of 232 DISEASES OF THE PEEICARDIUM, HEART, AND BLOOD-VESSELS. this auricle it can be distinctly seen. Above the curve of the pulmonary- artery we see the curve of the descending portion of the arch of the aorta. The latter shadow of the aorta can usually be traced from its origin, and its continuation can be followed posterior to the cardiac shadow. The Pathologic Heart. — In the study of the pathologic heart one records its size, form, position, its mobility, and its peristaltic movements. Departures from the normal give valuable evidence in each of the various cardiac affections. Displacements of the heart can be recognized, and their causes demon- strated. When the entire heart is displaced to the right, one must always think of a transposition of the viscera. If the displacement is due to this condition, one will find by the rays a corresponding reversal of the stomach, liver, and spleen. If due to adhesions, these adhesive bands can often be seen, and when examined fluoroscopically, the displacement is sure to become more marked during inspiration. This is usually due to bands which are adherent to the pericardium. Other displacements are due to abnormal conditions in the surrounding structures. The heart is supported by the great vessels above, and rests upon the diaphragm below. It is pressed by the lungs on each side, which form an elastic cushion. Any modification in any of these structures will tend to displace the heart. Therefore any condition which will raise the left side of the diaphragm (such as eventratia diaphragmatica, abnormal disten- tion of the fundus of the stomach with gas, tumors, subdiaphragmatic abscess, etc.) will raise the heart, and if the right side of the diaphragm is not equally raised, the heart will be rotated to the right. Likewise if the right side of the diaphragm is elevated (enlarged liver, subdiaphragmatic abscess), the heart will be crowded to the left. With an elevation of both sides of the diaphragm (ascites, meteorism, pregnancy) the heart is seen to lie more transversely. Emphysema causes a depression of the diaphragm, and therefore a more centrally located and a lower elongated cardiac shadow is obtained. Tuberculosis. — Early apical tuberculosis on the left side may give a high position of the left side of the diaphragm, and, therefore, displacement of the heart to the right. If adhesions are present, it may be drawn to the affected side. With an atelectasis on one side, the heart will be crowded toward the affected side by the compensatory emphysema of the opposite side. Pneumothorax, pyopneumothorax, and pleural effusions maybe seen to crowd the heart toward the opposite side. Aneuirisms and mediastinal new-growths are variable in their effect upon the position of the heart, but usually there is a displacement downward. Abnormal Mobility of the Heart. — Adhesions interfere with the normal downward movement of the heart if the attachments are from above, and increase the mobility if from below. All conditions in which one lung is contracted or compressed will be associated with movement of the heart toward the affected side during deep inspiration. Abnormal Cardiac Pulsations. — Weak and wavy pulsations are seen in tachycardia, especially in myocarditis and in Basedow's disease. Strong general contractions are seen in bradycardia and heart-block (Groedel), and in general cardiac hypertrophy. The strongest pulsations of the left ventricle are seen in connection with aortic insufficiency. The shadow of the pulmonary artery may be seen to THE HEAET. 233 pulsate in obstruction to the lesser circulation, especially in connection with mitral insufficiency. Strong pulsation is also seen in persistence of the ductus arteriosus. In tricuspid insufficiency a strong pulsation of the right auricle may be seen. Abnormal Size of the Heart. — Chronic nephritis gives a large heart of a globular form. The small heart which is often found associated with chronic tuberculosis is probably, in the first place, a part of the general atrophy of the body, associated with the wasting disease (since it is found in other chronic wasting diseases), and, secondly, the smallness of the shadow is more apparent than real, because of a rotation of the heart upon its axis. The lejt ventricle may become enlarged in any of the following condi- tions: Aortic stenosis, Aortic regurgitation. Aneurism of the first part of the aorta. Mitral Regurgitation. Dilatation of the left ventricle. Overexertion as Seen in: Athletes, Acrobats, Pugilists, Marathon runners. Those following laborious occupations, e. g., stokers, firemen, etc. : Arteriosclerosis, Nephritis, Hepatic cirrhosis, Alcoholism, Exophthalmic goiter, Congenital heart conditions. Abnormal Form of the Heart. — Persistence of the ductus arteriosus gives an increase in the shadow of the arteriopulmonalis (de la Camp). Aortic insufficiency gives a decided increase in the size of the left ventricle; the shadow of the whole heart is more horizontal, and the apex does not show through the diaphragm. Aortic stenosis gives a very similar picture, but to a lesser degree, and the enlargement of the left ventricle is proportionately less. Aortic sclerosis and dilatation give an increased shadow in the region of the ascending aorta. Mitral stenosis gives a remarkably small heart and enlargement of the left auricle. This cannot always be seen. Mitral insufficiency gives a general enlargement of the heart — only the shadow of the curves of the great vessels on the right side and the aorta on the left remain unchanged. The heart assumes a globular form. The right auricular shadow is increased, and the enlargement of the left ventricle is more upward, toward the axilla, than to the left. Tricuspid insufficiency is usually associated with other lesions and, there- fore, gives nothing characteristic unless there is a pronounced increase in the shadow of the right auricle. The right ventricle lies upon the diaphragm and cannot be definitely demonstrated. 234 DISEASES OF THE PERICARDIUM, HEART, AND BLOOD-VESSELS. THE MEDIASTINUM. By good technic the entire mediastinum can be explored, and not only a positive, but often a negative, diagnosis can be made. Anteropos- terior, postero-anterior, and oblique views, and then familiarity with the normal appearances, are necessary. Mediastinal Tumors. — These are : 1. Tumors involving the mediastinal lymphatic glands, either primary or secondary, and due to tuberculosis, syphilis, leukemia, pseudoleukemia, carcinoma, and sarcoma. 2. Cystic tumors (simple dermoid or echinococcus). 3. Substernal struma and thymus tumors. Fia. 108. — Aneurism of the Arch of the Aorta (Pfahler). Note compression and congestion of the left lung. In general, if the patient is examined before dyspnea and weakness be- come too marked, and before there are marked secondary changes in the surrounding lung tissue, one obtains rather definite outlines of the tumors. They should be examined both roentgenoscopically and roentgenographically. The size, shape, extent, and definite location can be obtained in relation to other organs or tissues. The degree of density of the shadow, and whether multiple (nodular) or uniform, should be noted. One should decide upon the absence of expansile pulsation to eliminate aneurism. .Pulsatory movements may be transmitted from the great vessels, but these are not expansile. In ANEUBISM. 235 this, as in all other affections, all the clinical evidence should be taken into consideration ij^i making a diagnosis. In my observations in the study of metastatic mediastinal carcinoma there is usually a rather diffuse central shadow in the upper part of the mediastinum, and from this radiating shadows of small tumors can be seen extending into the lung area. The larger tumors of the mediastinum are often sharply outlined, and may be single or multiple. If single, the absence of expansile pulsation, the peculiar shape, and the loca- tion outside of the line of the aorta will eliminate aneurism. ANEURISM. In aneurism one finds an abnormal shadow in the course of the aorta. One should give attention to its size, form, location, degree of density, pul- FiG. 109. — Tortuosity of the Arch of the Aorta, Simulating Aneurism (Pfahler). Notice the projection outward on the level with the second interspace. Autopsy in this case showed no aneurism. The left ventricle is hj'pertrophied. satmg appearances, the movement in swallowing, the delay in the passage of food through the esophagus (Lange), and any changes in the position of neighboring organs. Examinations should be made both fluoroscopically and by plates. With the fluoroscope one can usually recognize the expansile pulsations, and with the plate a permanent record is made which enables one to recognize changes that may occur. Pulsation. — Probably the most important point of investigation, after an abnormal shadow has been found, is to determine the presence or absence 236 DISEASES OF THE PERICARDIUM, HEART, AND BLOOD-VESSELS. of pulsation. This pulsation should be of an expansile character, and when obtained, it is pathognomonic. Pulsation may be transmitted to other mediastinal tumors, but this is not of an expansile character. On the other hand, an aneurism may not give pulsation if its walls are very thick, or if filled with an organized clot. Its border is usuall)^ round and distinctly outlined by contrast with the transparent lung. This will not he true, however, if adhesions have formed or if there is accompanying atelectasis of the lung. One should be very careful to make examinations in different positions. I have examined several patients who only complained of anginoid pain under the sternum, and in whom the usual physical signs were absent, but by the rays I was enaljled to demonstrate a thin, flat, dissecting aneurism under the sternum, which gave an expansile pulsation, and which was visible only anteriorly. A plate made with the patients lying on the back in these instances would not have shown the aneurism. FiQ. 110.- -TOHTUOSITT OF THE .4rCH OF THE AoHTA.WITH MARKED ENLARGEMENT OF THE LeFT VEN- TRICLE (Pfahler). Tortuosity of the aorta gives appearances simulating a beginning aneurism in the descending portion of the arch of the aorta. There is a bulging in the shadow at this point, and often there are associated suggestive physical signs, such as diminution in the left radial pulse, episternal pulsation, and an abnormal area of dullness in the left second interspace, but fluoro- scopically one does not get any expansile pulsation. With this condition one usually finds evidence of arteriosclerosis elsewhere in the body. Arteriosclerosis in the extremities can often be demonstrated. This depends upon a deposit of hme salts in the vessel-walls. In the upper ex- tremities the Roentgen examination will not often be necessary, but in the PERICARDITIS. 237 lower extremities, where the arteries are not so easily palpated, the sclerosis can be shown. In dysbasia arteriosclerotica one may only find isolated plaques instead of the entire outline of the artery (Krause). DISEASES OF THE PERICARDIUM. PERICARDITIS. Pathologic Definition. — An acute or subacute condition, character- ized by inflammatory changes in the serous coverings of the heart; these changes are usually localized, although they may occasionally be general. At the onset the serous membrane is smooth, swollen, and congested, and punctate ecchymotic spots may be visible; with the progress of the disease, however, the affected serous surface becomes grayish in color and roughened, as the result of the deposit of a thin layer of fibrin. If the accumulation of fibrin upon the inflamed surface is profuse, the friction of the two surfaces of the pericardium gives it a honeycombed appearance. Following acute pericarditis there may be an accumulation of a serous exudate into the pericardial sac. Varieties. — For convenience of study inflammatory changes of the pericardium may be considered under the following subheads: (1) Acute plastic or fibrinous; (2) subacute or serofibrinous; (3) purulent; (4) hem- orrhagic; (5) chronic adhesive; and (6) tuberculosis of the pericardium as the result of direct extension from the lung. Predisposing and Exciting Factors. — In cases representing the different varieties of pericarditis special contributing factors will be found that make classification of the conditions that predispose to this malady difficult. In acute plastic and in the serofibrinous variety of pericarditis the etiologic factors are practically the same, and the origin of the disease is bacterial. Acute plastic pericarditis frequently attacks males during early adult life, and, indeed, the disease not infrequently occurs as a complication of acute articular rheumatism, chronic nephritis, lobar pneumonia, and less often is it seen during the course of other acute infections. Barring the few eases in which pericarditis is either tuberculous or cancerous as the result of direct extension from adjacent viscera, we find that the infective agents are conveyed to the pericardium through the circulatory system. Too great importance cannot be attached to the development of a pericarditis as the result of direct extension from the lung, pleura, esophagus, or bronchial glands. Pericarditis may be seen following disease of the aortic valves, but this particular form of direct extension of disease to the pericardium is far less common than the other varieties mentioned. Acute pericarditis is prone to develop, without plausible explanation, during the course of acute articular rheumatism. Certain other acute maladies appear to show a predilection to attack the pericardium and other serous membranes; among these should be mentioned chorea, gonorrhea, scarlet fever, and epidemic meningitis. Bacteriology. — When a pus-producing micro-organism gains access to the pericardium, it may set up an acute pericarditis. Among the bacteria recovered from the pericardial sac are the Staphylococcus aureus, the pneumococcus, the gonococcus, the tubercle bacillus, the streptococcus, Bacillus coli communis, and Bacillus pyocyaneus. The symptoms of peri- carditis may be displayed, and yet no bacteria be found present in the peri- cardial fluid. 238 diseases of the pericardium, heart, and blood-vessels. Acute Plastic Pericarditis. Pathologic Definition.— The pathologic changes upon which the symptoms and signs are based are the presence of early localized areas of con- gestion and punctate ecchymotic spots, and, later, the same areas become roughened and covered with fibrin. Principal Complaint. — Since, as previously stated, acute plastic pericarditis is seldom a primary malady, there may be but few, if any, symptoms pointing directly to this condition. As a rule, the symptoms are obscure. A history of acute articular rheumatism is common, although even in this class of cases subjective symptoms may be lacking. In selected cases of a severe type the patient complains of pain in the region of the precordium, and of a feeling of distress or constriction about the chest. Actual pain may be absent. When pain is well established, with the accumulation of fluid in the pericardial sac, it diminishes gradually, but prior to this time the patient often complains of distress or pain that radiates from the heart to the left shoulder, the back, and the left arm. Pain in the region of the ensiform cartilage and over the upper portion of the abdomen may also be a marked or, at least, an annoying symptom. The pain of pericarditis is distinguished from similar thoracic pains by the fact that it is uninfluenced by pressure over the heart. Palpitation may be experienced before there is distinct pain, and as the condition advances, this annoying symptom is likely to become more and more pronounced. Dyspnea is a frequent, although by no means constant, complaint during the early stage of pericarditis. Thermic Features. — ^The temperature will be found to rise one, two, or three degrees, depending upon the severity of the case in question. If pericarditis develops as a complication during the course of another febrile malady, rise in the temperature of one or two degrees is to be expected. Physical Signs. — Inspection. — In those cases in which pericardial pain is severe the expression is anxious and the features are somewhat pinched. If dyspnea is present, rapid action of the chest and distention of the nostrils occurs. The impulse of the apex-beat is always vigorous and frequent. Palpation confirms what has previously been detected by inspection, i. e., the character of the respiration and of the apex-beat. In the early stage of pericarditis, and while the serous surfaces are comparatively dry, the hand over the heart will detect a distinct friction fremitus. This fremitus results from the rubbing of the congested or roughened pericardial layers one upon the other, and is, as a rule, most pronounced near the base of the heart and to the left of the sternal margin. At the onset the pulse is increased in frequency, of good force, and the tension remains normal or increased until late in the disease, when it becomes appreciably weakened. If the cardiac muscle becomes involved later, the pulse is irregular. Auscultation. — Among the signs of pericarditis the most valuable is the distinct friction sound, which is usuaUy synchronous with the heart's action. The site of greatest intensity of the friction murmur is ordinarily at the junc- tion of the fourth or fifth interspace with the sternum (Fig. Ill), although it is commonly audible over the greater portion of the base of the heart. The friction murmur may, in selected cases, be distinctly localized to a small area, or it may be most intense over certain selected areas located near the PERICARDITIS. 239 base of the heart, and, indeed, the friction murmur may be heard best at the original location of some one of tlie endocardial murmurs. If the friction murmur is most distinct over an aiea where endocardial disease of a certain valve would be audible, the distinction between these murmurs is made by exerting firm pressure upon the stethoscope, when, if the murmur has its origin in the endocardium, it is not affected by pressure; on the other hand, peri- cardial murmurs are often intensified as the residt of bringing a greater ai-ea of the diseased pericardial laj'ers into proximity. Pressure sufficiently strong to cause the layers of the pericardimn to remain in contact \^"ould, on the other hand, prevent a pericardial murmur. Pleural and pleuropericardial murmurs may also be audible antl varj' with the acts of respiration. Forced inspiration may possilily influence pericardial murmurs. There is no distinct quality that attaches itself to the pericardial friction-sound, yet in the majority of cases this sound is harsh, grating, or rubbing in charac- ter, and at times has a somewhat crackling quality. When the character Fig. hi. — Sh.^ded .\rea Show.s Where Pericardi-al Friction Murmur is Commonly Heard and Where Friction Fremitus is to be Detected. of the exudate is soft and the action of the heart unusually feeble, a soft murmur is heard, and, indeed, a characteristic murmur may be absent. A marked feature of the pericardial friction-sound is its superficial character. Time. — The pericardial murmur may apparently be doulale, and seem to be produced by the movements of the heart, yet the murmurs in all cases are not synchronous with the heart-sounds. The murmur may or may not exceed the sound of the heart in volume and in duration. Caution. — "A to-anrl-fro friction sound is, as a rule, indicative of plastic pericarditis, although it is an error to regard it as an infalhble sign, since complete calcification of the coronar)^ arteries, as well as excessive dryness of the pericardial surfaces, may rarel}' produce friction nmrniurs" (Anders). Ivaboratory Diagnosis. — The character of the urine ^^•ill be in- fluenced largely by the preexisting disease in which pericarditis developed as a complication. As a rule, it is diminished in quantity, of high color, and rich in solids. Fluid recovered from the pericardium maj' contain 240 DISEASES OP THE PEHICAHDIUM, HEART, AND BLOOD-VESSELS. pathogenic bacteria. A case now under the care of one of us at the Philadel- phia Hospital was found to have tubercle bacilli in the pericardial fluid twelve days after onset of pericarditis. Summary of Diag:iiosis. — ^The clinical history, and particularly the preexistence of rheumatism, chorea, and gonorrhea, should not be neg- lected. Other diseases of the thorax, and particularly of the lung and pleura, may precede, and often have a direct bearing upon, acute plastic pericarditis. The character of the pericardial distress and possibly the existence of pain radiating to the arm and upper portion of the abdomen, occurring in those who have recently displayed an elevation of tempera- ture of one or two degrees, should suggest pericardial involvement. The detection of a friction fremitus over the heart, and especially the presence of a friction murmur, are among the most important data in establishing a diagnosis. Clinical Course and Duration. — Favorable cases of acute plastic pericarditis terminate in recovery within the course ofj a few weeks, although complete resolution may not follow; the pericardial exudate fre- quently continues to form fibrinous tissue, thus materially damaging the pericardium. Acute plastic pericarditis is often the first stage of sero- fibrinous Ipericarditis, to be described later. The clinical course is also modified by the presence or absence of complications — e. g., pleurisy, pul- monary diseases, and nephritis, all of which materially retard, and often prevent, permanent recovery. Complications. — Where the inflammatory process is sufficiently extensive to spread to the external surface of the pericardium and to the pleura, the case becomes one of pleurisy, or the so-called " pleuropericar- dial " type of this disease, known as mediastinopericarditis. Subacute or Serofibrinous Pericarditis, Pathologic Definition. — An accumulation of effused serum in the pericardium. The quantity of serum present varies in mild cases from two to ten ounces, but in the more severe grades of pericarditis one, two, or more pints may be contained within the pericardial sac. The lesions are similar in kind, but are more intense than those of acute plastic pericarditis, just described. Predisposing and Bxciting Factors.— In certain cases the excit- ing factor is doubtless acute plastic pericarditis, but in the vast majority of instances serofibrinous pericarditis develops during the course of acute articular rheumatism,— in from 30 to 50 per cent, of cases, — chronic nephritis, and chronic pulmonary tuberculosis. "I believe that, exceptionally, both serofibrinous and plastic pericarditis may occur in the course of rheumatic dyscrasia without the slightest evidence of arthritis" (Anders). Serofibrinous pericarditis may occur as a complication during the course of certain of the acute eruptive fevers, and it may occur in acute lobar pneu- monia. The extravasation of serum into the pericardial sac may result from bacterial infection— e. g., by the tubercle bacillus. Inflammatory disease of other portions of the chest may, by direct extension to the peri- cardium, result in pericardial effusion. Principal Complaint.— In a small percentage of cases there is doubtless a primary pericarditis, during which the patient complains of a chill or of chilly sensations, anorexia, nausea, vomiting, prostration, and feverishness, and at or about the same period there is experienced a peculiar PERICARDITIS. 241 duU or aching sensation in the chest, although the patient's description of this discomfort may be quite indefinite. Acute pain is an occasional complaint, and suggests an associated pleuritis. Secondary pericarditis may be well developed without causing any special discomfort or annoyance to the patient. Certain cases experience precordial oppression, with a variable degree of discomfort, pain, and soreness as an early symptom. Dyspnea may be the initial complaint that points toward pericardial effusion, and in many cases shortness of breath develops simultaneously with the accumulation of fluid in the pericardium. Orthopnea is an occasional manifestation. The dyspnea in the case of a large effusion into the peri- cardium is due to two causes, since pressure is exerted both upon the heart and upon the lungs. Cardiac diastole may be materially interfered with, owing to pressure upon the right ventricle. When this occurs, the great veins fail to discharge their blood freely into the heart, and, as a consequence, the arterial system is imperfectly filled — a condition that must in time reduce the blood-pressure. Nervous Manifestations. — Headache develops as an early symptom, and may be intense, particularly in those cases in which the circulation is feeble. Delirium may develop during the night, and in severe cases it is continuous, and may progress until stupor, and even coma, intervene. Maniacal delirium has been known to occur. Thermic Features. — ^Typical cases display an irregular temperature, varying between 100° and 103° F. In those cases that terminate favorably the fever falls by lysis, whereas in those tending toward a fatal termination the fever is either continuous for an indefinite period, or suddenly rises to from 103° to 105° F., and with such hyperpyrexia the general clinical picture becomes less favorable. In those cases following acute articular rheumatism high fever is of grave prognostic import. Physical Signs. — Inspection. — ^At first the skin appears unusually pale, but after a large effusion has accumulated there is cyanosis of both the skin and the mucous surfaces. Duskiness of the face has been a con- spicuous feature in our experience. The veins of the neck are prominent, and in extreme cases they may display decided pulsation. The respiratory movements are hurried, labored, and may be irregular in rhythm. If the effusion is large, the expression is anxious, and the patient elects to rest in the recumbent posture, with his head and shoulders well elevated; as the condition advances from bad to worse it may be necessary for him to sit continuously. Should a large effusion be present, he reclines toward the left. When there is but slight effusion, the apex-beat is exaggerated, but as the exudate increases in volume the heart is forced upward and backward, and the apex lies up and to the left of its normal site. In the presence of a large effusion the apex-beat is weak, but more diffuse than normal. If the pericardial sac is fiUed with fluid, the apex-beat may be imperceptible, since, owing to the heart being surrounded by liquid, the organ is not in contact with the chest-wall. In adults who have previously suffered from pleurisy and in whom the lung tissue has shrunken away from the heart, a large pericardial effusion may produce bulging of the left side of the chest. The diaphragm may also be depressed, and the left superior abdominal quadrant rendered unduly prominent as the result of a large pericardial effusion. In children, whenever the pericardial sac becomes well filled with fluid, the interspaces are promi- nent, and there may be distinct bulging of the precordium. In young 16 242 DISEASES OF THE PERICARDIUM, HEART, AND BLOOD-VESSELS. children the respiratory movements of the left side are restricted as the result of a large pericardial effusion. Emaciation is rapid. Palpation.— PwZse.— When the quantity of fluid in the pericardium is small, the pulse is full and sti:ong; when, however, the effusion increases in amount, it may interfere with the heart's action, and the pulse is then apt to be small, feeble, and irregular. When, comparatively speaking, the peri- cardium is filled with fluid, the radial pulse is often absent during the act of inspiration — the so-called "pulsus paradoxus." (See Pulse, p. 198.) Palpation confirms in many respects the data ascertained by inspection, and particularly is this true as regards the strength, location, and distribution of the apex-beat. The impulse of the apex-beat is elevated to the left, the degree of elevation depending upon the quantity of pericardial fluid present. Again, the position of the patient also alters the position of the apex-beat. When the pericardium is well filled, and the patient is in the sitting posture, the apex-beat may be imperceptible, but if he is directed to incline his body forward or to lie upon the left side, the apical impulse will be detected at some portion of the chest. When making a clinical analysis of the force of the apex impulse three factors are to be taken into considera- tion — (a) Whether or not the patient is at present suffering from myocardial changes; (b) the quantity of fluid contained in the pericardium; and (c) pericardial adhesions when associated with cardiac hjrpertrophy may be responsible for a forcible apex-beat when the pericardium is nearly filled with fluid. The friction fremitus, which is a common sign in acute plastic pericarditis, may even be present during an effusion, and is oftenest felt over the base of the heart. This fremitus generally returns during the stage of absorption, and may then continue for an indefinite period. Diminished expansion of the affected side of the chest is occasionally detected in children suffering from a large pericardial effusion, and fluctua- tion is rarely observed. Owing to pressure exerted by a large pericardial effusion, the left lobe of the liver may be forced from one to one and one-half inches below its normal position, rendering it easily palpable in those cases in which the abdominal wall is relaxed. Percussion. — In pericardial effusion the area of cardiac dullness is inverted, and also greatly increased, assuming a triangular outline with the base directed downward when the patient is sitting or standing. The apex of the triangle may be as liigh as the third or even the second inter- space, and is usually most marked along the left sternal border, The lateral boundary lines of cardiac flatness diverge from the apex of the triangular area (Fig. 59), the right passing obhquely downward to the right edge of the sternum to the seventh rib, and the left passing in a similar manner to the anterior axillary line (Fig. 59). A flat note may be obtained well into the left axilla, and, if the effusion is large, in Traube's semilunar space. In those cases in which the effusion is large and, owing to some anatomic or pathologic cause, occupies a position toward the back of the chest, there may be dullness over the lower lobe of the left lung posteriorly as the result of pressure from the pericardial fluid. In selected cases of pericardial effusion a small area of dullness may be found over the scapular region. Auscultatory percussion serves to reveal, with considerable accuracy, the lower border of the pericardial fluid, as well as the beginning of liver dullness. Even though the quantity of fluid in the pericardium is moderate, PEKICARDITIS. 243 a flat note is obtained in the fifth interspace immediately to the right of the sternum (patient erect). If the pericardial effusion is large and a portion of the lung anteriorly is compressed or restricted, skodaic resonance is likely to be present around the area of flatness. Again, pleural adhesions may have bound the lung to the anterior wall of the chest, in which case the pericardial fluid is forced to the back of the chest, and the anterior area of cardiac flatness may be smaller than is to be expected from a given quantity of fluid. Auscultation. — A friction murmur may be audible when the quantity of effusion is moderate during the stage of resorption. The characteristics of this murmur have been described under Plastic Pericarditis (p. 238). If the effusion is large, the sounds of the heart are distant, indistinct, or muffled. The second cardiac sound is less altered by a large pericardial effusion than is the first sound, consequently it may, at times, be heard clearly at the base of the iieart throughout the entire course of serofibrinous pericarditis. The lower portion of the left lung may be compressed, in which case bronchial breathing would be audible at that portion of the chest over- lying either congested or collapsed pulmonary tissue. laboratory Diag^nosis. — During the febrile period the urine is highly colored, of high specific gravity, and may be rich in sohds. The quantity of urine excreted is appreciably diminished in those cases that de- velop extensive edema. Serum obtained by aspirating the pericardium will be found to simulate closely that recovered from the pleura in cases of subacute pleurisy. (See p. 150.) Pericardial serous fluid is, as a rule, free from bacteria. Summary of Diagnosis. — ^The history of a preexisting condition that markedly predisposes to pericarditis, such as rheumatism or nephritis, is of great value in formulating a diagnosis. A previous attack of acute plastic pericarditis always suggests the possibility of a serofibrinous type as a sequel. Doubtless, pericardial effusion often escapes notice, since it requires a more careful physical examination of the chest than is, as a rule, made in routine work. The physical signs possess the greatest value; thus the inverted triangular area of fiatness and the friction sound, when both are present, make the diagnosis positive. The recovery of fluid from the pericardium by aspiration also furnishes positive evidence. Atypical cases of pericarditis are by no means uncommon, and in these the diagnosis is occasionaUy made only by exclusion. We recaU studying several cases where, due to old pleural adhesions, aspiration alone made the diagnosis possible. (See also x-Ray Diagnosis, p. 229.) Diflferential Diagnosis. — Cardiac Dilatation. — Unless a clear history of the case can be obtained, cardiac dilatation may be mistaken for pericardial effusion, and, indeed, in our hospital experience we have not infrequently encountered patients admitted to the medical wards in whom this mistake was made. The following table, modified from Anders, shows the points of differentiation between these two conditions: Pericarditis with Effusion. Cardiac Dilatation. Clinical History. 1. Recent history of gout, acute rheu- 1. Usual history of chronic valvular matism, acute infectious or septic disease of the heart, disease, scurvy, nephritis, or tubercu- losis, chronic gonorrhea. 2. Fever and slight pain often associated. 2. No fever or pain, as a rule. 3. Nervous symptoms are often present. 3. Absent or but shght. 244 DISEASES OF THE PERICARDIUM, HEART, AND BLOOD-VESSELS. Pericarditis with Effusion. Cardiac Dilatation. Physical Signs. 4. Inspection often reveals bulging (more 4. Apex-beat usually visible, wavy, and marked in the young). Apex-beat is diffuse, elevated, feeble, and later absent. ,.,,,,. i • i ui 6. Heart's impulse usually absent, or oc- 5. Though feeble, the impulse is palpable. cupies center or upper border of duU area. Friction fremitus may be pres- 6 PeTCUssion shows a triangular flat area, 6. Dull area varies with the chambers and the boundary hne above changes dilated; it is coexistent with a wavy on altering the position of the patient. impulse, does not extend so high (ex- There is dull tympany (flatness in cept in mitral stenosis), and does not massive exudations) in the axillary vary with change of position. There region. Dullness over left lung below is no duU tympany, angle of scapula common. 7. Auscultation shows the first sound dis- 7. First sound clear, short and sharp re- tant and muffled: a friction-rub is sembhng the second sound (tetal often present. heart). Friction murmur rare, but an endocardial murmur may appear later. 8 a;-Ray shows triangular, movable 8. Upper level of shadow (quadrangular) shadow. (See page 230.) ^^f.<^- . , . , j • 9. Digitahs has little or no influence. 9. Cardiac stimulants cause marked im- provement. Pleurisy.— Serofibrinous pleurisy, in which a large effusion occupies the left pleura, is to be distinguished from pericardial effusion. The pre- existing maladies that predispose to the development of pericarditis also predispose to the development of pleurisy. A clinical feature of great distinctive value is that of pain, which is always acute early during the course of pleurisy — a condition rarely seen in pericarditis. In pleurisy the area of flatness occupies the entire base of the left thorax, and changes perceptibly with the position of the patient, whereas in pericarditis the area of flatness is always triangular when sitting and limited to the pericar- dial region. The adjacent \'iscera are displaced to a greater degree by pleural effusion than by fluid in the pericardium. In pericardial effusion the apex-beat is displaced upward and to the left, whereas in a left pleural effusion it is displaced to the right, or may be absent, on account of that por- tion of the heart being pushed behind the sternum. A pleural friction murmur is heard only with respiration, whereas the pericardial murmur is more or less closely synchronous with the heart's action. (See x-Ray Diagnosis of Pleurisy, p. 76.) Encysted pleurisy with effusion, when occupying the anterolateral portion of the left chest, may give an area of flatness resembling closely that produced by pericardial effusion. During the course of encapsulated pleurisy the sounds of the heart are normal, and the apex-beat, if at all displaced, is pushed to the right. Again, the friction murmur is likely to be absent in encapsulated pleurisy, whereas the pericardial friction murmur (synchronous with the heart's action) is audible early and during the stage of resorption in pericardial effusion. Clinical Course and Duration. — ^This will be found to vary con- siderably, owing to the individual peculiarities of the patient and the severity of the type of infection. In certain cases three distinct stages of peri- carditis follow one another in rapid succession — e. g., the dry or plastic stage, the stage of effusion or serofibrinous stage, and the stage of absorption. In another type of case the first stage may continue for one, two, or more PERICARDITIS. 245 weeks, and the second and third stages be greatly prolonged. This last class of cases is often referred to as subacute or chronic pericarmtis. The second stage of pericarditis may follow the initial stage within the course of a few days, and then the condition assumes a subacute or chronic fomi, absorption continuing for a period of several weeks. The effusion that collects in the pericardium following an attack of acute articular rheumatism often dis- appears within two or three weeks, absorption being quite rapid after the third stage is established. One of the chief evidences that convalescence is established is the fall of temperature by lysis in favorable cases; as a consequence, with the absorp- tion of the effusion the annojdng clinical symptoms gradually subside. Thus, the appetite improves, and the renal, respiratory, and circulatory- manifestations of the disease gradually approach the normal. Complications. — (I) Acute pleurisy is rarely seen to complicate pericarditis, and when present, the likelihood of recovery is materially lessened. (2) Myocarditis is one of the most serious complications, and its onset is usually marked by attacks of syncope. (3) Acute endocarditis complicating disease of the pericardium renders the condition more serious and delays convalescence. If the effusion into the pericardium is large, it may exert pressure upon the esophagus, and in this way produce dysphagia. Pressure upon the recurrent laryngeal nerve is followed by paralysis of the vocal apparatus, as the result of which the voice is altered and husky, and there is a peculiar brassy cough. Empyema of the pericardium, while un- usual, is a grave complication. Purulent Pericarditis (Empyema of the Pericardium). Pathologic Definition. — A condition characterized by an accumu- lation of pus within the pericardial sac. The membrane is appreciably thickened and presents a grayish, granular surface. Degenerative changes in the myocardium immediately beneath the serous covering are frequently seen. Predisposing and Bxciting Factors. — Empyema of the peri- cardium may follow serofibrinous pericarditis. The disease is occasionally encountered as a complication during the course of certain acute infections, — e. g., pneumonia and scarlatina, — and, in our experience, pneumococci have been cultivated from the purulent pericardial fluid of persons dead of lobar pneumonia. Purulent pericarditis may follow infection of the pericardium with the tubercle bacillus, and in some cases of empyema other pyogenic organisms may figure as etiologic factors. _ Clinical Picture. — ^The physical signs upon which emphasis was laid in connection with serofibrinous pericarditis (p. 241) are practically the same when the pericardium contains pus, although it is unusual to find the area of pericardial flatness of equal extent to that present in serofibrinous pericarditis. The temperature is usually high, and is often of the septic type. Diagnosis. — ^The diagnosis is rendered positive by the recovery of purulent fluid from the pericardium by aspiration. The a;-ray is of value. (Seep 230.) Aspirating the Pericardium. Different points of election and various methods for performing aspiration of the pericardium have been advocated from time to time, a few of which Will be considered here. 246 DISEASES OF THE PERICARDIUM, HEART, AND BLOOD-VESSELS. By the Xiphocostal Route.— Although, as a rule' aspiration of any one of the serous body cavities is condemned by many writers, it has been our custom, in private and in hospital practice, to perform aspiration on the pericardium, pleura, peritoneum, and spinal meninges. When, after a thorough physical examination, it has been determined that the pericar- dium contains an abnormal quantity of fluid, the next step is to outline accurately the lower border of dullness produced by the presence of such fluid. If it is found that the dullness extends well into the epigastrium, and that the diaphragm is appreciably depressed, the xiphocostal is the safest route by which to recover such pericardial exudate (Fig. 112). Fig. 112. — White Indicates Normal Outline of Heart and Aorta. X shows outline of pericardium when a large pericardial effusion is present; xx, costoxiphoid for aspiration of pericardium. Some prefer to insert the needle entering first at the costal margin of the left costoxiphoid angle. The method of procedure is as follows: Place the patient in the erect posture, or possibly permit him to incline slightly forward, and direct the nurse or attendant to steady his shoidders firmly. Next introduce the needle in the right xiphocostal angle, using local an- esthesia and all necessary aseptic precautions. The operator should gage approximately the thickness of the body-wall, and guard the needle with his finger, so that he may not enter further than is necessary in order to reach the pericardium; when this is accomplished, the needle should be immediately withdrawn, and the handle of the trocar so elevated as to pre- vent the tip of the instrument from being directed toward the heart. Many ])refer this route for the reason that there is but slight, if any, danger of wounding the heart, since as shown by the accompanying illustration (Fig. 112), during a large pericardial effusion, the body of the heart is elevated. In entering the pericardium through the costoxiphoid angle it is well to have a knowledge of the attachments to the xiphoid cartilage. On the posterior surface, attachment is afforded to some of the fibers of the dia- phragm and triangularis sterni muscles, hence by directing the needle slightly upward, the diaphragm may he avoided, since in a large pericardial effusion PERICARDITIS. 247 the diaphragm itself is appreciably depressed. The aponeuroses of the abdominal muscles are attached to the lateral borders of the ensiform cartilage. In removing fluid from the pericardium, the operator's hand should steady the instrument continuous!}'", and whenever the heart is felt to come in con- tact with the tip of the instrument, the latter should be inunediately with- FiG. 113. — Method of Pebforming Exploratory Puncture of the Pericardium, in Order to Determine the N.\ture of a Pehicardi.a.l Exudate (Eisendrath). The patient can be thus explored either in a recumbent or upright position. The needle should be Hiserted in either the fourth or fifth interspace, close to the sternum, great care being taken not to inaert it too deeply. drawn, since the dangers of wounding a coronary artery or the heart muscle are extremely great. Right Sternocostal Route. — If the pericardium is sufficiently distended to give flatness beyond the margin of the sternum, it is possible to reach the pericardium by inserting the needle in the fourth interspace at the right margin of the sternum. (See Topographic Anatomy of the Heart, p. 176.) This route is to he employed only when there is an unusually large effusion, but on account of the thin wall of the auricle, which normally rests near this situation, the danger of wounding the heart is greater than when the xiphocostal route is employed. Eisendrath, in his "Surgical Diagnosis." calls special attention to the method of entering the pericardium through either the fourth or the fifth interspace, close to the left margin of the sternum (Tig. 113, the point of the needle being directed toward the median line. Despite the observance of all possible precautions, however, this route is less safe than those pre- viously described. Another method that is occasionaUy employed when the effusion is 248 DISEASES OF THE PERICARDIUM, HEART, AND BLOOD-VESSELS. large is to enter the chest just external to the outer margin of cardiac flatness, directing the needle obliquely downward and inward. The point of insertion is usually one to two inches external to the apex-beat, and near the level of the nipple. It has been our privilege to employ this method with perfect satisfaction where the effusions were large. It has no advantages over the xiphocostal route. Advocates of this method of puncturing the peri- cardium claim that, in a large effusion, the heart is elevated and the apex- beat is somewhat to the left of the nipple, consequently the danger of wound- ing the heart is extremely slight. We would, however, call special attention to the fact that the impulse, supposedly the apex-beat, may not be produced by the apex of the organ when the heart is displaced, and that for this reason there is no accurate way of determining the position of the heart in a large pericardial effusion. Hemorrhagic Pericarditis. Pathologic Definition and Remarks. — ^An accumulation of blood within the pericardium. As the result of local inflammation there may be an extravasation of blood into the pericardium during acute plastic and purulent pericarditis. The pericardium may also be the seat of inflamma- tory processes that have extended from the lung and adjacent viscera. Pathologic changes in the blood-vessels and in the chemic composition of the blood may also be present. ^tiologic Factors. — A pericardial effusion that is purulent in character may also display a bloody color. Tuberculosis of the pericardium is a common cause of hemorrhagic pericarditis, as is also chronic nephritis of the aged. Bloody fluid may accumulate in the pericardium as the result of infection with pathogenic bacteria, as has been demonstrated by the re- covery of the pneumococcus from the pericardial fluid. Tiie clinical picture of purulent hemorrhagic pericarditis differs in no way from that given for empyema of the pericardium (see p. 245), and non-purulent hemorrhagic pericarditis displays both symptoms and signs quite analogous to those outlined under Serofibrinous Pericarditis (p. 240). Adhesive Pericarditis (Chronic Pericarditis). Pathologic Definition. — A condition characterized by the formation of dense pericardial and pleuropericardial adhesions. In some instances the opposed surfaces of the membrane are universally adherent, whereas in others the membranes are fairly adherent over a hmited area. An appreci- able thickening of the layers of the pericardium is observed, and such thickening will be found- to vary greatly in different cases. Predisposing and iExciting Factors.— Conditions known to pre- dispose to other types of pericarditis are also concerned in the production of this form of the disease ; special mention must be made, however, of tubercu- losis of the pericardium. Symptoms and Physical Signs.— These are in no way characteris- tic, and except that the heart is markedly displaced as the result of dense adhesive bands, this condition may pass unrecognized until the case comes to autopsy. In those cases in which an antemortem diagnosis was possible, the pulse was observed to be rapid, irregular, and of a low tension, whereas in our cases no pulse peculiarities were detected. There are dyspnea and the signs of cardiac enlargement at times sufficient to cause deformity of the chest. There is seen retraction of the chest overlying the heart. Dur- ing ventricular systole there is often seen Broadbent's sign. The veins of PEEICARDITIS CALLOSA. 249 the neck may distend during inspiration, which veins also display a sudden collapse with the beginning of diastole. The pulsus paradoxus (see p. 198) may, however, be present. Pericarditis Callosa. General Remarks. — ^A type of chronic pericarditis developing during childhood, and characterized by prominence of the jugular veins, cyanosis, and moderate edema. In this type of pericarditis the entire circulation may become embarrassed, in which case there is effusion into the serous sacs. Physical Signs. — Inspection. — ^The left side of the chest is usually seen to be somewhat retracted, and there may be unequal expansion of the two sides of the thorax. With each pulsation of the heart undue depression at certain of the intercostal spaces generally occurs, and such depression is, as a rule, synchronous with systole. In the region where the apex should normally be seen the entire chest-wall may be depressed with each systole, and in extreme cases the greater portion of the precordial space is thus affected by the heart's action. Respiration exerts some influence upon the degree of depression of the precordial area with systole. Friedreich's sign may be observed, and consists in a sudden collapse of the jugulars during diastole. This sign is also seen in cardiac dilatation. In those cases in which there is decided cardiac hypertrophy, the impulse of the heart is forcible, and the apex-beat is visible over an increased area of the chest. In many cases it is not until myocardial changes have taken place that the patient consults his physician, and there is often, at this time, a moderate amount of dilatation, with weakening of the impulse. Where there is adhesive pericarditis, change of position of the patient will cause the apex-beat to remain at one point — a valuable sign obtained by inspection. Palpation confirms inspection as to the force of the apex-beat, and further detects any irregularity in the heart's action as the result of respiration. A diastolic shock, when present, is of great diagnostic value, and consists in the heart's forcible rebound during diastole. A diastolic shock is a prom- inent feature in adhesive pericarditis, while the heart's action is yet strong, but after dilatation has developed, it may be but feebly expressed. Percussion. — ^The area of cardiac dullness is increased upward and to the left, owing to the presence of the following pathologic conditions : (a) Extensive pleuropericardial adhesions; (b) adhesions preventing the lung from overlapping the heart, as it does under normal conditions; conse- quently the upper border of the lung overlying the heart is retracted; (c) the area of cardiac dullness is not materially changed by change of position of the patient or by deep inspiration. In those cases that have displayed myocardial and tricuspid regurgita- tion for an indefinite period the area of hepatic dullness will be found to be increased. Auscultation. — ;A systoUc murmur is frequently heard at the ensiform cartilage, and signifies that the right heart has become appreciably embar- rassed, thus permitting of tricuspid regurgitation. Extensive pericardial adhesions may exist without evincing audible murmurs over any portion of the heart, whereas in other cases numerous murmurs, apparently endo- cardial in origin, are distinctly audible ; yet it is with extreme difficulty that we are able to attach definite clinical significance to such murmurs. Differential Diagnosis.-— In those cases of chronic pericarditis in which there is also a moderate amount of effusion into the pericardium. 250 DISEASES OF THE PERICARDIUM, HEART, AND BLOOD-VESSELS. it may be necessary to distinguish between this condition and serofibrinous pericarditis. The clinical history, however, will usually serve to differentiate these two conditions, since serofibrinous pericarditis has, as a rule, been of short duration. In chronic pericarditis the apex-beat is forced upward, as is seen in pericardial effusion, but in the latter condition change of position of the patient will be found to alter the position of the apex-beat. Dis- tinct bulging of the chest may result in adhesive pericarditis of the young, and here, again, it becomes necessary to differentiate this malady from a large pericardial effusion. The inverted triangular area of cardiac flatness, together with flatness extending well to the right of the sternum, will make the diagnosis of pericardial effusion positive. Hydropericardium (Dropsy of the Pericardium). Pathologic Definition. — ^A secondary condition characterized by distention of the pericardium by transuded fluid in the absence of inflam- mation of the pericardial surface. The symptoms are usually those of the preexisting malady, with a possible increase in the frequency of the pulse-rate and dyspnea. The physical signs are practically those described for serofibrinous pericarditis (p. 241), except that the friction murmur is absent. HEMOPERICARDIUM. Remarks. — A rare condition in which pure blood escapes into the peri- cardium. The conditions that favor hemorrhage into the pericardial sac are: (a) Traumatism with rupture of the coronary artery; (b) rupture of the heart; (c) rupture of a thoracic aneurism; (d) stab wounds of the heart. If the condition results from the rupture of a thoracic aneurism, a large quantity of blood suddenly enters the pericardium and materially interferes with the heart's action. Following injury of the heart the blood may escape slowly into the pericardium. The physical signs are difficult respiration, cyanosis, and the signs characteristic of serum in the pericardium. (See Pericardial Effusion.) PNEUMOPERICARDIUM (Air or Gas in the Pericardium j Pyopneumoperi- CARDIUM). Pathologic Definition. — ^A condition characterized by the accumula- tion of air (gas), pus, and frequently blood, in the pericardium. Predisposing and Exciting F'actors. — (1) Serofibrinous peri- carditis in which the fluid becomes infected with gas-producing bacteria. (2) Stab and gun-shot wounds of the chest that have penetrated the peri- cardium. (3) Traumatism with fracture of the ribs and penetration of the pericardium. (4) The formation of a fistulous communication between a tuberculous cavity in the lung and the pericardium. (5) A fistulous com- munication between an empyema and the pericardium. (6) Subdiaphrag- matic pneumopericardium, a condition in which gastric ulcer has perforated the diaphragm and communicated directly with the pericardial sac. Principal Complaint. — ^This resembles closely what has been out- lined under serofibrinous pericarditis, except that the condition in question usually develops somewhat abruptly, and the patient suffers more intensely from dyspnea than he would in the presence of a simple pericardial effusion. Physical Signs. — Palpation may be negative, although the apex of the heart will usually be felt at some point over the precordium. Percussion yields a tympanitic note over the greater portion of the ENDOCARDITIS. 251 precordia, whenever the quantity of fluid present is large a variable degree of flatness is readily outlined. It is of great importance in the diagnosis that the position of the patient be changed; in this way the percussion-note will be materially modified — e. g., dullness will be found to shift as the result of posture. Upon auscultation the heart-sounds are usually intensified, and rasping friction murmurs, displaying a distinctly metallic quahty, are audible. Besides pericardial murmurs, there is a loud, splashing sound with each impulse of the heart. In two cases in our practice the heart- sounds were feeble. DiflFerential Diagnosis. — Fluid and gas in the pericardium exhibit physical signs that closely resemble those resulting from fluid and gaseous substances in the pleura, the leading differential features of which are set forth in the accompanying table: Pneumopericardium. Pyopneumothorax (Left). 1. Patient has complained of a sense of 1. Sudden pain in the left side of chest. discomfort in the pericardial region for several days, and possibly for weeks. 2. Apex-beat displaced upward and to the 2. Apex-beat displaced to the right and left. may be as far as the right nipple. 3. Diaphragm but moderately depressed. 3. Diaphragm markedly depressed. 4. Heart-sounds clear, but confused by 4. Heart-sounds unaffected. harsh, crackhng splash. 5. Vocal resonance unaltered. 5. Amphoric in quality and absent at base of chest over area occupied by fluid. 6. Small area of flatness at base of chest 6. The entire base of left chest is occupied anteriorly. by fluid that gives a fiat note. 7. Vocal tactile fremitus normal. 7. Absent. 8. Bell tympany seldom present over the 8. Present over the entire left pleura. precordium. Note. — In encysted pyopneumothorax (rare) the diagnosis may be diffi- cult and even impossible. Clinical Course. — The majority of cases run a rapid course, termi- nating fatally within from a few days to a week. Diseases of the Endocardium, endocarditis. Pathologic Definition. — A condition characterized by either an acute or a chronic inflammation of the lining membrane of the heart, which attacks most often the leaflets, but may involve any portion of the endo- cardium. Varieties. — (1) Simple acute endocarditis; (2) ulcerative endocar- ditis; (3) chronic endocarditis. Simple Acute Endocarditis. General Remarks. — In this variety of endocardial inflammation there are slight vegetations upon the endocardial lining, these growths being most often situated near the base of the cardiac leaflets and on that surface opposed to the blood-current. Exciting and Predisposing Factors.— Bacterial Infection.— The disease may result from infection of the endocardium with a variety of 252 DISEASES OF THE PERICARDIUM, HEART, AND BLOOD-VESSELS. pathogenic micro-organisms, and it may possibly be excited by the toxins of micro-organisms. Among the bacteria that have been isolated from the diseased endocardimn are: The staphylococcus pyogenes aureus, which is conceded by some writers to be the chief agent in the production of this malady, the diplococcus of pneumonia, bacillus coh communis, streptococcus, gonococcus, bacillus of Eberth, the diphtheria bacillus, and the meningo- coccus.* (1) "The most frequent cause of acute endocarditis is acute articular rheumatism, which induces the disease in not less than 40 per cent, of cases" (Anders). (2) Children and young adults suffering from articular rheu- matism are more hkely to develop endocardial disease than are older sub- jects. (3) It has been repeatedly shown that the severity of the attack of rheumatism has no influence on the Ukelihood of endocardial disease to develop as a complication. (4) Endocarditis may occasionally antedate articular rheumatism, although such instances are comparatively few ia America. (5) Tonsillitis appears to be a predisposing factor in a certain percentage of all cases. (6) Children suffering from chorea may later develop acute endocarditis, and here the disease is likely to assume a chronic course. Chronic suppurative processes are not without influence in the production of simple endocarditis, and it is difficult to determine the effect of gonorrhea upon this type of the disease. (7) In the specific fevers simple endocarditis may develop as a compUcation, and although this is by no means common, it is encountered in diphtheria, measles, scarlatina, tj^hoid fever, small-pox, erysipelas, and, particularly, in pneumonia. (8) Simple endocarditis may also develop in those suffering from pulmonary tuberculosis, and from other maladies in which a large area of suppxiration has existed. (9) Chronic disease of the kidneys and diabetes appear to predispose to the develop- ment of endocarditis. (10) Acute endocarditis may suddenly be attached to a chronic inflammatory process of the endocardium — the so-called recurrent endocarditis. Principal Complaint. — ^The history usually shows that the patient has suffered from one or more attacks of rheumatism or other malady known to predispose to diseases of the endocardium. (See Predisposing and Ex- citing Factors, above.) The subjective symptoms of acute endocarditis are, as a rule, vague, and, indeed, may be absent. Precordial pain is an occasional complaint, and is sometimes described as extending to the left shoulder and down the left arm. Dyspnea is an early and annoying symptom, and is often the one for which the patient seeks rehef. The heart palpitates vio- lently upon the slightest exertion, and the patient may complain of throbbing at the temples and at the base of the brain. Thermic Features. — In the majority of cases the temperature will be found to rise abruptly from 99° to 102° F., but the fever is often influenced by the preexisting disease, so that the onset of endocarditis is in no way heralded by a special thermic phenomenon. In those cases in which one or more emboli are present, the symptoms of such involvement materially alter the general clinical picture. Physical Signs. — ^The actual physical signs resulting from a simple endocarditis will be found to vary greatly, depending upon the valve that is involved and upon the extent of such involvement; for which reasons * "Cerebrospinal Meningitis with Ulcerative Endocarditis and Abscess of Myocar- dium, Due to the Diplococcus Intracellularis of Weichselbaum," Med. Record, Septem- ber 2 1S99. (Boston.) ^ ENDOCARDITIS. 253 brief mention will be made of the types of murmurs produced by such lesion. Inspection. — ^The area of visible cardiac impulse is increased, and in the majority of instances this increase is observed to extend downward and to the left. The impulse may be forcible and irregular as to time and strength. Palpation. — In addition to confirming what has previously been detected by inspection, the force of the impulse will be found to vary greatly at differ- ent stages of the disease, and, indeed, there may be an appreciable difference in the volume of the apex-beat from day to day. As a rule, the force of the apical impulse lessens as the disease advances. After myocardial changes have developed, the apex-beat is feeble and may be almost imperceptible. When we are dealing with a recurrent endocarditis, a heaving impulse is to be expected, owing to a preexisting hypertrophy of the heart the result of a previous endocardial disease. Rarely a systoUc thrill is palpable over the area of the heart. Percussion. — Early during the course of the disease the area of cardiac duUness is not altered, but as the disease advances enlargement in the transverse diameter is common, the area of cardiac dullness being ap- preciably increased to the left in well-marked cases — a condition that is believed to result from increased diastolic tension in the left ventricle. The right ventricle also meets with undue resistance and may, though rarely, be so seriously affected as to show an appreciable degree of dilatation. The more marked is the increase in cardiac dullness in simple endocarditis, the more extensive will be the area of cardiac impulse. Auscultation. — Since the mitral leaflets are most often attacked, a soft, blowing murmur, systohc in time, is heard at the apex in the majority of cases. If the aortic leaflets are involved, the systolic murmur may be heard at the second right intercostal cartilage. Considering that the mitral valve is the site of the initial involvement, the area of maximum intensity of the systoliq murmur, of which mention has just been made, is at the apex, or about one to one and one-half inches below the nipple and within the left midclavicular line. The apical systolic murmur is transmitted in the direc- tion of the axilla to a variable degree. (See Mitral Regurgitation, Fig. 124.) During the course of acute articular rheumatism, and when endocarditis is about to develop as a complication, a distinct prolongation of the first cardiac sound is heard if the stethoscope is placed near the apex of the organ. Careful examination will show that the second pulmonic sound is also accen- tuated at this time. In selected cases the first indication of cardiac involve- ment of the mitral valve is a muffled or "woolly" first sound, which, owing to its alteration, causes the second sound to be apparently intensified. The presence of a presystohc mitral murmur indicates that stenosis exists at the mitral ring, and may be detected early in certain cases of simple endocarditis. It is possible that when a distinct systohc mitral murmur is audible, a questionable murmur may also be heard at the same time over the aortic area (second right costal cartilage). Early during the course of endo- cardial involvement one may detect an extremely soft, low-toned systolic murmur at the ensiform cartilage, and when present, this murmur has its origin at the tricuspid orifice, and suggests a probable relative incompetency. An acute endocarditis developing in an endocardium that has previously suffered one or more attacks of the disease may in no way alter the murmurs that were already present; consequently auscultation does not furnish a means for the recognition of an existing recurrent endocarditis. I^aboratory Diagnosis. — During the febrile period the urine is 254 DISEASES OF THE PERICARDIUM, HEART, AND BLOOD-VESSELS. slightly diminished in quantity, and its color is increased. Blood cultures are, as a rule, negative, since this form of the disease may develop without pathogenic bacteria circulating in the blood. Stunmary of Diagnosis. — This is attained largely from a knowledge of one or more preexisting conditions that tend to favor the development of simple endocarditis. Fever that has continued for several days, together with a moderate increase in the area of cardiac dullness, is strongly suggestive of this condition. Distinct cardiac murmurs, although always suggestive of a lesion of the endocardium, give us no information as to its extent and dura- tion, and tend in themselves often to cause confusion regarding the nature of the endocardial disease in question. When the patient is seen sufficiently early, or, better, when the cardiac sounds have been analyzed from day to day during the course of an attack of rheumatism, considerable importance attaches itself to the presence of a slight prolongation or indistinctness (muffling) of the first sounds of the heart. Diflferential Diagnosis. — The murmurs of acute endocarditis must be differentiated from functional murmurs heard during the course of acute fevers, and in those who are debilitated from any cause. In both conditions the murmurs are likely to be systolic in time. The murmur of endocarditis is heard most often at the apex of the heart, whereas functional heart mur- murs are most clearly audible over the base of the organ, and frequently in the region of the pulmonary cartilage. Again, if a normal pulmonic second sound is present, and there is no appreciable increase in the area of cardiac dullness, the murmur in question is functional rather than organic. Pericarditis. — ^The physical signs of acute simple endocarditis and those of pericarditis are widely different if either condition exists alone, but the fact that these two maladies may coexist in the same person and at the same time should always be borne in mind. If signs of endocarditis are present in a patient in whom both endocarditis and pericarditis exist, they will be ob- scured later by the development of a pericardial effusion. Acute endocarditis may be distinguished from an old endocarditis by the fact that, in the former, but moderate cardiac hypertrophy exists. Endocardial lesions of long standing are likely to give rise to a distinct systolic murmur at the apex and a more marked accentuation of the pul- monic sound; at the same time there may be abnormalities as to the force and volume of the pulse, all of which features are less marked in the acute type of the disease. In well-marked cases of chronic endocarditis in which myocardial changes have taken place there is little or no difficulty in differen- tiating between these two conditions. Clinical Course and Duration.— This is influenced largely by the character of the preexisting disease and by the extent of involvement of the endocardium. Certain cases of acute simple endocarditis do not recover until the endocardium has been permanently damaged. Complications. — Myocarditis may result from direct extension of the endocardial process. (See Myocarditis, p. 296.) Ulcerative Endocarditis (Malignant Endocarditis, Infectious endocarditis). Pathologic Definition. — A disease characterized by ulceration of the endocardium, and possibly suppuration, or by both. Primarily, the leaflets are the seat of vegetations, such as are seen in simple acute endocar- ditis; these vegetations undergo necrotic changes and tend to increase in area, destroying a variable surface of the endocardium. Suppuration ENDOCARDITIS. 256 may take place in the interior of the vegetations, and the resulting abscesses rupture, leaving an ulcerating surface. The vegetations, as a rule, become grayish or yellowish in color, and histologically they are composed of granu- lation tissue, fibrin, and micro-organisms. A distinct area of congestion may surround certain of the vegetations. Foci of suppuration generally develop in the viscera (brain, liver, kidney) as the result of particles of the sloughing ulcers and their bacteria being carried by the blood-current. Varieties. — (a) Ulcerative endocarditis may, in rare instances, be a primary condition, but, as a rule, this particular type of endocarditis de- velops as a complication during the course of one of the acute infectious fevers — e. g., pneumonia, sepsis, scarlet fever, etc.; (b) cerebral ulcerative endocarditis, characterized clinically by a predominance of nervous symp- toms; (c) recurrent malignant endocarditis. Predisposing and l^xciting Factors.— (1) Ulcerative endocar- ditis with but few exceptions is probably a secondary condition, and develops in conjunction with the pathologic lesions of the endocardium characteristic of simple acute endocarditis; and, indeed, the simple type of the disease frequently precedes the ulcerative form. (2) Endocarditis develops as a complication in about 10 per cent, of all cases of acute articular rheumatism. (3) Ulcerative endocarditis is quite a frequent complication of lobar pneumonia, and occurs almost as often as the simple type of endocardial involvement. (4) The endocardium may be attacked during the course of such acute infections as smaU-pox, erysipelas, scarlet fever, typhoid fever, epidemic meningitis, and tuberculosis. (5) Ulcerative endocarditis sometimes develops during gonorrheal in- fection and in puerperal sepsis, and is less often encountered during the course of chronic nephritis. Bacteriology. — ^The streptococcus pyogenes has frequently been iso- lated from the endocardial lesions, although the initial disease from which the patient was suffering may not have been excited by the streptococcus; the development of such malady, however, has furnished opportunity for the invasion of the endocardium by streptococci. Pyogenic staphylococci, bacillus coli communis, the diphtheria bacillus, and the anthrax bacillus have repeatedly been cultivated from the endocardium. The pneumococcus is present in a large percentage of cases complicating lobar pneumonia, and the gonococcus is a fairly common finding in those cases in which ulcerative endocarditis follows a virulent type of gonorrhea. One of us has isolated the bacillus of Friedlander from the endocardial ulcerations in a case dead of Friedlander's pneumonia, and the diplococcus of Weichselbaum has been found in endocarditis complicating epidemic meningitis. Clinical Picture. — ^Ulcerative endocarditis frequently develops during the course of septic disease, and then the regular symptoms of the initial malady are intensified; it is important, in this connection, to bear in mind the fact that the endocarditis is secondary, and that its symptoms are, to a greater or lesser degree, masked by those known to accompany the primary disease. It is impossible to separate satisfactorily the symptoms resulting from the disease of the endocardium and those following general sepsis, which probably antedate the endocardial lesion, although it is under- stood that, after the endocardium has been attacked, sepsis may be dis- seminated, with consequent pollution of the blood. Ulcerative endocarditis may present a varied number of clinical pictures, many of which are in no 256 DISEASES OF THE PERICARDIUM, HEART, AND BLOOD-VESSELS. way distinctive; and, indeed, unless laboratory methods have been employed as a means of diagnosis, one often foUows a case to autopsy before he is thoroughly convinced that endocarditis existed. We shall describe here the more common or typhoid form of ulcerative endocarditis. The onset is somewhat abrupt, and is frequently heralded by a distinct rigor that may be repeated every twenty-four or forty-eight hours, or pos- sibly every sixth to eighth day. The fulse and fever are also quite charac- teristic. (See Physical Signs and Thermic Features, pp. 256, 257.) Contrary to what would ordinarily be expected in so virulent a disease as ulcerative endocarditis, local symptoms may be absent; when, how- ever, the existing disease is one in which ulcerative endocarditis is a common complication, and when we are alert in watching for the development of endocarditis, the following symptoms may be recognized: Slight oppression in the region of the precordium, which may, at times, be described by the patient as a faint pain. Extraprecordial distress in the region of the different viscera, due to the irritation excited by emboli that occupy the special organs in question — e. g., pain in the region of the spleen is quite common, and is ascribable to involvement of the peritoneum overlying the organ; pain in the region of the liver is probably due to a similar process involving the hepatic tissue and its capsule. Mvltiple abscesses may occur either in the viscera or in practically any portion of the body as a result of septic emboli; these usually in turn excite not only pain, but the general symptoms and signs of a localized septic process. Ecchymoses and multiple cutaneous hemorrhages may also follow emboli of the skin. Gastro-intestinal symptoms are, as a rule, well marked, and vomiting may develop early during the course of endocarditis; diarrhea is by no means an uncommon symptom. Ocular Symptoms. — Dimness of vision and specks floating before the eyes may be due to retinal hemorrhage, septic emboh of the eye, or septic renal emboli that in turn excite acute nephritis. Cutaneous Manifestations. — Profuse sweating develops as an early and annoying symptom, and it is not uncommon for the patient to experience one or more attacks of sweating daily. In well-marked cases it is frequently necessary to change the bed-linen after the patient has suffered from one of these drenching sweats, and in women the soaking of the hair by perspiration becomes a most annoying condition, it being often impossible to dry the hair between the attacks. The patient rapidly emaciates, and will be found to lose several pounds a week while the disease continues. Nervous Symptoms. — At first the patient may be unduly nervous and hypersensitive; the most annoying early symptom, however, is headache. As the disease advances mild delirium develops at night, and may progress until it becomes maniacal; later the patient becomes sonmolent and, finally, comatose. Thermic Features.— The fever is of the continued type, although it may be decidedly intermittent in some cases, whereas in others the remissions are but slightly manifest. The temperature may reach 105° or even 106° F. at various times during the day, whUe in other cases it continues quite stead- ily at from 102° to 103° F., seldom falling to the 100° mark. In one case coming under our care the temperature was of the continued tj^je for from three to seven weeks, and in another a continued fever of 103° to 104° F, was displayed for forty-two days. ENDOCARDITIS. 257 Physical Signs. — ^These may, in selected cases, be negative as re- gards the heart. In a case recently observed this characteristic was ex- emplified, since at no time during the attack was any definite information obtained by auscultation, yet laboratory methods showed that the patient was suffering from malignant endocarditis, a fact that was proved at autopsy. Inspection. — Early during the attack the face may be flushed; the skin is bathed with perspiration, and respiration is rapid. As the disease advances emaciation becomes apparent; the lips become fissiu-ed; the ton- gue is heavily coated, the eyes are sunken, and the impulse of the heart is unusually conspicuous. The skin may show ecchymotic areas and even petechise. Small cutaneous abscesses are occasionally seen on various parts of the body. Palpation. — ^At the onset the pulse is usually rapid — 120 beats a minute — and irregular. As the disease advances it may, in certain cases, become more and more rapid, weak, irregular, dicrotic, and readily compressible, whereas in other cases the number of pulse-beats a minute will be found to diminish with the advance of the disease. The fact that an associ- ated nephritis, with the consequent production of uremia, would tend to slow the pulse should be borne in mind in this coimection. In those cases in which the pulse tends to become less frequent and the arterial tension to become increased during the course of ulcerative endocarditis, renal complications should be suspected. Localized areas of tenderness will be found over septic emboli of the skin or of certain of the viscera — e. g., splenic tenderness is not uncommon and, indeed, the spleen is, as a rule, enlarged and readily palpable. The liver is also felt to extend for some distance (two or more finger-breadths) below the costal margin, and may or may not be sensitive to firm pressure. Involvement of the bases of the lungs is generally followed by local tenderness when firm pressure is made upon the chest. Percussion gives no definite information with reference to the heart. The areas of splenic and hepatic dullness are increased, and there may be areas of consolidation at the base of one or of both lungs as the result of a septic pulmonic process. Auscultation. — In the majority of cases a systolic murmur is present, but this is of special value in diagnosis only when other symptoms and signs of malignant endocarditis are present. The disease may continue throughout its entire course without a distinct cardiac murmur being audible over any portion of the precordium. Auscultation determines the force and quality of the heart-sound, as well as the rapidity and regularity of its action. Late during the course of the disease, and when the patient shows much emacia- tion and prostration, the heart-sounds are not only weak and rapid, but the first sound is lacking in muscular quality. In these cases of recurrent mahg- nant endocarditis there is distinct accentuation of the second sound, and a moderate degree of accentuation is heard during the initial stage of this malady. A distinct murmur may be audible over one of the larger arteries. The breath-sounds are usually increased over the base of the left lung, and in the event of an associated pneumonia or pulmonary embolism, the physical signs of lobar pneumonia may be present. The breath-sounds are increased m frequency in proportion to the degree of weakness of the patient, and as the heart becomes weak, numerous moist riles are audible over both lungs. I/aboratory Diagnosis. — Cultures made from the venous blood (see p.^ 255) will, in the majority of cases, be found to develop colonies of bacteria, and the reasons for failure to do this have been given (p. 255). 17 258 DISEASES OP THE PERICABDIUM, HEART, AND BLOOD-VESSELS. If the disease continues for a long period, well-marked secondary anemia develops, in which case both the red cells and hemoglobin are markedly decreased. Early during the course of malignant endocarditis the number of leukocytes in a cubic mihimeter may be decidedly increased, but after a profound septic process has existed for some time the leukocyte count is of less clinical value. Smears of blood, when fixed and stained, will be found to display marked degeneration of the red cells (poikiloc3ftosis, alteration in the size of the cells, and the presence of numerous cracks, fissures, and inequaUty of stain- ing with eosin). ]\Iicrocytes and macrocytes are common, and nucleated red cells may be an occasional finding. A differential leukocyte count may show the polynuclear elements to be increased, a feature that is most con- stant early during the course of the disease. C/nne. — During the period when the fever is continuous the urine is high colored and contains albumin, but if septic nephritis develops, the urine is scanty, and anuria may obtain for several hours, or even until death. If the quantity of urine excreted is small during an acute septic nephritis, it will be found to be of high specific gravity, rich in albumin, and, in the majority of instances, to contain numerous bacteria, streptococci, and staphylococci. Cultures from such urine are, as a rule, positive. The colloidal albumin coefficient is increased. (See Gastric Cancer, p. 501.) Microscopically, renal casts (granular, blood, and pus) may be present. Leukocytes and pus-cells are, as a rule, plentiful, and red corpuscles are a not uncommon finding. Pus obtained from the local abscesses of the skin will be found, both by direct staining and by cultural methods, to contain pathogenic bacteria. The feces are at first liquid in character, but if septic diarrhea follows, they may contain an unusual quantity of serum; a microscopic study of such serum shows it to be rich in bacteria, and particularly in cocci. Cultural studies of the feces may be employed with positive results, but it is not recommended as a practical procedure, since it is possible to obtain positive data from other more available and more satisfactory sources. Sputum. — If pulmonary infarction or pulmonary emboli develop, the sputum becomes bloody, and, indeed, quite characteristic: the patient ex- pectorates with but little difficulty, and always in mouthfuls, so that a large, globular, bloody mass (size of a silver quarter or a half dollar) will float upon the surface of water. Illustrative Case of Acute Ulcerative Endocarditis. — David C, male, aged forty- five; height, 5 feet lOt inches; usual weight, 162 pounds; present weight, 155 pounds. Family History. — Father died of pneumonia at the age of sixty-five; mother living at eighty. An older brother died of typhoid fever; a sister and two older brothers be- lieved to be living and were ia good health five years ago. There is no history of malig- nancy, diabetes, insanity, or tuberculosis in the family. Previous History. — The patient believes he had the diseases of childhood, and recalls having had a severe attack of sore throat at the age of sixteen. At about thirty he de- veloped typhoid fever, from which he made a perfect recovery. Four years ago he had an attack of acute articular rheumatism involving the left knee and right wrist, but he states that he was not confined to bed during this attack, although it incapacitated him for work for some weeks. Nine months ago he suffered from what his physician re- garded as an attack of influenza. At this time he was confined to his bed for six weeks, and has never since felt perfectly well. Social History. — Married, two daughters, aged sixteen and eighteen respectively, ap- pear to be in good health. Patient is a teamster by occupation, and has not been com- pelled to lose a day's work. His occupation subjects him to exposure to cold and wet, although he claims that he was always well clothed and protected from cold and storms. Present Illness. — Three weeks before coming to the hospital he developed an acute cold that terminated in a somewhat violent form of tonsillitis, although abscess forma- ENDOCARDITIS. 259 tion did not occur. He states that swallowing was painful for several days, and that he felt feverish, had extreme aching in the back, muscles, arms, and lower extremities, was greatly prostrated, and had a distaste for all foods. Constipation was present, and the tongue was heavily coated. When admitted to the hospital he was extremely pros- trated, being unable even to sit in bed. The most careful questioning failed to extract any definite information with reference to his disease other than that ])reviously given. There was slight cough, which was not accompanied by expectoration, but at no time was it especially annoying. The patient grew rapidly worse, and in contrast to the condition that existed at the time of his admission to the hosj^ital, he developed maniacal delirium during the night, and low muttering delirivmi was present during the i-lay, with some picking at the bed- clothes. Subsultus tendinum was present for a period of seven days, and there was a variable degree of delirium for three weeks following his admission to the hospital. The temperature was 102° F., and of a continuous type, with slight morning remissions, fluctuating, as it did, between 102° and 103° K. for a period of three weeks, when the re- missions became more conspicuous; the temperature, however, did not become normal and remain at that i>oint during his stay of six weeks in the hospital. Physical Examination. — General. — The expression was anxious, the features pinched, and the skin \\rinkled as the rcsidt of emaciation. The patient was almost con- tinuously bathed in perspiration, and showed little or no tendency to move about the bed until ilelirium developed. (See Nervous Phenomena, p. 256.) Local Examination. — Inspection. — The cheeks were flushed at certain times of the day; the tongue was heavily furred, and after approximately two weeks of fever, it became deeply fis- sured, the base being brown in color. The lips became fissured and bleeding, and were covered with heavy, crust-like scabs. The impulse of the heart was unusually conspicuous, and there was some pulsation of the vessels of the neck. Palpation. — The pulse-beats at first numbered 110 a minute, and were of good volume; as the disease advanced the pulse became more rapid, — from 1.30 to 160 beats a minute, — was weak, showed a tendency toward dicrotism, and was readily compressible; occasion- ally it was found to be intermittent. Early during his stay in the hospital the impulse of the apex-beat was forcible, but later it became feeble, and could scarcely be felt when the patient rested upon his back. The bony skeleton became vmusually prominent, a conihtion that gave further evidence of rapid and progressive emaciation. Auscultation. — The heart sounds were rapid and weak, and at the end of the third week the muscular quality of the first sound was wanting. Two weeks after entering the hospital a distinct diastolic murmur was present at the aortic cartilage, but this murmur was not at any time unusually harsh nor lovid, and its area of transmission ex- tended only for about 1 J inches down along the right l)order of the sternum. No mur- mur was audible over the mitral area, although there was an appreciable roughening of the first cardiac sound. Laboratory Findings.— The so-called "febrile" urine was present at those times when the fever was high, containing as it did a trace of albumin, but renal casts were never detected. Upon admission the number of leukocytes was 26,800 per c.mm. , and the red cells numbered 3, (180,000 per c.mm. After five weeks' stay in the hospital the red cells numbered 2,100,000, and the color index was 0..54. A differential count of the leukocytes showed that 84 to 88 per cent, of them were of the polynucleai- variety. A cultural study of the blood was made upon four occasions by obtaining lilood directly from the veins of the arm, but all such studies gave negative results. W'idal reaction negative. Fig. 114. — Black Spot Indicates whfrk. Thrill. WAS Felt One Year Foli-Owin«: an Attack OF Ulcerative Endocarditis (Personal Observation at Philadelphia General Hospital). 260 DISEASES OF THE PERICARDIUM, HEART, AND BLOOD-VESSELS. Diagnosis by Induction from Clinical Data. — The history of the condition be- ginning as tonsillitis was not ignored, and the additional evidence that this attack was followed by a period when the patient displayed a continued type of tempera- ture. The rapidity of the pulse and the high grade of prostration were considered as positive evidences of the gravity of his malady. In the absence of definite physical signs with reference to the heart the diagnosis still remained obscure, until laboratory methods were resorted to; the examination of the blood revealed a well-marked leukocy- tosis, and further showed that an abnormally large proportion of such leukocytes were of the polynuclear variety, a fact that strongly favored the existence of a septic process. Difierential Diagnosis. — The temperature, nervous symptoms, and prostration suggested the possibility of typhoid infection. His malady was differentiated from typhoid fever, however, by the following: (a) The absence of the Widal reaction; (6) the absence of well-marked abdominal signs; and (c) the freedom from diarrhea. Course of the Disease. — For the first six weeks of his stay in the hospital the cHnical course was practically typical of that described for acute ulcerative endocarditis. (See p. 255.) Emaciation progressed rapidly after his admission, and continued even for weeks after the temperature had reached the normal. One year later we found that this patient had not recovered sufficiently to leave the hospital, although he is able to walk about the ward. He now displays the general signs and many of the symptoms of well-marked aortic regurgitation (see p. 267), and there is also quite a loud, though soft, systolic murmur heard at the apex; this murmur is sufficiently loud to be heard distinctly as far to the left as the midaxillary line. Since the patient left his bed he has gained thirty pounds, but is yet far below his normal weight. Summary of Diagnosis. — It is important to consider the history and all the individual circumstances connected with the case in question, and this should be done particularly with reference to preexisting disease. The symptoms of ulcerative endocarditis may be confounded with those of other septic conditions, miliary tuberculosis, and typhoid fever (see Differential Diagnosis, below), and these are best differentiated by laboratory methods. Considerable stress should be laid upon the early symptoms of this condi- tion, and particularly upon the severe rigor, the character of the temperature, the presence of profuse sweating, and the occurrence of abscess as the result of septic emboU. Cultural studies of the blood serve as a positive means of diagnosis in the majority of instances. (See Cerebral Type, p. 262.) With reference to the recurrent endocarditis, acute ulcerative endocarditis should be suspected, at least, whenever questionable symptoms arise in a patient who has previously suffered one or more attacks of endocarditis, and who has been known to have displayed an endocardial lesion prior to the present attack. Differential Diagnosis.— The preceding remarks in reference to the cUnical picture of acute ulcerative endocarditis will show conclusively that this disease must be distinguished from practically any condition that is characterized by continued fever. In our experience we frequently have to differentiate between acute ulcerative endocarditis, typhoid fever, and miliary tuberculosis. The subjoined table sets forth the distinctive differen- tial features of these three conditions: Ulceeative Endocardi- Typhoid Fever. Acute General Miliary "^is- Tuberculosis. 1. Patient is at present 1. Previous history nega- 1. Family history of tu- suffermg from, or has tive, as a rule. His- berculosis, probably probably previously tory of an epidemic or presence of an old had, acute articular of association with tuberculous focus or of rheumatism, gonor- other members of the association with per- rhea, puerperal sepsis, same family who have sons ill of tuberculosis, chorea, or simple en- recently suffered from docarditis. typhoid. ENDOCAEDITIS. 261 ULCEEATrVE EnDOCAEDI- TIS. 2. Disease not a primary- condition. 3. Ushered in with a se- vere chill or a series of chills. 4. Fever rises abruptly following the chill, and is, as a rule, decidedly irregular. 5. Unusual. 6. Symptoms of emboli (hemiplegia, cutane- ous abscesses, etc.) may be present. 7. Respirations moder- ately increased in fre- quency. 8. The face is flushed early, but may later become cyanosed. 9. Diarrhea may develop at any time during the attack. 10. Absent. 11. Widal reaction absent, leukocytosis the rule. 12. Cultures made from the blood usually de- velop colonies of mi- croorganisms other than the typhoid ba- cillus. 13. Sputum may be in- creased. 14. Ophthalmologic exam- ination may rarely de- tect emboli. Typhoid Fever. 2. Primary, with charac- teristic prodromes — headache, malaise, etc. 3. May be a recurrence of chilly sensations, but the disease develops rather insidiously. 4. Rises gradually, mount- ing higher day by day, until the tenth to the tweKth days. 5. Epistaxis common dm-- ing first week. 6. Thrombosis of the fem- oral and spermatic veins may develop late during the disease. 7. Respirations but slight- ly increased in uncom- pBcated cases. 8. Cyanosis only when there are associated cardiac or pulmonary complications. 9. Diarrhea develops dur- ing the first week, and is characterized by pea-soup-Uke stools. 10. Hemorrhage from the bowel quite common. 11. Widal reaction posi- tive; leukopenia. 12. Colonies of typhoid bacilli are the only- evidence of bacteri- 13. An associated bronchi- tis may give increase in sputum. 14. Negative. Acute General Miliary Tdbercttlosis. 2. Develops more rapidly than typhoid. 3. Severe rigor unusual. 4. Temperature rises rap- idly and remains high, though decidedly ir- regular. 5. Absent. 6. Absent. 7. Respirations rapid — 30 to 60 a minute. 8. The face is dusky. 9. Constipation the rule. Feces show tubercle bacilli. 10. Extremely rare. 11. Absent. 12. Tubercle bacilli may be present. 13. If there is chronic pul- monary tuberculosis, tubercle bacilli are present. 14. Miliary tubercles of the retina are some- what common. Recurrent Malignant Endocarditis. This is a pathologic condition in -which acute endocarditis develops during the course of chronic val-\ailar heart disease. Recurrent attacks of simple acute endocarditis, to -which reference has previously been made, are fairly common, although such recurrences may be so mild in character as to escape notice. Any type of endocarditis that predisposes markedly to infection of the endocardium with streptococci and other pathogenic bac- teria favors the development of acute ulceration of the endocardium. The onset is abrupt, with a moderate chill, or possibly a distinct rigor. The temperature rises suddenly to 103° or 104° F., and -within the course of one or two days it may become decidedly intermittent, although a continued type of fever is possible. The general symptomatology of this form of endocarditis resem- 262 DISEASES OF THE PERICARDIUM, HEART, AND BLOOD-VESSELS. bles closely that described at length under acute ulcerative endocarditis, except that in the latter, in many instances, the recurrence of chills and the sweating are more pronounced than in the form now under consideration. The engrafting of an acute ulcerative process upon a chronic endocardial lesion may, in selected cases, render the endocardial murmurs that have existed for an indefinite period more intense, but it is to be borne in mind that postmortem examination frequently discloses extensive acute ulceration of the endocardium where the physical signs of chronic endocarditis were not appreciably altered during the acute attack. The increase in the fre- quency of the pulse is quite a constant feature, and, indeed, acute endocardial ulceration may develop at a time when there is loss of compensation, in which case it simply aggravates the symptoms already present. Recurrent malignant endocarditis may run a subacute course; the tem- perature may not exceed 100° to 102° F., and the general clinical picture is marked by mild symptoms. Cerebral Type of Malignant Endocarditis. In this form of endocarditis the clinical picture is that of acute purulent meningitis (see p. 1124), and on account of the predominance of meningeal symptoms, there is practically nothing to direct the attention to disease of the endocardium. A murmur may be present, although this is not a con- stant physical sign. In the so-called cerebral type of ulcerative endocarditis the general clinical picture also resembles closely that of epidemic menin- gitis, and the only clue to the diagnosis is obtained by lumbar puncture and by making cultural and other studies of the blood. Clinical Course. — In recurrent malignant endocarditis the disease runs a rapid course, the patient's condition progressing from bad to worse for a period of from three to six weeks. This type of endocarditis is an exceedingly grave disease, and despite the early recognition of the disease and the application of treatment, recovery is doubtful. The cerebral type of endocarditis continues from a few days to possibly two or three weeks, terminating in coma. Recurrent malignant endocarditis may assume a subacute or chronic course, and in this variety of the disease the patient may suffer repeated attacks, lasting over a period of months or even years. Chronic Endocarditis. Pathologic Definition. — A disease characterized by a chronic inflammatory process of the endocardium, the most characteristic lesions consisting of infiltration and exudation, followed by cohesion of the segments with roughening of their surfaces, and a tendency to perforate the endocar- dium, with the development of slow infiltration, the formation of fibrous tissue, and consequent retraction of the leaflets. Varieties. — (a) Chronic endocarditis developing as the result of an acute inflammatory process of the endocardium; (6) a second variety, in which the endocardial changes are sclerotic in nature from the time of their recognition, and progress steadily from bad to worse for a period of several years. Predisposing and :exciting Factors.— (1) Chief among the con- ditions that predispose to the development of chronic endocarditis should be placed acute rheumatic endocarditis, a condition that is far more com- mon in children than it is in the adult. (2) Endocarditis may be the only cUnical expression of a rheumatic diathesis, and in selected cases of chronic endocarditis the endocardial condition appears to be extremely mild from ENDOCARDITIS. 263 the onset. (3) " Not less than one-half of all cases of organic valvular dis- ease are caused by rheumatism, and more than one-half occur between twenty and thirty years of age" (Anders). (4) Chronic endocarditis may frequently follow an acute attack that develops during the course of pneu- monia, measles, chorea, or tonsillitis. The second variety of chronic endocarditis, in which there are likely to be decided interstitial changes, is oftenest seen to follow: (1) Certain questionable biologic irritants. (2) Protracted malarial fever, chronic rheumatism, and neglected syphilis. (3) Persons suffering from the so- called uric-acid diathesis are especially prone to develop chronic endocardial changes, as are also those addicted to the excessive use of alcoholic beverages; lead workers likewise suffer from endocardial changes, as has been demon- strated by an examination of nearly 200 men employed for two or more years in the lead factories of Philadelphia, among whom over 80 per cent, gave evidence of chronic endocarditis and of hardening of the arteries. (4) Undue muscular strain must be regarded as a potent factor in the production of chronic endocardial disease; consequently those following certain occupa- tions that necessitate heavy lifting, long-distance running, rapid marching, and athletic work are especially likely to develop the condition. (5) Arteriosclerosis, which is separated from endocarditis only with difficulty, is a decided predisposing factor, and is best exemplified by the condition of the heart in those cases of chronic Bright's disease and of lead workers in whom there are present extensive degenerative changes in the peripheral arteries. (6) Increased arterial tension, whether due to pathologic changes of the liver, lung, kidneys, or arterial system, should always be considered a potent factor in the production of chronic endocardial disease. Among the other conditions that predispose to chronic endocarditis should be considered : (a) Heredity. In this connection it may be stated that the parents of those suffering from chronic endocarditis may also have suffered from acute articular rheumatism, and the child has inherited a rheumatic tendency rather than a predisposition to simple endocardial disease. (6) Congenital deformity of the cardiac leaflets, although it bears a close relation to heredity, must be considered as a predisposing factor of chronic endocardial disease. (c) Age is not without influence, since during childhood and in young adults infectious diseases, including rheumatism, are frequent, and the mitral valves are most often attacked. After middle life and during old age the aortic valves are those most likely to be affected, although it is by no means uncommon to find aortic disease during early adult life, and, indeed, it is encountered during childhood by nearly every clinician. (rf) Sex exerts but moderate influence as a predisposing factor in this type of endocarditis. Chorea and acute rheumatism are found more com- monly in females than in males, hence females are especially predisposed to chronic endocarditis; this predisposition, however, is probably to some de- gree overbalanced by the character of work (physical strain) to which males are subjected. Illustrative Case of Chronic Endocarditis.— L. H., female, aged eleven; weight, 73 pounds. Family History. — Father living at the age of thirty-three, mother at the age of twenty-nine, both in good health. One younger sister is also healthy. No history of heart disease, gout, or rheumatism in grandparents. Previous History. — The patient had the diseases of childhood, including scarlet 264 DISEASES OF THE PERICARDIUM, HEART, AND BLOOD-VESSELS. fever at the age of seven years. At eight years of age she suffered from an attack of typhoid fever. When nine years of age she developed chorea, and the mother stated that the child's nervous condition did not completely subside for nearly one year, during which time several physicians were consulted, all of whom pronounced the case an unusually severe one. Social History. — Since the attack of chorea she attended school until two months ago, when her physician advised that she discontinue school. Present Illness. — ^This probably dates from the attack of chorea, for during that illness she frequently complained of shortness of breath, and now, one year after her well-marked nervous symptoms have subsided, she complains of the following: Shortness of breath upon slight exertion; cardiac palpitation, which may come on dur- ing sleep, and which is common after ascending a flight of stairs; a peculiar throbbing sensation in the head; ringing of the ears and lassitude. Walking or any form of exer- cise brings on violent coughing, which continues until the patient has rested for a few minutes. There is moderate constipation, and the appetite is somewhat disturbed, although she is able to eat one fairly heavy meal during the day. If an unusual a,mount of exercise is indulged in during the day, she may be annoyed by nausea and possibly by vomiting, and the following day she is unable to take food because of extreme nausea, which becomes more annoying when in the erect posture and when walking. Headache is frequently present, although never severe. There is at times a sense of weight or of oppression over the precordiiim, but distinct pain in this region is not experienced. Cough, as previously mentioned, follows exertion, and after an unusual amount of exercise there may be considerable cough for two or more days. Violent paroxysmal cough has also occasionally been known to follow undue mental excitement. The child is highly irritable, becomes startled upon hearing sounds, and at times displays moreor less typical hysteric outbreaks. Physical Examination. — General. — She appears fairly well nourished, although the skin and mucous membrane of the lips are pale. The general attitude is that suggestive of neurasthenia, and she persists in talking about her malady, always expressing considerable fear with reference to the outcome. Following exertion the finger-tips become somewhat cyanosed, and the hands and feet are cold. The muscles are fairly well nourished and firm, and the reflexes are normal. There is no evidence of choreiform movements. Local Examination. — Inspection. — The impulse of the heart is forcible, and is seen approximately two inches below and just outside the left nipple. Upon exertion there is distinct pulsation over the greater part of the precordia, together with pulsation of the vessels of the right side of the neck. Following exertion epigastric pulsation is also conspicuous. When the patient is directed to sit with her arms partially elevated (see Fig. 115), there is visible pulsation of the axillary, brachial, and radial arteries. The femoral artery and the arteries in the superior surface of the feet are also seen to pulsate violently. Mucous membrane of the lips pale. Tongue coated. Palpation confimis inspection with reference to cardiac pulsations. There is a pecuhar impression offered to the palpating finger by the large arteries. Upon lifting the hand above the level of the body, the typical Corrigan pulse is detected at the radial artery. Following pressure upon the skin there is a peculiar flushing and paling of the forehead, back, and front of the chest. By compressing the nail of the finger gently, the red line (blood line) is seen to advance and recede with each impulse of the heart. (See Fig. 65.) By placing an ordinary glass slide, such as is used for microscopic work, upon the lip (see Fig. 64), a distinct pulsation of the vessels of the mucous surface is apparent. Percussion. — The area of cardiac dullness is much increased, that of absolute dull- ness being about twice the size of the normal, whereas relative cardiac dullness extends to 2J inches below and 2 inches to the left of the left nipple. The line of dullness ex- tends from this point obliquely to the tip of the ensiform cartilage, and thence to a dis- tance of approximately one inch to the right of the right border of the sternum. The superior boundary of the cardiac dullness is at or near to its normal level. The heart, therefore, is markedly enlarged. The area of hver dullness extends about IJ inches below the right costal border. By auscultatory percussion the size of the spleen is found to be greater than normal for a child of her age. Auscultation. — When ausculting at the apex there is some alteration in the first sound, but no distinct murmur is discernible. A pronounced diastolic murmur, moder- ately harsh in quality, is audible at the aortic cartilage, and this murmur is transmitted for a distance of 2J inches obliquely downward and across the sternum. The murmur is not appreciably altered by exercise, and is sufficiently loud to be distinctly heard when the ear is placed directly on the chest-wall. Numerous r41es are to be heard over the AORTIC REGUEGITATION. 265 bases of both lungs after undue exertion, being more conspicuous at such times as the patient suffers from paroxysmal attacks of coughing. Laboratory Findings. — The hemic changes are those of secondary anemia, when the blood is drawn from the ear; but blood taken from the finger-tip after the hand has been allowed to hang below the level of the body shows the number of red cells to be above the normal (false polycythemia or polycythemia of cyanosis). Course of the Disease. — Following rest and the administration of mild doses of cardiac stimulants, together with general tonics, the patient's condition improved until she was able to go about her usual duties without inconvenience. At the age of puberty the cardiac condition appeared to be somewhat aggravated for a few months, but after menstruation had been regularly established aU the cardiac symptoms seemed to im- prove, although the physical signs were in no way changed. From the fourteenth to the sixteenth years nysteric outbreaks were somewhat more common than before puberty. At present, at nineteen years of age, the nervous condition, and also the general health, has greatly improved, yet at no time since her attack of chorea has she enjoyed perfect health. Valvular Disease. AORTIC REGURGITATION (Aortic Incompetency, Aortic Insufficiency). Pathologic Definition. — A disease characterized by alterations (sclerosis and deformity) in the leaflets of the aortic valve, which prevent them from closing tightly after each systole, and permit a return flow of blood from the aorta into the left ventricle. Later microscopic changes with fatty degeneration of the heart muscle develop. Atheroma of the arteries, and especially of the coronary arteries, is also common. Mechanic Influence of the I^esion, — The reflux current passes from the aorta backward through the imperfectly closed aortic valve into the left ventricle during the diastole of the heart, or while the left ventricle is being filled from the normal blood-flow from the auricle. Overdis- tention of the left ventricle results from two simultaneous influx currents of blood. To expel this increased cardiac power is required, and this over- exertion causes a compensatory hypertrophy. Dilatation and hypertrophy of the left ventricle, therefore, develop pari passu until the left ventricle reaches enormous dimensions, a condition known as cor bovinum (Fig. 117). Under existing pathologic conditions the arterial system is overcharged at each ventricular systole. Early in the disease the reflux of blood from the aorta into' the left ventricle lessens the volume of blood distributed through the arterial tree, but this loss is counterbalanced by the large volume of blood expelled from the left ventricle with each systole; conse- quently the tissues are amply supplied with blood early during aortic regurgitation. To meet the requirements an abnormal volume of blood is forced into the aorta with each systole, so that arterial tension is increased; this pre- disposes to arteriosclerosis, affecting more particularly the aorta at the point where the coronary arteries are given off, and, as a consequence, inter- ference with the nutrition of the cardiac muscle follows. Fatty and fibroid changes in the cardiac muscle are attended by secondary dilatation, which in turn overcomes the original hypertrophy. In consequence of the increased tension to which the mitral leaflets are constantly subjected, they may become the seat of sclerotic endocarditis, and later a variable grade of mitral incompetency may develop. Secondary dilatation, however, is the principal cause of insufficiency at the mitral orifice, and the blood-current through the mitral ring, before mitral regur- gitation has developed, may be obstructed by the simultaneous influx into the left ventricle from the aorta, thus causing pulmonary congestion. Irrespective of the cause of mitral regurgitation or obstruction, the blood is 266 DISEASES OF THE PERICARDIUM, HEART, AND BLOOD-VESSELS. dammed back through the left auricle into the pulmonary tissue, producing obstruction to the current of blood coming to the lungs, and thereby increas- ing the work of the right ventricle. Here, again, the mechanism of the right side of the heart is quite like that previously outlined, hence tricuspid regurgi- tation eventually follows, with venous stasis, first, of the liver, and later, of the other abdominal structures and lower extremities (modified from Anders). Special Bxciting and Predisposing Factors. — Incomplete recovery from acute endocarditis is doubtless the most potent factor in the production of the chronic type of the disease, and in old subjects rheu- matic endocarditis is to be considered. Disease of the aortic leaflets may develop during the course of chronic infectious processes, as is exemplified in syphilis, yet it must be remembered that those suffering from luetic infection are not infrequently exposed to violent exercise, heavy lifting, and the like. Certain chemic irritants. appear to exert a selective action upon the endocardium, and consequently endocardial and particularly aortic disease is often encountered in gouty subjects, such patients also generally display- ing general endarteritis. Rheumatic subjects, in whom the disease is due probably to a pathologic process, are also prone to develop endocardial (aortic) disease. It is common to find degenerative changes in the endocardium among lead workers and those exposed to the inhalation of poisonous substances, although the condition is, as a rule, associated with pathologic changes in the kidney and more or less extensive atheroma throughout the general arterial tree. Those who imbibe too freely of alcoholic stimulants fre- quently develop chronic valvular disease. when endarteritis involves the aorta, it may, and probably does in selected cases, extend to the aoi'tic leaflets. Increased Arterial Tension. — As previously stated, increased arterial tension, particularly when it is the result of heavy manual labor, stimu- lants, and narcotics, tends to increase the liability to the development of chronic endocarditis at the aortic ring, and it may be possible that increased arterial tension from whatever cause favors the development of chronic endocarditis. In this connection special attention is called to the fact that it is the more or less constant increase of tension that tends to produce disease of the endocardium. Aneurism (a pathologic condition that is secondary to arteriosclerosis) is a potent factor in the production of aortic disease, since in this condition the increased work upon the part of the left ventricle is constant, even while the patient is at rest. Age and sex are marked predisposing factors in chronic disease of the endocardium at the aortic orifice. Aortic disease is far more common in males than in females, a fact that possibly depends upon the variety of exercise and exertion to which males are subjected. The greatest number of cases are discovered late during middle life, although it is possible to meet with disease of the endocardium at the aortic orifice in early adult life and even during childhood. Principal Complaint.— Before Failure of Compensation.— " So long as the hypertrophy of the left ventricle successfully overcomes the otherwise injurious consequences of the valvular defects, the harmonious balance of forces is maintained, and there is an almost entire absence of symp- toms'' (Anders). Compensation is, as a ride, lost later in young subjects than it is in older ones, consequently a decided aortic [lesion may exist for a prolonged period without manifesting symptoms. After the heart has be- AORTIC REGURGITATION. 267 come markedly hypertrophied, undue muscular effort and even emotional and mental strain produce overaction of the heart, and give rise to one or more of the following symptoms: pulsation and tension at the occiput, beating of the temples, a peculiar throbbing headache, tinnitus aurium, and attacks of vertigo. When, in addition to an aortic lesion permitting of regurgitation, extensive arteriosclerosis is also present, anemia of the brain follows, and, as a consequence, extreme pallor, headache, flashes of light, dizziness and even distinct vertigo occur, especially when the patient changes from the recum- bent to the erect posture. Dyspnea may be an annoying symptom at any time during the course of aortic regurgitation, but early during the disease it is experienced only after undue exertion, and is, as a rule, the result of pulmonary congestion. When the heart has become markedly hypertrophied, precordial oppres- sion is quite common, but seldom gives rise to decided annoyance. A dull aching pain may be felt over the precordium, and will at times radiate to the shoulders and possibly to the left arm. In a small percentage of cases pain will be definitely localized to the left shoulder. Angina pectoris may develop during the course of aortic regurgitation. (See p. 302.) After Failure of Compensation. — When failure of compensation takes place and the cardiopulmonary circulation becomes retarded, this unbalanc- ing of the circulation through the lung produces dyspnea, which is increased upon even slight exertion. Among the symptoms now present are cough and the occasional expectoration of blood-streaked sputum. (See Mitral Disease, p. 277.) Sooner or later a moderate degree of general venous con- gestion occurs, and dyspnea becomes severe, compelling the patient to as- sume a recumbent or semirecumbent posture. The latter symptom is, as a rule, more marked during the night and early morning hours. During the course of aortic disease emboli may be deposited in the various organs, — e. g., in the brain, spleen, eye, kidney, and liver, at which time the symptoms referable to embolism of any particular viscus may arise. Plugging of the coronary arteries and of certain of the cerebral arteries, although more common in aortic regurgitation than in other forms of cardiac disease, is stiU somewhat rare. It is a cause of sudden death. Nervous Manifestations. — At first there are decided irritability and peevishness after compensation has failed, and if the patient suffers from cerebral anemia, he may be unable to sleep. Melancholia may be a per- manent feature late during the disease, although it is occasionally regarded as merely a coincident symptom. Thermic Features. — Irregular fever, when present, is due either to the mtercurrence of acute endocarditis or to some other inflammatory process. Physical Signs. — Inspection (Local). — The area of cardiac impulse is greatly increased; the impulse of the apex is displaced downward and to the left, and may be seen as low as the sixth or seventh interspace, and external to the nipple. The precordial region may show some bulging, a feature more common in young subjects. Throbbing in the region of the apex-beat should always arouse suspicion, and suggests a forcible impulse. The arteries in the carotid region throb vigorously, and when the patient is directed to raise his hands (Fig. 115), the axillary, brachial, and arteries of the forearm will be seen to pulsate. Pulsation of the temporal arteries is also common, and when the femoral region is exposed, throbbing of the femoral artery is observed; the arteries of the feet are also seen to pulsate. When myocardial degeneration is present, the pulsation over the pre- cordium and the throbbing of the arteries become less and less conspicuous, 268 DISEASES OF THE PERICARDIUM, HEART, AND BLOOD-'\'ESSELS. owing to deficient cardiac muscular power. Later in the disease, and after tricuspid insufficiency has developed, there is decided pulsation over the veins of the neck. As a result of dilatation of the right heart, epigastric pulsation occurs. The fingers are cyanosed and often clubbed and the mucous membrane of the tongue is bluish. Cutaneous Manifestations. — On drawing the finger firmly across the patient's chest or back, there is first seen a decided paling, which is soon followed by a marked reddening of the same area, which subsequently pales, flushes again, and then pales, imtil it is practically the same color as the sur- rounding^skin. On holding the patient's finger and making general pressure Fig. 115. — Position for Inspection of Chest and .\RTEniES. Special position for making prominent the pulsation of the axillary, brachial, and arteries of the forearm in aortic regurgitation. upon the tip of the nail (Fig. 65), the red or flushed line, -n-hich is well marked underneath the nail, will be seen to advance and recede with each cardiac pulsation — another evidence of the existence of Quincke's pulse. Rarely, the veins of the hands and those of the feet are seen to pidsate. Lastly, Quincke's pulse will be olitained by placing a glass slide over the lip and exerting moderate pressure, when, with each cardiac pulsation the mu- cous membrane underneath the slide will be seen to flush and pale (Fig. 64). Ocular Phenomenon. — I'pon ophthahiwscopic examination the retinal vessels are seen to pulsate in well-marked ca.ses of aortic regurgitation, while cardiac hypertrophy is present. Palpation. — A forcible heaving impulse is felt in the region of the apex of the heart before myocardial changes have appreciably weakened the cardiac muscle, but whenever dilatation predominates over hypertrophy, the impulse is proportionately weakened. A diastolic thrill may be felt over the base of the heart, although this is a somewhat luicommon sign. A pre- systolic thrill may rarely he present. When aortic regurgitation has continued long enough for regurgitation at the tricuspid ring to result, the liver becomes increased in size as the result of venous congestion, and palpation may elicit the fact that the lower liorder AORTIC REGURGITATION. 269 of this organ is well below the margin of the ribs, and in extreme cases it may extend to near the level of the umbilicus. Rarely, in these ca.ses, the liver will be found to pulsate. The Pulse. — The pulse in itself is characteristic of aortic regurgitation — e. g., a quick, leaping, full pulse is the initial impression conveyed to the pal- pating finger, but as the pulse-wave strikes the finger, an abrupt recession is noted, giving a somewhat double sensation — the so- called " Corrigan" or "water-hammer" pulse. When the arm is lifted above the level of the head, a sudden collapse of the pulse is observed, and it is this method of examination that is usu- ally employed for the demonstration of the Cor- rigan pulse. (See also Fig. 116.) After the heart has become greatly weak- ened and marked dilata- tion has occurred, the Corrigan pulse loses most of its characteristics, and it may then be possiljle to obtain the typical pulse only when the patient's arm is on a level with his body. When dilatation has become extreme, the water-hammer pulse is absent. (See Sphygmo- graphic Tracing, p. 271.) Percussion. — The area of cardiac dullness is in direct correlation with the degree of hypertro- phy or of dilatation, consequently cardiac dullness may be found to ex- tend far to the left and even beyond the anterior axillary line, although it is also possible to find it extended downward to the border of the sixth, seventh, or even the eighth rib (Fig. 117). When secondary dilatation of the left auricle has developed, the area of didlness is increased upward and to the left. It is customary for rluUness due to hypertrophy of the right ventricle to increase downward anrl to the right, extending well to the epi- gastrium. When dilatation exists, the area of cardiac dullness is seen to be greatest in its transverse diameter, although it extends slighth^ up- ward, and the apex of the organ is appreciably rounded, as compared with the normal (Fig. 117). After the development of tricuspid regurgitation the area of hepatic dullness is increased, and as the disease advances, the liver note may be found to extend some distance below the costal margin, and will also be found to be lower than normal when percussion is made over the median line. The spleen may also become enlarged as the result of venous conges- tion, consequently the area of .splenic dullne.ss is perceptibly increased during the later stages of this type of valvular disease. Ascites may develop late. Fig. 110. — A S\TlHrArTORT Mi:THor) for Eiictttnt, thk HVM.MKK 1'l'LSI'; SuGiJ±.STEl> BY HaWKE. Trip- 270 DISEASES OF THE PERICARDIUM, HEART, AND BLOOD-VESSELS. and when it does, percussion will disclose the note characteristic of this condition. (See Ascites, p. 567.) A transudate may accumulate in the pleura, when a flat percussion-note will he ol^tained. (See Pleurisy, Hydro- thorax, and also Physical Signs of Pericardial Effusion.) Auscultatory percussion confirms both palpation and percussion with reference to the size of the heart, liver, and spleen. Auscultatio n. — The characteristic murmur of aortic regurgitation is audi- ble when hypertrophy of the left ventricle is in advance of dilatation ; its distinctive features are as follows: A soft, blowing murmur — it may he loud in selected cases — heard at the second costal cartilage, to the right of the sternum, its area of greatest intensity being a trifle below and to the left of this point. This mur- mur is diastolic in time, and is transmitted along the left edge of the sternum as low as the ensiform. To the left, from the xiphoid cartilage, the murmur of aortic regurgitation may be heard as a diastolic whisper as far to the left as the ax- illa, and rarely close to the spine. This faint v-fhisper- ing sound is occasionally transmitted to the vessels of the neck, and is heard best in the right carotid region. Aortic regurgitant murmur may be best heard when the patient is in the recumbent posture. Occasionally no murmur is audible over the aortic cartilage, while a faint murmur is heard along the sternum or over the pulmonary area. Quality of the Murmur. — Ordinarily, the murmur is soft and blowing, but when there is extensive atheroma at the aortic ring, it may be more or less musical, roughened, and at times loud. Determination of Time. — In order to determine the rhythm of an aortic regurgitant murmur the stethoscope should l^e placed at the base of the heart and at the lower liorder of the second right costal cartilage. One or more fingers should then be placed either upon one of the carotids or upon the subclavian artery. The closer the palpating finger is to the heart, the more readily will the murmur be timed. It requires but a small amount of practice for the student to determine the murmur of aortic regurgitation, heard immediately following the impression conveyed by the artery to the palpating finger. The method here outlined for timing cardiac murmurs has been found to be most satisfactory. Again, the rhythm of a murmur should be further studied \\ith reference to the following characteristics: (a) Is the character of the murmur the same (as to length, loudness, etc.) during each pulsation of the heart or does it vary when the patient is at rest? (h) What influence, if any, has exercise 1 Fig. 117.— White Illustrative of Normal Heart. Shai)kt> Area Shows Extreme Hvpkrtroi'HY ok Left Ventricle as Seen in Aortic Regurgitation while Compensation is Perfect. h 1 \ 1 1 \ \ \ \ 1 \ \ \ -J \J w \j V M \ \ AORTIC REGURGITATION. 271 upon the murmur in question? (c) Is the murmur increased, lessened, or absent during forced inspiration, and how, if at all, is the murmur influenced by the ordinary respiratory act? (See Pulsus Paradoxus, p. 198.) A fact ever to be borne in mind is that the murmur of aortic incompetencj^ is a prominent sign before dilatation has become pronounced, and that after extreme dilatation has occurred, it is materially modified and may, in many instances, be absent. Associated Murmurs. — In the majority of cases in which aortic regurgi- tation has continued for a prolonged period other cardiac murmurs — e. g., those of aortic stenosis, mitral regurgitation, and tricuspid regurgitation, — will be audible; the characteristics of each of these murmurs will be discussed at length under special headings. Flint Murmur. — In the late stages of cases of aortic regurgitation, when the left ventricle is dilated to its maximum, a presystolic murmur, which is not transmitted, is often heard at the apex. This is the so-called Flint mur- mur. It is supposed to be due to the fioating inward of the anterior leaflet of the mitral valve by the regiu'gi- tating blood from the aorta, so that the stream of l^lood coming into the left ven- tricle from the left auricle meets with an obstruction. Opny g^mOgTRp mC Fig. IIS. — Pulse-tracing in a Cask of Aortic Regurgi- TraCing.— This method of '^■^"o^ (WilUam Ho£fman). detecting aortic regurgita- tion is quite valuable, giving, as it does, evidence that is characteristic of the condition, more particularly since it discloses the presence of arhythmia and irregularity in the force of the heart's action. (See p. 213; also Fig. 118.) I/aboratory Diagnosis. — This is of no special value in determining the character of the cardiac lesion in question, but is of great importance in formulating a prognosis. Prolonged venous congestion of the kidneys may eventually lead to albuminuria and even to anuria. The characteristic evidences of acute nephritis (renal casts and albumin) may also be detected. Late during the course of aortic regurgitation there is a high-grade secondary anemia, the hemoglobin falling to 70 or even as low as 50 per cent., with a corresponding reduction in the red cells, although, in uncomplicated cases, the leukocytes are, as a rule, but slightly, if at all, disturbed. Staining methods reveal advanced degeneration of the red cells (irregularity in size, shape, and in the distribution of hemoglobin). (See Blood Changes of Secondary Anemia, p. 356.) Summary of Diagnosis. — A history of previous attacks of acute endocarditis, rheumatism, or of one of the diseases known to predispose to degeneration of the endocardium should not l^e overlooked when formulating a diagnosis, and especially is this precaution necessary if the case is studied before a distinct diastolic murmur is heard at the aortic cartilage. Pro- nounced cardiac hypertrophy, as shown both by percussion and by the force of impulse at the apex, is strongly suggestive of disease at the aortic valve, and when the cutaneous manifestations of the disease — e. g., throbbing of the arteries, Quincke's capillary pulse as shown on the skin, at the finger-nails, and on the mucous membrane of the lips — are also present, the evidence of aortic regurgitation is complete. The detection of a soft, blowing diastolic murmur that is heard best at 272 DISEASES OF THE PERICARDIUM, HEART, AND BLOOD-VESSELS. the second costal cartilage, to the right of the sternum, and is transmitted along the left border of the sternum, is quite characteristic of the existence of aortic regurgitation, and upon the evidence of this finding the diagnosis may be established. In the early stages of aortic regurgitation the murmur may be feeble, and at this time it may be necessary to make the diagnosis from the other evidences previously detailed. (See Cutaneous Features, p. 268.) Complications. — Among the more common of these are: Chronic gastritis, ascites, hydrothorax, myocarditis, and angina pectoris. Clinical Course. — In young subjects aortic regurgitation may be present for a number of years without causing any discomfort as the result of cardiac diseases. As a rule, the patient survives the condition for a period of months and often several years after compensation has been broken. Sudden death occasionally occurs, although many patients are invalids after compensation has become ruptured. AORTIC STENOSIS. Pathologic Definition. — A disease of the endocardium character- ized by a narrowing of the lumen of the aortic orifice, together with thick- ening and possibly the formation Of adhesions of the aortic leafiets, and finally by the development of myocarditis. General Remarks. — Simple aortic stenosis is a very rare condition. The development of stenosis of the aortic orifice is sooner or later followed by disease of the aortic valves, in consequence of which blood is regurgitated from the aorta into the left ventricle following each systole. Although it is common to find both aortic stenosis and aortic regurgitation in the same patient, in some cases aortic stenosis may appear to have been the primary lesion, and to have induced aortic regurgitation, whereas in a much smaller proportion of cases, aortic stenosis follows aortic regurgitation. :Kxciting and Predisposing Factors. — (a) The exciting factor, as a rule, is a slowly progressing sclerosis of the aortic leaflets, together with the formation of calcareous deposits both in the leaflets and surrounding the aortic ring. Peter has called special attention to atheromatous changes at the root of the aorta, and, indeed, calcareous deposits are frequently found to extend into the coronary arteries. (&) Rarely, rheumatic endo- carditis leads to the development of aortic stenosis. Seldom, indeed, this condition may be found to have followed other tj'pes of endocardial disease, (c) Age and sex are potent predisposing factors, since sclerotic changes at the root of the aorta, of the aortic leaflets, and of the endocardium at the aortic ring are common to males of advanced life. Mechanic Influence of the l/csion. — The wall of the left ventricle hypertrophies as the result of having to force the blood from the ventricle through the small aortic opening into the aorta, and since the constriction of the aortic orifice has been gradually increasing, ventricular hypertrophy has likewise developed slowly; for these reasons but slight dilatation is present, unless a variable degree of regurgitation at the aortic ring also exists. Increased ventricular tension, which results from the obstruction encountered at the aortic orifice, is believed to favor the development of sclerotic changes at the mitral orifice. Hypertrophy of the left ventricle continues until it reaches a point when the cardiac muscle can no longer be nourished by the coronary arteries, when degenerative changes in the muscu- lar tissue develop, soon to be followed by well-marked dilatation — dilatation in advance of hypertrophy. Following cardiac dilatation the result of a AORTIC STENOSIS. 273 primary aortic stenosis, mitral incompetency (relative) occurs, which permits the blood to be regurgitated into the left auricle and the pulmonary veins, thereby increasing pulmonary tension. Owing to the obstruction in the lung, the right heart first hypertrophies, later dilates, and then permits of tricuspid regurgitation, which is followed by general venous stasis. Principal Complaint. — Aortic stenosis may be present for years without giving rise to any inconvenience, and the symptoms, as a rule, date from the first evidence of failure of compensation. At this time the patient complains of frequent attacks of slight dizziness, which may, however, be sufficiently severe to cause him to sit or cling to some object for fear of falling — a condition that usually follows exertion and is caused by an in- adequate volume of blood entering the aorta. Attacks of syncope may be annoying, and headache is more or less constant. Owing to the roughening of the aortic leaflets, small clots are likely to form behind and about these atheromatous areas, and are frequently dislodged and escape into the circu- lation. As a consequence, embolism of the spleen, kidney, brain, lung, etc., tends to develop. The existence of an embolus will be manifested by characteristic symptoms and signs, depending upon the location in which the clot lodges. (See Pulmonary Embolus, p. 117.) Physical Si£:ns. — Inspection.— During attacks of vertigo there is extreme pallor, both of the face and of the extremities. Soon after com- pensation has been ruptured edema of the ankles and feet occurs, and gradu- ally increases as the disease advances. The apex-beat is seen one or more inches below its normal area, and in or to the left of the nipple-line, a feature that is explained by the high grade of hypertrophy of the left ventricle present. The cardiac impulse is, as a rule, slow, and may be of such force as to cause an appreciable heaving of the precordium, although in some cases the apparent impulse of the heart is not exaggerated. Depending upon the condition of the myocardium the area of. the apex impulse may be diminished, and in emphysematous patients it may be absent. Palpation. — After failure of compensation has occurred, the skin of the lower extremities pits upon pressure. As the result of an associated tri- cuspid regurgitation with venous congestion, the liver and spleen may be enlarged. Ordinarily, the impulse of the heart is forcible, except when pulmonary emphysema or cardiac dilatation is present. On placing the hand over the base of the heart a well-marked systolic thrill is often detected, its area of greatest intensity being near the second right costal cartilage. In selected eases, in which an apical thrill is palpable, it may be felt in the region of the apex-beat. The same sensation is more pronounced near the base of the heart. The pulse is quite characteristic, being small, regular, not readily com- pressed, and of slightly lessened frequency. (See Sphygmographic Tracing, p. 274, Fig. 120.) Percussion. — Despite the high grade of cardiac hypertrophy, the area of cardiac dullness is not so decidedly increased in aortic stenosis as it is in aortic incompetency. In uncomplicated cases the area of cardiac dullness will be found to be increased downward and to the left. Auscultation. — A harsh and sometimes rasping murmur is heard in the^ second right interspace; this murmur is systolic in time, and in typical cases is transmitted to the vessels of the neck. (See Fig. 119.) After compensation has been ruptured the murmur may be much softer and smoother in quality than it was during the early stage of the disease. ■18 274 DISEASES OF THE PERICARDIUM, HEART, AND BLOOD-VESSELS. In our practice cases of aortic stenosis have frequently been followed ovei a prolonged period and it has been observed that within the course of one oi more years a harsh, rasping murmur may entirely disapl pear, after which, instead oi the booming quality of the heart that was originally pres- ent, the first sound has also lost its muscular element, and, indeed, the second cardiac sound, always diminished, may become practically inaudible. (See Differential Diagnosis, p. 275.) Caution. — Aortic regurgita- tion is so commonly associated with aortic stenosis that a mur- mur will probably be heard with both systole and diastole. (See Fig. 119.) Owing to the con- striction at the aortic orifice and to the various blood-cur- rents that are created as the re- sult of roughening in the region of the aortic orifice, one some- times detects an almost contin-j uous, saw-like murmur. The so-called " double murmur heard at the aortic cartilage refers to the distinct systolic (aortic stenotic) murmur and a diastolic (aortic regurgitant) murmur. In those cases of cardiac disease in which arhj^thmia is a conspicuous symptom it is ofttimes practically impossible to time the murmur with any degree of satisfaction; the clinician must, therefore, depend upon the area of transmission of the murmur as the factor on which to base his diagnosis. The murmur of aortic stenosis is, with but few exceptions, transmitted to the vessels of the neck, and in well-marked cases it is heard as high as the angle of the jaw (Fig. 119). The murmur of aortic incompetency is seldom transmitted to the neck, iDut in nearly all in.stances it is heard along the sternum and, at times, from the aortic cartilage toward the apex of the heart. Every clinician has frequently found selected cases in which either a stenotiq or a regurgitant aortic murmur may be heard over the entire precordial region, and at times well into the neck. In this last type of cases the diagnosis is attained not by auscultation alone, but by careful examination and judicious balancing of all the symptoms and signs displayed in the indi- vidual case. Sphygmographic Tracing. — The sphj^gmographic tracing of aortia stenosis (Fig. 120) is in itself quite characteristic, showing, as it does, a marked slowness of the ascending curve and a gradual, step-like de- scent. Summary of Diagnosis. — A most important factor in the diagnosis of aortic stenosis is the slowness of the heart's action, together with the small, soft, although not readily compressible, pulse. Repeated attacks of vertigo, associated with extreme pallor, and a tendency toward syncope are to be FiQ. 119. — Superior Area of Shading is Illustra- tive OF .\rea of Greatest Intensity and Dis- tribution OF the Systolic Murmur of Aortic Stenosis. Shaded Portion Below Second Cartilage and as High as Clavicle is where Aortic Regurgitation is Heard. a, Area where mitral systolic murmur i3 audible. AORTIC STENOSIS. 275 considered in connection with this disease, although these symptoms may also be encountered during the course of other cardiac conditions. The detection, at the aortic cartilage, of a systolic murmur that is transmitted well above the clavicle and at times as far as the angle of the jaw (Fig. 120), coupled with a systolic thrill at the base and a small, tense pulse, makes the diagnosis of aortic stenosis positive. Differential Diagnosis. — Calcareous deposits at the root of the aorta, especially when they involve the aortic segments, may create an Fig. 120. — Sphtomoqbam op Aortic Stenosis fhom a Man Aged Sixty Years (Anders ). adventitious sound that is systolic in time and resembles closely true aortic stenosis; this murmur is seldom, if ever, musical in character, a feature of aortic stenosis. In aortic stenosis the second sound is enfeebled or absent, whereas in those cases in which the murmur is due to sclerotic change in and about the aortic orifice distinct accentuation of the second sound is common. During the course of chronic Bright's disease a high grade of aortic sclerosis is generally present, together with hypertrophy of the left ventricle, and, in consequence of such changes, a systolic murmur may be audible at the aortic cartilage. In these cases an analysis of the urine may give posi- tive evidence of nephritis. A distinctly accentuated second sound favors a diagnosis of nephritic changes rather than one of aortic stenosis. In aortic regurgitation a systolic murmur is not infrequently also present, but in such instances the condition should not be regarded as aortic stenosis unless the actual muscular quality and a systolic thrill are also pres- ent. Again, it is to be remembered that the pulse of aortic stenosis is not characteristic, when both stenosis and regurgitation are present at the aortic ring. The accompanying differential table sets forth the distinctive features between aortic stenosis and aortic regurgitation: Aortic Stenosis. 1. Absent. 2. Arteries not well filled with blood at each systole. 3. Arteries are not seen to pulsate. 4. Pulse slow and small, systolic thrill felt at base. 5. Cardiac hypertrophy moderate. 6. Murmur rather harsh, systolic in time, and transmitted to the vessels of the neck. Aortic Regurgitation. 1. Capillary pulse (Quincke's) is present over the skin, finger-nails, and mu- cous surfaces. 2. Arteries well filled at each systole. 3. Throbbing of the arteries of the arms and extremities. 4. Characteristic "trip-hammer" pulse. Thrill uncommon, diastolic in time. 5. Hypertrophy of the left ventricle ex- treme. 6. Murmur less harsh, and usually soft in character, diastolic in time, trans- mitted downward along the sternum or toward the apex. 276 DISEASES OF THE PERICARDIUM, HEART, AND BLOOD-VESSELS. The so-called " hemic murmurs," heard best over the base of the heart, are to be distinguished from the murmur of aortic stenosis. Hemic murmurs, while systolic in time, are soft and indistinct, and are not associated with hypertrophy of the left ventricle or a systohc thrill. Again, heniic murmurs are present only in those patients suffering from some pathologic condition in which profound primary or secondary anemia is a prominent feature. Clinical Course. — Stenosis at the aortic ring develops somewhat gradually, and the patient may thus be afflicted for a number of years before any inconvenience is experienced. After the first symptoms, which become manifest at the time compensation becomes embarrassed, aortic regurgitation runs a chronic course, and may continue over a number of years. Sudden death, however, may result from the escape of certain calcareous particles into the blood-current, causing embolism of the brain or other organs. - MITRAL REGURGITATION (Mitral Insufficiency, Mitral Incompetency). Pathologic Definition. — A disease of the endocardium, secondary to acute endocarditis, and characterized by sclerotic changes, which are followed by constriction or rupture of the mitral leaflets, which prevents the mitral orifice from closing completely during each systole; it is also caused by dilatation of the left ventricle, which, by increasing the lumen of the mitral orifice, makes it impossible for the mitral leaflets to come in direct apposition to each other during systole; the condition is also, though rarely, due to disease of the chordae tendinese. After regvirgitation has existed for an indefinite period hypertrophy of the left ventricle occurs, and in typical cases hypertrophy and dilatation of the ventricle develop simul- taneously. The wall of the ventricle becomes greatly thickened, and re- mains so until the myocardium is not perfectly nourished, when myocardial degeneration sets in and permits of dilatation. Mechanic Influence of the I/CSion. — Incomplete closure of the mitral leaflets permits a portion of the blood to return into the left auricle during systole. The regurgitated blood meets the normal current simultane- ously, coming through the pulmonary veins to the left auricle, and offers an obstruction to the escape of venous blood from the lungs. A meeting of these two blood-currents in the left auricle — one of venous blood from the lung, the other of regurgitated blood from the left ventricle — must create an abnormal current in the left auricle, which probably gives rise to a murmur. As a result of blood entering the left auricle from the lung and from the left ventricle at the time of each systole, the auricle becomes overloaded, and this leads to dilatation, although an attempt at compensatory hyper- trophy of the auricular wall is also present. Now that the left auricle contains an abnormal volume of blood, an extra effort is made by this chamber of the heart to propel the increased volume of blood into the left ventricle; the result of such overaction eventually leads to overdistention of the left ventricle. Owing to the incomplete closure of the mitral orifice, all the blood now contained in the left ventricle is not expelled into the aorta with each systole, but, on the contrary, a portion of it again returns to the left auricle, which leakage demands extra work upon the part of the left ventricle, and, as a consequence, the walls of this chamber become hyper- trophied — hypertrophy and dilatation develop simultaneously. The hypertrophied left ventricle is capable, for an indefinite period, of forcing about the normal volume of blood into the aorta with each systole, and during this period the arterial tension approximates the normal. Sooner or later the cardiopulmonary circulation becomes impeded, and the blood- MITRAL REGURGITATION. 277 current returning from the lung to the left auricle through the pulmonary veins is so decidedly obstructed as to increase the arterial tension in the lung. The damming back of blood in the lung obstructs the current of blood flowing through the pulmonary artery and capillaries, and increased tension here sooner or later brings about sclerotic changes in the pulmonary arterial system, which act as an additional source of interference with the circulation of blood propelled by the right ventricle to the lung. Increased circulatory tension in the lung in time causes hypertrophy and dilatation of the right ventricle. The presence of such increased tension is detected clinically by accentuation of the second pulmonic sound. So long as the right and the left ventricle are sufficiently hypertrophied to maintain the circulatory equilibrium through the lung and through the general arterial tree, serious symptoms do not arise, but whenever this equilibrium is disturbed, dilata- tion of the right ventricle in excess of hypertrophy and tricuspid regurgita- tion follows. A regurgitant blood-current through the tricuspid orifice offers direct obstruction to the return of venous blood from both the ascending and de- scending vena cava, and as a result of this regurgitation the cardiac ventricles, particularly the left ventricle, are inadequately filled during each diastole, consequently the arterial tree does not receive the normal amount of blood. Again, on account of obstruction to the returning venous blood-supply, venous congestion of the viscera and of the extremities, together with the transudation of the fluid elements of the blood into the serous cavities, takes place. Predisposing and Bxciting Factors. — Among the predisposing factors should be considered those that favor acute endocarditis and, in addition, overwork, such as heavy lifting and the like. Acute endocarditis, whether rheumatic or simple in character, serves as the most potent factor in the production of mitral regurgitation. General arteriosclerosis also figures prominently in the causation, as do cirrhosis of the liver, chronic nephritis, and other forms of obstruction to the general circulation. Aortic stenosis occurring as a primary lesion may eventually produce mitral re- gurgitation. Moderate dilatation of the left ventricle, as is seen during the course of acute fevers and maladies characterized by profound anemia, may permit of a temporary regurgitation at the mitral orifice. Principal Complaint. — ^While Compensation is Maintained. — During this period otherwise healthy persons do not complain of symptoms referable to disease of the heart. After the lesion has continued for some time, — probably several years, — slight embarrassment of the pulmonary circulation may be seen to follow excitement and overexertion. The symp- toms now consist of temporary dyspnea, cough, and probably the expectora- tion of a small quantity of frothy, blood-streaked material. Many cases complain only of shortness of breath, and rarely of a dry, hacking cough which follows exertion. The physical signs present during this period are unusually interesting and of great diagnostic value. (See Physical Signs, below.) After Compensation is Ruptured. — When compensation is lost, the nght ventricle is no longer able to cope effectively with the existing circula- tory tension (obstruction) offered to the return flow of venous blood from the feneral system, which obstruction in turn extends rapidly from the right eart both to the periphery of the body and to the viscera, and soon affects the general system. Dyspnea, cough, expectoration, and the sj'^mptoms com- mon to the latter portion of the stage of compensation become intensified. 278 DISEASES OF THE PERICARDIUM, HEART, AND BLOOD-VESSELS. Cough is accompanied by a somewhat free expectoration, which is fre- quently bloody. The patient complains of cardiac palpifatwn, and this annoying symptom may follow even slight exertion. Vertigo and a ten- dency toward attacks of fainting mav be experienced. Pain is unusual, except in those cases in which a variable degree of stenosis is also present. Ga.stro-inlcstiml catarrh, nausea, the vomiting of mucus an;l at times of blood-streaked material, may be an early antl annoy- ing symptom. Following venous congestion of the liver hemorrhoids are likelv to develop. Physical Signs.— During Compensation.— /?ispedio».— Inspection may at first be negative, Imt as the disease progresses a distinct pallor is Fig, 121. — Clubbing of the Fingers Due to V.\lvular He.^rt Disf.^se. Child eight years of age. (Courtesy of Dr. J. A, McKenna.) perceptible, the features are somewhat pinched, the lips and ears are moder- atel}' cyano.sed, and the vessels of the neck are abnormally prominent. Clubbing of the finger-tips and nails is an almost constant feature in j^oung subjects and is fairly common after middle life (Figs. 121 and 123). After Rupture of Compensation. — Inspection. — The extremities are swollen, and in those cases in which compensation is fairly well maintained there is edema of the ankles. The aljclomen may become pemlulous as the result of an effusion into the peritoneum, and when ascites is present, the respirations are rapid and shallow (Fig. 122). Cyanosis becomes extreme, the lips, finger-tips, and nails displaying a variable degree of lividity. In well-marked cases the mucous membrane of the mouth becomes cyanosed and the face is dusky. In the majority of cases the precordial region is prominent, a feature that is more conspicuous in children than in adults. The apical impulse is unusually large, and even late in the disease a diffuse wave is seen in the region of the left nipple, often extending do-wTiward to the sixth interspace, and well toward the anterior axillary line. Pulsation of the epigastrium may MITRAL REGURGITATION. 279 also be present, and is a constant feature where there is associated dilatation of the right ventricle. After failure of the right heart has developed, a distinct wave is seen over the vessels of the neck. Fia. 122. — Bilateral Pnettmogram from a Case of Chetne-Stokes Respiration, Developing During Advanced Cardiovascular Disease (Boston and Ulman). Lower curves R and L were also made from the same patient. The marked downward summit of the curve, seen during the pause, resulted from the patient's sighing. (See Bilateral Movements of the Chest, p. 131.) Palpation. — A systolic thrill is sometimes detected at the apex of the heart. During that period of the disease in which compensation is well maintained the apex-beat is forcible and heaving in character, but with beginning failure of compensation its force is proportionately weakened. Late in the disease, and after the left ventricle has become markedly rlG. 123 — Clubbing op the Toes Due to Valvular Heart Disease. Child eight year.s of age. (Courtesy of Dr. J. A. JIcKenna.) dilated and myocardial changes have taken place, the apex-beat is weak and often irregular. Throbbing of the veins of the neck, when due to an associated tricuspid regurgitation, is arrested by exerting mild pressure with the finger upon the vein immediately above the clavicle — a sign that serves to distinguish venous from arterial pulsation. 280 DISEASES OF THE PERICARDIUM, HEART, AND BLOOD-VESSELS. The Pulse.— The force and tension of the pulse are, as a rule, in direct ratio to the strength of the impulse of the heart, and while compensation is maintained the pulse is full, regular, and strong, although its tension may be slightly lower than normal. (See Blood-pressure, p. 204.) After compensa- tion has become lost the tension, force, and regularity of the pulse are dis- turbed, and it is readily compressible. (See Fig. 78.) Arhythmia, how- ever while uncommon, may be present in selected cases during the stage of compensation. When the heart is markedly dilated, it may be possible to place the hand over the epigastrium, and, by gentle pressure, to feel the heart's impulse distinctly. After the application of judicious treatment it will frequently be seen that the dilated heart returns to nearly its normal size within the course of a few days, and that this sign— pulsation in the epigastrium— disappears. The lower border of the liver is often palpable and the spleen is also enlarged. (See Pulsation of the Liver, Tri- cuspid Regurgitation, p. 288.) Percussion. — The area of cardiac dullness is increased downward and to the left, and may extend to or beyond the anterior axillary line, this sign being present early, and often before the patient has experi- enced any symptoms referable to cardiac disease. The note of cardiac dullness extends to the right of that normally present, and in marked cases may be found one-half to one inch be- yond the right border of the sternum. When cardiac dila- tation has developed, the area of cardiac dullness is percepti- bly widened, consequently the increase is more pronounced in the transverse than in the ver- tical diameter. Dullness may also extend well into the left half of the epigastrium. Auscultation. — Preceding the development of failure of compensation a systolic murmur is audilsle, its seat of greatest intensity being at the apex of the heart Fig. 124) . In selected cases this systolic murmur may be heard most distinctly in the third or fourth interspace, in the left midclavicular line. Rarely, as has been pointed out by various clinicians, the systolic murmur of mitral regurgitation is heard best over the base of the heart. Posture may he an important factor in auscultating for the detection of mitral disease, since in some the murmur is audil^le only when the patient is in the recumbent posture, being absent when he is sitting or standing. A reverse condition was found in a man reported by C. J. HolDan, the mur- mur disappearing when the patient was hdng upon either his side or his back. The systolic murmur of mitral regurgitation is transmitted from its area of greatest intensity near the apex toward the axilla, and is not in- frequently audible as far to the left as the angle of the scapula. The mur- FlG. 124. — Area Where Tricuspid Regurgitation IS Heard. Showing area where a loud systolic mitral murmur may be detected in addition to being transmitted toward the axilla. MITEAL REGURGITATION. 281 mur, however, becomes less and less distinct as the stethoscope is carried toward the scapular region. In following the transmission of the mitral murmur it is well to keep the stethoscope directly over the rib or interspace where the murmur is found to be loudest at the apex, traveling on this line to the left. When the stethoscope is placed over the third left costal cartilage, the pulmonic second sound of the heart is appreciably accentuated during the course of mitral regurgitation, a clinical feature explained in the mechanism by which the lesion of this disease is produced. (See p. 276.) The loudness of a mitral murmur may depend upon certain elements, the most prominent of which are: (a) Strength of the heart; and (b) degree of sclerosis in the region of the mitral orifice. Other murmurs are frequently audible after mitral incompetency has con- tinued for a prolonged period. After compensation is broken, a murmur is au- dible at the ensiform cartilage (Fig. 124), and signifies that tricuspid regurgitation exists. I/aboratory Diagnosis. — Cough is, as a rule, accom- panied by quite free expecto- ration, which is found on microscopic examination to contain alveolar cells: within the body of many of these cells granules of a brownish pig- ment are to be seen. The spu- tum may be blood streaked, or the patient may expectorate nearly pure blood at intervals. Red blood-cells and leukocytes are, as a rule, present in the sputum, even though the mac- roscopic appearance does not suggest the presence of blood. After tricuspid regurgita- tion and congestion of the ab- dominal viscera have devel- oped, the quantity of urine voided during the twenty-four hours is greatly lessened, is of high specific gravity, and contains a trace of albumin. Casts and both red and white blood-cells are to be found late during the course of mitral regiu'gitation. Aspiration of the serous sacs, i. e., the pleura, peritoneum, and pericar- dium, may result in the recovery of a clear, slightly greenish, opalescent liquid, having a specific gravity of 1.002 to 1.005, or possibly 1.010, and giving a decided reaction for albumin. Summary of Diagnosis. — The history of previous attacks of acute endocarditis, or of those affections known to favor the development of disease 01 the endocardium (see Endocarditis, p. 251), must be taken into considera- tion in formulating a diagnosis. A high degree of hypertrophy of the left ventricle, with an increase in the area of cardiac dullness to the left and nght, is of great diagnostic value. The existence of mitral regurgitation is established by the detection of a systolic murmur, heard best at the apex, with its t3q)ical area of transmission. (See Fig. 126.) Marked accentua- FiG. 125. — Shaded Areas Show Areas of Distribu- tion OF Aortic Regurgitation and Mitral Re- gurgitation WHEN Latter Murmur is Unusually Loud. 282 DISEASES OF THE PEKICAEDIUM, HEAKT, AND BLOOD-VESSELS. tion of the second pulmonic sound is additional evidence of the existence of this disease. After cardiac dilatation has taken place the diagnosis of mitral incompetency is made only with great difficulty, and, indeed, in many cases it is often impossible at this time to determine the nature of the original cardiac lesion. Diflferential Diagnosis. — (a) The extensive transmission of the murmur of mitral insufficiency readily serves to distinguish this murmur from that of mitral stenosis, the latter being heard at the apex, and being but feebly, if at all, transmitted. (&) The time of these two murmurs also serves as a diagnostic factor, although in those cases in which arhythmia obtains, this clinical evidence may be uncertain, (c) The murmur of mitral regurgitation and that of aortic stenosis are both systolic in time, and the area of distribution serves as the most important factor for their differentia^ tion — e. g., the murmur of mitral incompetency is heard best at the apex of the heart, and is transmitted to the left, whereas that due to aortic stenosis is heard most distinctly at the second right intercostal space, and is trans- mitted to the vessels of the neck, (d) Again, in mitral regurgitation the pulmonary second sound is accentuated, a feature that is absent in aortic stenosis, (e) In mitral incompetency the thrill is most marked at the apex of the organ, in striking contrast to the thrill of aortic stenosis, which is rough and palpable at the base of the heart. (/) The pulse is likewise an important factor in differentiating these two cardiac lesions, the pulse of mitral regurgitation being large and moderately forcible, whereas that of aortic stenosis is always appreciably small. Functional murmurs are to be distinguished from the murmur of mitral insufficiency. The accompanying table, from Anders, wiU assist in differ- entiating between them : MiTRAi Incompetency. Functional MuHMtrKS. History. 1. Previous history of rheumatism or 1. History of causative factors of one or other disease causally related. other form of anemia and of debility. 2. Frequently there is definite knowledge 2. Absent. of coincident rheumatism or organic heart disease in the same person. Physical Signs. 3. Inspection. — Duskiness of mucous mem- 3. Pallor of skin and mucous surfaces branes and extremities; later, wavy present, pulsation in veins of neck. 4. Palpation. — Finger-tips placed over 4. Impulse of the heart feeble. Apex im- apex-beat are forcibly hfted. Pulse- pulse not displaced, tension somewhat lowered and not prolonged. Apex impulse displaced down and to the left. 5. Percussion. — Evidence of enlargement 5. Dilatation of right auricle in approxi- of the heart. mately one-half of all cases, giving rise to dullness upward and to the . right edge of the sternum. 6. Auscultation.-— A systolic apex murmur 6. Soft systohc murmur over body of (often musical), with characteristic heart (variable in intensity, rarely area of transmission. This murmur transmitted to axilla) ; there may be is often heard posteriorly; pulmonary a systolic murmur at apex, and a sound accentuated. venous hum over the vessels of the neck. Clinical Course. — Before Compensation is Lost.— This stage of the disease may vary from a few to several years, and during this time the MITRAL STENOSIS. 283 patient suffers little or no inconvenience, and, indeed, may 1)0 unconscious of the existence of cardiac disease. After Compensation is Ruptured. — Here the clinical course depends largely upon tlu; ability to curiy out judicious treatment, and upon the presence or absence of complications. In those cases in which it is possil)le to take the patient from his work and to prevent all undue excitement and the use of stinuilants, narcotics, and the like, life will be greatly prolonged. On the other hand, in those unfortunate individuals who must earn a liveli- hood and those who are addicted to the excessive use of stimulants the dis- ease runs a rapid course, terminating fatally in from one to three years. Embolism anil tlu-oml)Osis of the lung are likely to occur at any time during the course of miti-al regiu'gita- tion, and whenever tliis acci- dent develops, tlie life of the pa- tient is greatly cndangoi-0(l. MITRAL STENOSIS. Pathologic Definition. — A cardiac condition character- ized by a nari'owing of the lu- men of the mitral orifice the result of calcareous deposits, thickening of the mitral leaf- lets, adhesions of the mitral valves, disease of the chorda: tendincffi, or extensive atheroma of the endocardium immediately surrounding the orifice. Predisposing and Ex- citing Factors. — Practically all conditiijns that predispose to endocarditis (sec p. 251) likewise predispose to mitral stenosis. Age is an important factor, this cardiac lesion being more common in children after the fifth year and in young adults. Sex exercises a moderate in- fluence, females being attacked more often than males. . Mitral stenosis may 1)C seen to follow endocarditis compli- cating scarlatina, measles, and other of the acute infections, and many writers believe that the intense strain of whooping-cough favors its devel- opment. After middle life, in a large percentage of cases, mitral stenosis will 1)0 found to accompany chronic nephritis and general atheroma of the arterial system. Mechanic Influence of the I^esion.— On account of the dimin- ished size of the mitral orifi(-e, undue force on the part of the left auricle is required to jjropel the blood from the aui'icle to the left ventricle, and in consequence of this f)veraction the wall of the left auricle hypertrophies and may attain a thickness twice that of the normal. Since the auricle is believed to accomplish much less by hypertrophy than does the left ventricle, -RaRK ArKA of TnANSMIHfllON OF A LoUD Mitral liK(jUR f^ \ I ,1/ -u \ ' 1 L _J ,« i;;-.,-,;r. : ■ ':■":.-:. 1 CKyhemo- globin. Reduced Hemoglobia. Reduced Hematin. Mrlhemoglobin Acid. CO-hemoglobin. Hematin Alkaline. Acid Hemato- porphynnuria. Alkaline Hem- atoporphyrin- uria. FiQ. 142. — Diagram of the Spkctha of Eight Substancf.s Known to Concern us from a Diag- nostic Standpoint (Boston). small glass vials with flattened surfaces. The spectrum of fresh arterial blood is that of oxyhemoglobirij and shows two absorption-bands, between D and E (Fig. 142); one of these is sharp, dark, and well-defined near the orange, E. The indigo and most of the blue will be absorbed, and in strong solutions of oxyhemoglobin these two bands may unite. If ammonium sulphid is added to such solutions, the color of the fluid becomes dark, and the spectrum changes to that of reduced hemoglobin, when one band of absorption occurs between D and E (Fig. 142). A positive mdication of the presence of blood is evidenced by the fact that the spec- trum may be transformed from that of oxyhemoglobin to that of reduced hemoglobin by the addition of reducing agents to the solution. Cochineal and ammoniated carmin give spectra simulating the spectrum of oxy- 332 THE BLOOD. hemoglobin. The addition of boric acid to a solution of these substances causes their sjaectra to be displayed by the blue, whereas the spectrum of the blood is unchanged. Other of the vegetable dyes have spectra simulating those of Ijlood, but these become pale upon adding sodium bisulphite. Methemoglobin. — Hematin is produced by adding acids or strong alkalis to blood. In acid solution the spectrum simulates that of acid methemoglobin, whereas in alkaline solution it gives a broad band at D (Fig. 142). An important clinical finding is the change of oxyhemoglobin into methemoglobin; this is revealed by the chocolate color of the blood, and by the fact that in acid or neutral solution it gives four absorption- bands: one quite distinct, between C and D; a second faint narrow band in the yellow, just to the right of D; a third broad, fairly distinct band, between the yellow and the green, just to the left of E; and a fourth broad band, to the left of F, sometimes extending beyond the line F into the blue. Carbonic-oxid hemoglobin is present in cases of poisoning by illuminating gas, and may be de- tected by the rose-red color it lends to both arterial and venous blood. A 0.5 per cent, dilution of such blood gives a spectrum that differs from that of oxyhemoglobin only in that its bands are broader and that the band at D is displaced to the right. The addition of ammonium sulphid causes the spectrum of oxy- hemoglobin to be replaced by that of reduced hemoglobin, whereas that of carbonic-oxid hemoglobin is unchanged. Fig. 143. — Von Fi.eischl's Hemoglobinometeh. a, Stand; b, narrow wedge-shaped piece of colored glass fitted into a frame (c) , which passes under the chamber; d, hollow metal cyhnder, di- vided into two compartments, which holds the blood and water; e, pla.-^ter-of-Paris plate from which the light is reflected through the chamber; /, screw by which the frame containing the grad- uated colored glass is moved; p. capillary tube to collect the blood; h, pipet for adding the water; i, opening through which may be seen the scale indicating percentage of hemoglobin. Von Fleischl's Hemoglobinometer. This instrument consists of a stand that somewhat resembles the base and table of a microscope; a cylindric diluting chamber with a glass bottom, divided into halves; a plaster-of-Paris reflector; a gradu- ated color prism; a thumb-screw adjustment; and a capillary tube (Fig. 143). Method of Application.— 1. One compartment of the graduated cylinder is half filled with distilled water, care being previously exercised to cleanse the chambers of the cylinder. 2. The capillary tube, which has been cleansed and dried, is held hori- zontally, and brought into contact with the summit of a drop of blood, when it immediateh' fills by capillary attraction. All blood on the outer surface of the tube is removed with a soft handkerchief, and the tube is immersed in the distilled water contained in the cylinder. It is held hori- zontally, and shaken gently until apparently emptied, when a few drops of distilled water are forced from a dropper through the tube in order to wash every vestige of blood into the cylinder. HEMOGLOBIN. 333 3. After the expulsion of the blood, the solution is gently stirred with the metal handle of the pipet, in order to effect a perfect mixture. 4. With a dropper both compartments of the cylinder are filled to the brim with distilled water. Moisten the ground cover-glass with the breath, and then allow the glass to fall gently upon the cylinder, when two small bubbles will appear one upon each side of the part-ition. If the bubble upon the side containing the blood is large, it is evident that sufficient diluting fluid has not been added and that the reading will l^e too high. When too large an amount of distilled water has been added, the solution containing the blood may l^e forced across the partition to mingle with the clear water on the other side, thus again defeating our purpose. 5. With the cover-glass properly adjusted, turn the cylinder so that the portion containing the blood will be toward the light ; thus the portion con- taining only distilled water is over the graduated color prism. Fig. 144.— Sahli Hemometeb. 6. A dark room is necessary for making this estimation, and the candle should be placed directly in front of the instrument, and the plaster-of-Paris reflecting surface so adjusted as to bring the column of light through the solution. 7. The operator should stand at the side of the instrument, bringing his face directly over it, and should read with the eye that is farthest from the light — all direct light from the candle should be excluded from the eye by holding some object on the anterior edge of the stage of the instrument. This may be accomplished by rolling a paper in the form of a tube. 8. The thumb-screw should be turned with short, quick turns, for when it is turned slowly, it is difficult to detect the changes in the color in the diluting chamber. 9. When the percentage of coloring-matter is believed to be extremely low, two or more pipetfuls of blood should be placed in the solution. When 334 THE BLOOD. the reading is below 40 per cent, tiie estimation cannot be made with anj degree of accuracy. Sahli Hemoheter. The Sahli hemometer is composed of a frame divided into two compart- ments, having a back made of ground glass. A tube containing a standard solution of acid hematin fits in one of the compartments, and the other is occupied by a tulie of the same size graduated from 10 to 140. (Fig, 144). There is a capillary pipet graduated at 20 cubic millimeters, and a larger pipet for adding the diluting fluid, which is decinormal solution of hydro- chloric acid. In order to operate the instrument the graduated tube is filled to the 10 mark with the diluting fluid. Blood is then drawn into the capillary pipet up to the 20 cubic millimeter mark, and this is gently blown into the diluting fluid, care being taken to prevent the formation of bul^bles. The capillary pipet is then washed out two or three times with the diluting fluid, the washings being added to the contents of the graduated tube. The mixture of Ijlood and diluting fluid is now further diluted with the decinormal hydrochloric acid solu- tion or with distilled water until its color matches the color of the standard tube of acid hematin. The percentage of hemoglo- bin is then read from the scale on the graduated tube. The advantages of the Sahli hemoglobinometer are, first, that acid hematin is compared with acid hematin; and, second, that the comparison can be made with any form of illumination — day- light, gaslight, electric light, candle light, or lamp light. The decinormal hydrochloric acid solu- tion is prepared by adding 15 cubic centime- ters of strong hydrochloric acid to enough distilled water to make 1000 cubic centi- meters. 145. — Tali.qvist's Hemoglobin Scale. Blotting-paper Test for Hemoglobin. Tallqvist has devised a color scale, which is accompanied by a booklet containing small sheets of a prepared paper. The color scale is graduated from 10 to 100. The summit of a rather large drop of blood is touched with the paper, and as soon as the blood has been distributed over that portion of the paper which it will occupy, the paper is laid beside the color scale, and moved until it matches one of the color blocks (Fig. 145). This method will prove satisf actor}' for average clinical work, and one with limited ex- perience will obtain better results from this simple method than from the more elaborate methods previously described. COUNTING OF THE BLOOD-CORPUSCLES. Method of Thoma-2Jeiss. — Among the many instruments devised for this purpose, that of Thoma-Zeiss, with Zappert's modification of the COUNTING OF THE BLOOD-CORPUSCLES. 335 ruling of the counting chamber, is doubtless the best. The method of using the Thoma-Zeiss instrument is as follows : 1. The part to be punctured is cleansed, and the drop of blood obtained in the manner previously described. In addition it is necessary that the blood be diluted for this purpose, and the following solution will be found satisfactory for the purpose: Toisso7i's Mixture. Methyl-violet 0.025 gm. Sodium sulphate 8.000 " Sodium chlorid 1.000 " Pure glycerin 30.000 c.c. Distilled water 160.000 " This solution will preserve the red cells for twenty-four hours, and its specific gravity is such that the cells precipitate slowly. It stains the leukoc}^es a violet tint. This solution keeps well, but should be filtered 0100mm 4^0 1"T" ■^' -n^ Fig. 146. — TnOM.\-ZEiss Hemocytometer. u, Slide used in counting; b, sectional view; c, portion of ruled bottom of well; d, red pipet; e, white pipet. whenever it displays the" slightest cloudiness. A 0.5 per cent, solution of glacial acetic acid is used as a diluent when the white cells are to be counted. It should be remembered that acetic acid decolorizes the red cells and renders them transparent, so that, although the microscopic field is filled with red cells, they are not visible. Acetic acid also darkens the leukocytes and renders their protoplasm more granular, which makes these cells more conspicuous. The pipet for the counting of the red cells consists of a glass tube with an expanded portion near one end, which contains a glass ball. Below this expansion it is graduated into tenths to 1 , and above the expanded portion to 101 (Fig. 146). To one end of this tube a piece of rubber tubing is attached, which has a bone nipple at its other extremity. The pipet for the estimation of the white cells differs only in that it is larger and is graduated in tenths to 1, and then above the expanded portion to 11. It will readily be seen that after the pipet for the red cells is filled with blood to 1 , and then the solution is added until it reaches 101 , the dilution 336 THE BLOOD. of the blood will be 1 part of blood and 99 parts of the diluent, since there are 100 parts of solution between 1 and 101. The rubber tubing is now removed, the tube is shaken for two minutes, and the 1 part in the graduated portion is blown out. The white pipet, when filled to 1 with blood, and the solution added to reach 1 1 , gives us a dilution of 1 part of blood and 9 parts of the diluent. A dilution of 1 to 20, or even 1 to 40, is more satisfactory when a high degree of leukocytosis exists. The diluting fluids should be carefully watched, lest they become cloudy or contain any sediment that may obstruct the lumen of the capillary tube. The tip of the pipet is brought into contact with the summit of the drop of blood collected from either the ear or the finger, and gentle suction applied to the ruljl^er tube, the nipple of which is placed between the lips. When the blood is drawn to the desired graduation, the tongue is placed against the opening of the nipple, and the tube is withdrawn from the drop, Fig. 147. — Method of Collecting Blood into the Graduated Pipet (Boston). its tip cleansed with a soft towel, and the end of the tube now immersed in the diluting fluid. Suction is again made, and the pipet rotated rapidly between the thumb and index-finger as the diluting fluid enters — always holding the pipet in the vertical position. The glass ball in the expanded portion facilitates dissemination of the blood throughout the diluting fluid, and when sufficient fluid has been added to reach the 101 graduation, the tongue is again placed over the opening of the nipple, and the tube withdrawn from the solution. The rubber tube should be removed from the pipet, and after shaking for two minutes, the diluting fluid occupying the tube below its expanded portion should be blown out, since it plays no part in the dilution. Method of Counting.— The next thing to be considered in the process for estimating the number of the blood-cells is the slide, which contains at its center a chamber divided into 400 squares, each of these squares being ^ mm. square and j\ mm. deep, and having a capacity of j\ hy -^ hj ^ = tuVtj- c.mm. (Fig. 148). This chamber is surrounded by a narrow channel. COUNTING OF THE BLOOD-CORPUSCLES. 337 Every group of 16 of these small squares is surrounded by a double row of lines, and is known as a great square (Fig. 148). There is a special^ ground cover-glass which must be brought in direct apposition with the slide in order that each of the squares be exactly -^ mm. in depth. The tube containing the diluted blood is rotated rapidlv between the thumb and finger for two minutes. From four to eight drops of blood are forced out of the pipet by blowing through the rubber tube. A single drop is made to collect at the tip of the pipet and transferred to the center of the slide. Place the special cover-glass upon the edge of the raised portion / / 1 (l 1? 0° (g) I )0 oo > °( 1 @ ]\ f f^ K ?%°c °o2 °rP ® i •*-> - ^ Zi ^"--"^ ,-'-^' ^ " ^ ^ -' ~~ — 1 Fig. 148. — Thoma-Zeiss Counting Chamber. , 'p^P^'^'^|.yr ?iiV(7 c.mni. Sixteen great squares, heavily outlined, within the cross-lines, and bounded by double lines. Each great square contains 16 small squares. Each small square is yc mm. in depth by nj mm. square; -jV X sV X ^V ^ loW c.mm. Projected to upper left corner is one great square show- ing arrangement of red cells and number in each small square; also leukocytes in last column. Right hand shows small square containing 11 red cells. The floor of the chamber is ruled into 400 small squares (Boston). of the slide. The forefingers are placed upon the cover-glass, while the second fingers and thumbs hold the slide at its corners. The forefingers are forced forward, using firm pressure until the cover-glass has passed beyond the opposite margin of the channel that surrounds the graduated chamber. Counting the i^rythrocytes.— In the estimation of erythrocytes all corpuscles touching upon the top and left-hand boundary lines are uicluded m the square, whereas those resting upon the right and bottom lines are to De included m the count of the contiguous squares. (See Fig. 148.) In 338 THE BLOOD. this way the cells in the left-hand column can easily be counted, passing to the adjacent right-hand column until the four columns have been counted, which wUl give the total number of blood-cells for one great square — 16 small squares. The slide is now moved, and 4 other great squares are counted in a similar manner. A mechanic stage greatly facilitates this process, yet it is not absolutely necessary. Having found the number of cells in 5 great squares, we return to the degree of dilution and the capacity of the small squares as the other factors for the estimation of the number of red cells in a cubic millimeter. For example, if the dilution has been 1 in 200, and the number of red cells found in 5 great squares (80 small squares), 87, 95, 93, 86, 89 respectively, a total of 450, then— 450 = number of cells, j^^ mm. = area of small square. T^ mm. = depth of small square. 1 : 200 = dilution. 80 = number of small squares counted. Hence 450x400x10x200 = 360,000,000-^80 = 4,500,000, the number of cells in 1 c.mm. of undiluted blood. A rapid method of arriving at the number of cells in a cubic millimeter of undiluted blood (dilution 1 : 200) is to add 4 ciphers to the number of cells found in 80 small squares, — 450, — which gives us 4,500,000. Counting- the I/CUkocytes. — The counting of the white cells differs from the method just described for the red cells only in that we are deahng with a much lower dilution of the blood, and that we count 400 instead of 80 small squares. The 400 small squares may often be brought into the field under a two-thirds lens, and when the number of leukocytes is not great, they may readily be counted. When the number of leukocytes is large, however, it is necessary to use a one-fifth lens, beginning at the upper left-hand corner of the slide, and moving the slide gently so as to move each column of great squares until the entire slide has been covered (Fig. 148). Here again the same precaution of counting all cells touching upon the top and left-hand lines, and of omitting those cells resting upon the right and bottom lines, must be observed. After counting the cells in 400 small squares, diluted 1 : 20, and observ- ing the other rules for estimating the red cells, the direct method for estimating the number of leukocytes in 1 c.mm. of undiluted blood is to multiply the number of cells found in the 400 squares by 200. Suppose the number found to be 35, and the dilution used 1 : 20: 35 X 200 = 7000. ALKALINITY OF THE PERIPHERAL BLOOD. The alkalinity of the blood is due to the presence of carbonates, bicar- bonates, and albumins held in solution by the acid phosphates, hence it is difficult to estimate the changes in these several elements, and the varia- tions in the reaction produced by the several processes in alkalimetry. When serum alone is used for the estimation (by titration), the alkaline principles of the clot are not included; and if laked blood is used, peculiar chemic changes are produced that depend upon the delicately balanced albumins and phosphates. It has been clearly shown that certain fairly constant alkaline principles exist in the blood and in the serum; these ALKALINITY OF THE PERIPHERAL BLOOD. 339 may be sufficiently closely estimated by the processes about to be described to render this knowledge of clinical value. Again, it is evident that the degree of difference between the alkalinity of normal and that of diseased blood presents somewhat wide variation. Durmg life the reaction of the blood is alkaline, owing to the presence of disodium phosphate and sodium carbonate. Under normal conditions the degree of alkalinity is estimated in terms of sodium hydroxid, and corresponds to 182 to 218 mgm. for every 100 c.c. of blood. Von Jaksch, however, makes a higher estimate of alkalinity —260 to 230 mgm.; whereas Canard places it at 203 to 276. Estimation of Alkalinity by Dare's Hemoalkalimeter. — Dare's mstrument (Fig. 149) consists of a glass tube (a) provided with a glass stopper (&), through which passes an automatic capillary pipet that tapers at its exposed point. This capiUary pipet has a capacity of 20 c.mm. (15 mgm. by weight) of blood. The stopper and the capillary pipet are fitted tightly into the tube (o) , which is gradu- ated to 3 c.c, to present the equivalents in milligrams of NaOH to 100 c.c. of blood. The upper end of the tube is ex- panded, and upon this expansion is a mi- nute opening (c) for the admission of air. A medicine-dropper graduated at 2 c.c. and provided with a piece of rubber tubing, which is applied to the exposed end of the capillary tube, and serves for the in- troduction of the test solution. A spec- troscope is necessary, and for this pur- pose Browning's pocket instrument will be found satisfactory. Test Solution. Tartaric acid (Merck's reagent) 0.075 gm. Alcohol (94 per cent.) 20.000 c.c. Distilled \Tater enough to make 200.000 c.c. Method of Application. — 1. Obtain a drop of blood from the tip of the finger; hold the tube horizontally, and permit the exposed tip of the capillary pipet to touch the summit of a fairly large drop of blood, when it fills by capillary attraction. 2. Hold the tube vertically, and wash the contents of the pipet into the tube by forcing the distilled water from a medicine-dropper through the pipet. This washing is continued until the distilled water collected at the bottom of the tube reaches the graduated zero mark (0) . 3. Close the opening of the tube by the' finger, and invert the tube repeat- edly until the blood and distilled water are thoroughly mixed. 4. A dropper is now filled with the acid reagent, and this solution is forced through the capillary pipet into the tube. Caution. — Cover the opening in the e.xpanded portion of the large tube before releasing the pressure from the rubber bulb of the dropper. 5. Without detaching the dropper, hold it in a vertical position and invert the tube several times. Fig. 140. — Dare's Hemoalkalimeter. 340 THE BLOOD. 6. Place that portion of the tube (a) below the graduation (0) in the cleft of the spectroscope, and examine for the presence of the absorption-bands of oxyhemoglobin. The acid solution should be added carefully after each examination until these bands disappear. They will be observed to fade gradually as the point of neutralization is approached. Invert the tube (o) after each additional drop of the acid solution. Upon the disappearance of the bands of oxyhemoglobin the test is com- pleted. Note the result from the scale on tube (a), which is graduated both in cubic centimeters and in the equivalents expressed in milligrams of sodium hydroxid to 100 c.c. of blood. SCALE OF EQUIVALENTS COMPUTED FROM A BASIS OF 15 MGM. OF BLOOD TO 2 C.C. OF ACID SOLUTION (ONE TWO-HUN- DREDTHS OF THE NORMAL). Cubic Centimeters of Reagent. Milligrams op NaOH to 100 c.c. of Blood. 2.6 345.0 2.4 319.0 2.2 292.0 2.0 266.0 1.8 239.0 1.6 212.0 1.4 176.0 1.2 169.0 1.0 133.0 0.8 96.0 0.6 79.0 0.4 53.0 0.2 26.6 Clinical Significance. — Decrease. — The alkalinity of the blood is low in women and children during the latter stage of digestion, when the hydrochloric acid and peptones are reabsorbed, and after violent exercise. Pathologically, a reduction occurs in several forms of anemia (primary or secondary or pernicious), leukemia, chronic hepatic disease, nephritis, dia- betes, pseudoleukemia, and in the cachexia resulting from carcinoma. High fever, general toxemia, the prolonged use of acids, poisoning by acids or by carbon monoxid, acute mania (stage of excitement), and epilepsy are attended by a low degree of alkalinity. In the last-named disease the reduction begins just prior to a seizure, and continues to fall after the convulsion, varying according to the muscular contraction occurring during the convul- sion. The normal alkalinity is restored in from five to six hours after a convulsion. Increase. — An increased alkalinity is found early during the process of digestion and after a cold bath. For every 2.2 c.c. of reagent employed, the equivalent of 292 mgm. of sodium hydroxid to 100 c.c. of blood is read from the graduation on tube a. Dare employed unshielded gas-light in making his observations. Glycogen. — Blood smeared upon slides or cover-glasses in the usual manner and dried in the air isMained for from three to five minutes with the following: lodin, pure, 1 part; potassium iodid, 3 parts; water, 100 parts; pulverized acacia, in excess. In the presence of glycogen a number of small granules of a mahogany-brown tint are seen in the leukocytes, and occasion- ally in the plasma. Clinical Significance. — ^An increase in the number of granules, ALKALINITY OF THE PERIPHEEAL BLOOD. 341 as seen in disease, is shown by the presence of intracellular granules. Extra- cellular granules are possibly derived as the result of degeneration of leu- kocytes. Neutrophilic leukocytes have been known to contain these granules in cases of leukemia and diabetes, and they have been found in the plasma in other pathologic conditions ; in fact, iodophilia may be present m any con- dition of which anemia is a symptom. The true clinical significance of these granules is not known. I^ipemia. — Normal blood contains between 0.75 and 0.85 per cent, of fat. The presence of fat in the blood may be demonstrated by fixing the films in a 1 per cent, solution of osmic acid for twenty-four hours, and stain- ing for from one-half to one minute with a 0.5 per cent, aqueous solution of eosin. The particles of fat are stained black with the osmic acid, while the remainder of the field takes the eosin stain. Since all granules staining black may not be fat, a control method is necessary, and should be conducted as follows: Fix the film for twenty-four hours in alcohol and ether, and then in the osmic acid for twenty-four hours; counterstain with eosin and extract the fat by ether; the absence of black particles in the cells and plasma is evidence that the blackening displayed by the first specimen was due to fat. Free fat (palmitin, stearin, and olein) may be detected in the blood in heahh and in disease, but it is usually present in comparatively small amounts, and although recognized with some difficulty under an oil-immersion objective, the granules are at times conspicuous. The quantitative estimation of the blood-fats is not practical for clinical purposes. Clinical Significance. — The quantity of fat in the blood is increased after a heavy meal and in acute alcoholism. An excess of 0.05 to 0.16 per cent, has been found in the blood of diabetes, 0.1 to 0.5 per cent, in nephritis, 0.15 per cent, in pneumonia, and 0.16 per cent, in typhoid fever. An increased quantity has been observed in starvation, phthisis, fatty embolism, carcin- oma of the esophagus, and poisoning by carbonic oxid. A fat-splitting ferment has been detected in the blood. Von Jaksch has demonstrated the presence of fatty acids in the blood of diabetic coma, acute yellow atrophy (hepatic), acute infections, and leukemia. Glucose. — Normal blood contains a trace of glucose, but the quantity may fluctuate, depending upon a diet rich in carbohydrates (increase) ; it is also influenced by muscular exercise and hunger (decrease) . The Freezing-point of Blood. — Cryoscopy as applied to the body fluids and secretions, especially to the blood, has as yet yielded but few definite results, and this is probably due to the fact that there are at present no practical methods for determining the freezing-point of blood and urine. Certain clinical changes are said to be accompanied by changes in the freez- ing-point of both the blood and the urme. Clinical Significance. — When the metabolic products are retained in the blood as the result of renal insufficiency, its molecular concentration is in- creased, and consequently its freezing-point is lowered, as has been found in the blood of nephritis, hydronephrosis, pyonephrosis, and experimentally in animals after ligation of the ureters. The freezing-point of the blood is unchanged when, after unilateral nephrectomy, the remaining kidney com- pensates. When the freezing-point of the blood is lowered to — 0.58° to — 0.61° C, and both kidneys are diseased, surgical operations of any kind should be deferred until the freezing-point is about — 0.56° C. When the freezing-point of the urine is less than — 0.9° C.,this indicates kidney insufficiency^, and when 342 THE BLOOD. one kidney alone is believed to be affected, the determination of the freezing- point of the urine obtained by catheterization of the ureters or by segrega- tion may be of clinical value. Urine from the diseased kidney will congeal at a higher point than will that from its fellow; e. g., urine from the diseased kidney freezes at — 0.-50° C, whereas that from a healthy kidney freezes at — 1.75° C. Generally speaking, it is impossible to draw definite deductions from the estimation of the freezing-point of the urine, owing to the wide phy- siologic limits between which it may fluctuate— from —0.1° to — 2.0°C. Tinl^er has recently asserted that cryoscopy is of value as an index to renal insufficiency. The method of Claude and Balthazard has lately appeared in a detailed translation l^y F. Burthe. Thus far cryoscopy is adaptable for use only by physiologists and is not readily employed by clinicians. STUDY OF FIXED AND STAINED BLOOD. Slides and Cover-glasses. The first step in the preparation of smears or films upon either cover- glasses or slides has been previously described on p. 326. Such spreads are fixed by one of the following methods : The most satisfactory and available method is to use a strip of copper, about ^ by 6 by 15 inches (Fig. 150), placing one end of this over the flame of a Bunsen burner. After the copper has been thoroughly heated, fill a pipet with cold water and drop it on the plate at different distances from the flame. When the water boils, but not sufficiently to cause bubbles that bounce off the stage, place the cover- glasses or slides at these points, specimen side down, and allow them to heat for from twenty minutes to several hours. After fixation the films should be stained at once. A very satisfactory method of fixation of blood films is to expose them for about fifteen minutes to the action of pure methyl-alcohol. The slide containing the smear is immensed in the methyl-alcohol contained in a suitable ve.ssel. Merck's or Kahlbaum's acetone-free methyl-alcohol should be used. Fig. 1.50. — Stage for Fixing Blood. Staining. One of the most essential facts in the staining of blood is that the results secured should be obtained by the simplest method possible. In 1891 Roma- nowsky detailed a method for the staining of malarial parasites by which the chromatin and the cytoplasm were stained differently. Since the appearance of Romanowsky's original paper, others have attempted to perfect similar staining methods. Thus Jenner detailed a most practical stain for 1)lood, and Leishman simplified Jenner's method to some extent. It was not until 1902, however, that J. H. Wright perfected this method and made its practical application possible. Bosin, Hematoxylin, and Methylene-blue. — The solutions necessary in this method of staining the blood are: 0.5 per cent, eosin in SERUM DIAGNOSIS. 343 70 per cent, alcohol; Delafield's hematoxylin; and 2 per cent, aqueous methylene-blue. Application of Stain. — First stain the specimen with eosin for one-half minute and wash in water. Then, without drying, stain with hematoxylin for from one to three minutes, the time varying greatly with different stains, even though they be prepared in essentially the same manner. Wash and dry the specimen, and mount as previously described. Wright's Staining Method. — The blood is smeared on slides or cover- glasses and allowed to dry in the air. The spread blood does not stain well after it has been exposed to the air for several months. Although the labora- tory worker usually prepares his own stain, the inexperienced will find it better to procure the stain from dealers in laboratory supplies. 1. Add to the specimen enough of an alcoholic solution of the stain to cover the film, and allow it to stand for one minute, in order to fix the cor- puscles. 2. To the alcoholic solution of the stain now on the specimen add water, drop by drop, until the stain becomes semitranslucent, and a yellowish, metallic scum forms on the surface. Allow this diluted stain to cover the specimen for two or three minutes. 3. Wash the heavily stained specimen in water until the film of blood presents a yellowish or pink tint to the naked eye. 4. When the desired tint is attained, dry immediately between blotting- paper, lest decolorization be carried too far. The specimen is now ready to be mounted in Canada balsam. Stained Blood. — The red cells are orange or pink, the nuclei of the nu- cleated red cells are deep blue. By this stain granular basic degeneration of the red cells is made evident. Polymorphonuclear neutrophilic leukocytes show dark-blue or dark, lilac-colored nuclei, and the granules are of a reddish-lilac color. Lymphocytes have dark, purplish-blue nuclei; cyto- plasm is robin's-egg blue, and in it are seen a few dark-blue or purplish granules. Eosinophiles display blue or dark, lilac-colored nuclei. The granules are stained red by the eosin, but the cytoplasm in which they are embedded is of a blue color. Large mononuclears present blue or dark, lilac-colored nuclei. Some of these cells show pale-blue or lilac cytoplasm, whereas others contain, in addition, dark-lilac or deep-purple granules. Mast-cells resemble the ordinary polymorphonuclear leukocytes, and in addition display coarse spheric granules which are stained dark blue, purple, or at times blackish. Myelocytes contain purplish or dark -lilac nuclei. In the cytoplasm numerous dark-lUac or reddish-lUac granules are seen. Blood-plates appear as small round or oval bodies, and are stained blue or purplish. These bodies show irregular margins, and their substance contains fine blue or purplish dots. SERUH DIAGNOSIS. Serum diagnosis is based upon a study of the action of blood-serum on pure cultures of known microorganisms. It has been found of the utmost importance in the recognition of disease, although it is only possible, at present, by its means to detect the presence of a limited number of affections. Specific serum reactions have been secured in Malta fever, dysentery, pneu- monia, tuberculosis, plague, cholera, paratjrphoid fever, and glanders, but as yet their application as a means of diagnosis is not practical in these infec- tions. 344 THE BLOOD. The Widal Reaction. The most characteristic and valuable among the reactions used in serum diagnosis is that known as the Widal reaction, which finds its chief field of usefulness in typhoid and paratyphoid fever. Method of Collecting the Blood. — Two methods of collecting the blood for the Widal reaction are employed: (1) The dry method, in which a piece of glazed paper is allowed to touch the summit of a drop of blood, which is then dried in the air; (2) the method of collecting the blood in a capillary pipet and diluting it. Wright has suggested a special pipet for collecting the blood. (1) Draw the blood into the pipet; heat the ends to seal them, after which the pipet and its contents may be transferred to the room in which the test is to be performed. (2) After sufficient time has elapsed to permit the serum to separate from the clot, break off the ends of the pipet and place the serum in a sterile watch-glass. (3) Transfer a portion of the serum to another watch- glass containing saline solution. In this manner dilutions of 1 : 20, 1 : 100, 1 : 500 or more are readily effected. Culture. — A pure eighteen-hour-old bouillon culture of typhoid bacilli should be employed in the making of the Widal reaction. 1. To blood collected upon glazed paper add 20 to 40 times its quantity of sterile bouillon to the drop; then make gentle friction with a platinum loop over the surface of the drop at its margin, thus assisting in its solution and in mixing the serum with the bouillon. Place a drop of the mixture (blood and Fig. 151. — Typhoid Bacilli, Unagglu- TiNATED (Jordan). Fig. 1.52.— Typhoid Bacilli, showing Typical Clumping by Typhoid Se- rum (Jordan). bouillon) upon the center of a cover-glass, and to it add a small drop of the eighteen-hour-old bouillon culture of typhoid bacilli. 2. A ring of vaselin is placed at the margin of the excavation on a hanging- drop slide, and then the slide is inverted over the cover-glass. Invert the slide quickly, and the specimen is ready for examination under the micro- scope. Characteristics of the Reaction.— The various steps in the reaction are as follows : (a) Place the center of the drop of liquid under the objective, when actively motile bacilli will be seen throughout the entire field. (b) The first evidence that the reaction is taking place is detected by the SERUM DIAGNOSIS. 345 retarding movements of the bacilli, (c) A small bacillus attaches itself to the side of a larger organism, — the Y formation, — and later other bacilli are seen to come in contact with these, some of them remaining to form a clump, and others appearing free in the liquid. As the movements of the bacilli lessen, more and more bacilli became attached (Y formation), until there are decided aggregations of bacilli in certain areas through- out the entire drop of liquid, (d) The reaction is not complete until all motility of the organisms composing these various aggregations has ceased. Clinical Significance. — A positive agglutination test, with a 1 to 40 dilution of blood-serum, indicates that the patient now has or has had typhoid fever. A negative agglutination test indicates that the disease from which the patient is suffering is probably caused by some other organism than bacillus typhosus. Pseudo-reactions should be considered negative. They are usually found in infections with other bacilli of the same (typhoid-colon) group — ^bacUlus paratyphosus, bacillus coli communis, bacillus dysenterise, etc. A positive reaction may appear late in typhoid and during convalescence. Wassermann and Noguchi Reactions for Syphilis. (See Sypbilis of the Nervous System> p. JJ2J). The principles of the serum diagnosis of syphilis will not be discussed and only the technic of the Wassermann and Noguchi reactions is given as briefly as possible. Inasmuch as these reactions differ in the hands of different workers, it is impossible to formulate absolute rules. The reader is referred to the more extensive writings on this subject by Wassermann, Noguchi and Kaplan.* The technic is copied from the latter. ■WASSERMANN REACTION. Bc[tlipment. — At least one dozen or more of Mohr's pipets, 1 c.c, graduated into 1-100. One dozen 10 c.c. pipets, graduated into 1-10. One gross of ordinary test-tubes. One gross of test-tubes 1 cm. in diameter, 12 cm. high. One-quarter dozen of graduated cyHnders, 50 c.c; J dozen 100 c.c. Two 50 c.c. measuring flasks with glass stoppers. A few pounds of glass tubing, 5 nun. bore, to make capillary pipets. One-half dozen test- tube racks for Wassermann tubes; J dozen test-tube racks for Noguchi tubes. A piece of rubber tubing for tourniquet. One artery clamp for above. One dozen hypodermic needles, 19 bore. One thermostat regulated at 57° and one regulated at 37° C. One electric centrifuge. Labels and pen- cil_ for writing on glass. One taU glass for flushing through used pipets, height to be greater than any pipet used. One dozen petri dishes. One dozen beakers, 100 c.c. capacity. Two fine forceps and two Hagedorn needles. One package of quantitative filter-paper. One razor (for killing guinea-pigs). One 15 c.c. Luer syringe. Technic— Obtaining blood from patient: A fairly stout piece of rabber tubing is placed a little above the elbow and held in place by an artery clamp. Do not obUterate the pulse. This brings into prominence the veins at the bend of the elbow. To a stout hypodermic needle (Kaplan uses a 19 bore l^nch needle) attach a 2-inch piece of rubber tubing. Holding the free end of the rubber tubing in an ordinary sterile test-tube, quickly Kaplan, D. M.: American Journal of Medical Sciences, January and July, 1910. 346 THE BLOOD. plunge the needle into the most prominent vein; if expertly done, the patient wiU hardly feel it and the blood will immediately begin to flow. About 6 to 10 c.c. of blood is withdrawn and placed in an ice-box overnight to co- agulate. The serum separates and may be pipeted off absolutely clear with- out cells. It is advisable to take the blood as far from a meal as possible, as proximity to a meal makes the blood lipemic, interfering with perfect working conditions. Having obtained 1 or 2 c.c. of clear serum, it is placed in a test-tube in the thermostat at 56° for one hour. Care must be taken not to permit the heat to rise too high (over 58°). After this, 0.2 c.c. is placed in each of two test-tubes, one the test, the other the control. To each is now added 0.1 c.c. fresh complement. To the test portion is added one unit of antigen. The control does not receive any antigen. Each tube receives now 3 c.c. of a 0.95 per cent. NaCl solution. In order to be able to judge properly the correctness of the procedure, the more controls one has the better; it is therefore necessary to compare the seruEq to be tested with two sera from known positive and negative bloods. Shake every tube well and place in incubator at 37° or 38° for one hour. During this time, if the serum is luetic the antibodies present will, together with the antigen, bind the complement and render it inactive for hemolysis. After one hour incubation each tube receives two units of amboceptor and 1 c.c. of a 5 per cent, suspension of sheep cells in 0.95 NaCl. The tubes are again vigorously shaken and placed in the incubator at 37° and inspected after ten minutes. If the reagents are properly adjusted, hemolysis begins in the control tubes in fifteen to twenty minutes, and careful watching becomes a very essential point at this stage of the test. As soon as the control is com- pletely hemolyzed the tubes are compared; only those should be pronounced negative that show a transparent fluid the same as the control. Permitting the tubes to stand undisturbed in a cool place (15° to 17°) for twenty-four hours shows in the positive test a deposit of red cells, the size of the deposit depending upon the severity of the infection or proximity to the initial lesion as weU as upon the degree of balance of the reagents used. Usually a markedly positive serum gives at the end of twenty-four hours a clear supernatant fluid of a light pink hue with a Bordeaux red accumulation on the bottom of the tube. The weaker the reaction, the redder the supemar tant fluid and the scantier the deposit of ceUs. In testing more than one serum, the reaction in each individual test must be considered as finished as soon as the controls are completely hemolyzed, in which case the two tubes are immediately removed to a cool place. NOGUCHI REACTION. With a capillary pipet allow one drop of fresh serum to fall into a narrow (1 cm. lumen) test-tube. The pipet is not to be used for any other serum. Add 0.05 c.c. fresh complement. To the front row (rear row for control) add one piece (more or less, depending upon the titer) of antigen paper. Prepare a suspension of human cells, 1 drop of blood to 4 c.c. NaCl 0.95 per cent. It is best to prepare about 60 c.c. of NaCl solution and allow 15 PLATE 11 1^ M « S39 in Wassermann reaction: a, Tube represents complete hemolysis — the end reaction of negative serum; b, represents partial hemolysis, some cells being hemolyzed, this repre- senting a tube of a strongly positive "3 plus" (+ ++) serum after standing to sediment over night; c, represents inhibition of hemolysis — of a very strongly positive serum — "■1 plus" ( + -1 — |--)-) after standing over night to sediment. SEBUM DIAGNOSIS. 347 drops of blood to fall from the experimenter's finger into the solution. The human cell suspension is placed overnight in the ice-box. Next morning the supernatant clear salt solution is pipeted off and a fresh quantity of NaCl is added (about 55 c.c.) to the cells in the beaker. Of this cell sus- pension add 1 c.c. to every tube in the rack. Incubate for three-quarters of one hour at 38° or 39°, preferably in a large dish of warm water. Occasionally shake the tubes, to insure proper solution of the biologic substance on the antigen paper. Add to each tube (after incubation), front and back rows, one piece of amboceptor paper (more or less, the quantity depending upon the titer) and replace in the incubator, observing the result after ten minutes, and watching carefully the controls. It will be noted in about fifteen minutes, more or less, that the rear row begins to get clear, and when complete transparency is obtained the test and control tubes are to be removed to a cool place and observed. If the reac- tion is positive, then the front tube (test) will be opaque, in marked contrast to the control, which is transparent. For convenience of observation, Kaplan makes use of a fine sealed tube (about 1 mm. in diameter) filled with black ink, which, when placed behind the control, will appear as a clear black line, whereas the positive tube will not show the black line, or it appears as a dim shadow — depending upon the strength of the reaction. It has been stated that a positive Noguchi test and a negative Wasser- mann is often due to the presence in the patient's serum of antisheep ambo- ceptors. It is not necessary to perform this test with every serum as a con- trol. Only sera giving the above results need be subjected to a verification. To demonstrate the antisheep amboceptor, place 1 c.c. of a 5 per cent, sus- pension of sheep cells in a test-tube, add 0.2 c.c. of patient's serum and 0.1 c.c. complement, add 3 c.c. of NaCl solution, place in incubator, and observe. If the amboceptor is present, the cells will dissolve and the mixture become transparent. The time consumed depends upon the number of amboceptor units present. Kaplan observed sera capable of hemolyzing the cells com- pletely in ten minutes. Rationale of Controls. — In the Wassermann and Noguchi reac- tions it is of vital importance to have every possible error excluded. For this purpose the controls used will answer. The substances to be controlled are the antigen, the amboceptor, and each individual serum. The Antigen Control. — This biologic reagent, as is known, can per se inhibit hemolysis. To measure the degree of such interference, a tube con- taining a well-known normal serum (or, as Kaplan foimd just as serviceable, no serum at all), plus antigen, plus complement, and antisheep amboceptor plus sheep cells ought to hemolyze in about twenty or thirty minutes. No reaction is to be considered as finished before the antigen control tube is completely hemolyzed. The Amboceptor Control. — Upon the eflSciency of the antisheep ambo- ceptor depends the rapidity of hemolysis of the sheep cells. It is therefore necessary to establish the amboceptor efficiency in a separate tube containing sheep cells, plus complement, plus antisheep amboceptor. It is not essential to add normal serum. The tube containing the above ingredients is always the first to hemolyze, requiring about fifteen or twenty minutes for a com- plete hemolysis. Control for Each Serum. — Every serum more or less has the power to interfere with hemolysis to a slight degree. In order to control the factor 348 THE BLOOD. of inhibition, every serum tested is placed in each of two tubes; the front tube contains the antigen and all other biologic reagents, the rear tube receives everjrthing but the antigen. This shows the degree of individual inhibition as compared with the tube containing the amboceptor control. Efficiency of the Entire System. — For this a well-known luetic serum is utilized. The reaction is to be positive, and hemolysis should not occur in the front tube, even if exposed to incubation temperature for hours after the controls hemolyzed. Opsonins and the Opsonic Index. Consideration. — This clinical method is based on the fact that cer- tain substances present in the circulating blood or in the blood-serum render various bacteria subject to phagocytosis. Among the organisms that are affected are pathogenic streptococci, staphylococci, meningococci, gonococci, pneumococci, anthrax bacillus, tubercle bacillus, influenza bacillus, bacil- lus of diphtheria, bacillus pestis, the colon bacillus, typhoid bacillus, and numerous other organisms. The normal human blood-serum displays opsonic influence upon the bacteria above named, but it is worthy of special attention that in the case of certain bacteria phagocytosis is but feeble or does not occur, unless the bacteria present are not highly virulent. Again, phagocytosis may take place with certain bacteria (bacUlus subtilis) in normal salt solution and in the absence of blood-serum. It may be well to call the reader's attention to the fact that the chemical nature of the opsonins is unknown, and likewise the structure of the opsonins remains in question. Opsonins occur in practically all vertebrates, and actual experiments have shown that serum obtained from the guinea-pig, calf, rabbit, sheep, swine, dog, cat, chicken, frog, and turtle is capable of activating' certain microorganisms for phagocytosis by leukoc3rtes obtained from animals of a different species. In addition to bacteria, other cells are also capable of being opsonified; Hektoen having observed that the blas- tomycetes obtained from a human lesion became surrounded by leukocytes in the presence of human serum and of dog serum. The same author calls attention to the phagocyiiosis of trypanosomes, and Lavtchenko and Mel- kich observed pronounced phagocytosis of the spirochseta of relapsing fever while using the serum of convalescent patients. Barrath has observed the presence of opsonins for the red blood-cells. Clinical Significance. — Wright and others have observed that during the course of certain bacterial infections the opsonins are at times diminished, and that by the use of bacterial vaccines it is possible to raise the opsonic value and thus to increase the patient's resisting power to the bacterium in question. From the foregoing statement it will be seen that a knowledge of the opsonic index gives an idea of the resisting power of the patient to the action of a specific organism, and may further indicate to the clinician whether treatment with a bacterial vaccine should be instituted. It has been satisfactorily demonstrated that bacterial vaccines represent a most important part as a therapeutic agent, and indeed it is often possible, in selected cases, to hasten improvement by the use of these vaccines. In chronic bacterial infections, both superficial and deep, vaccines may be found of inestimable value. The opsonic index serves as a guide to the administration of bacterial vaccines in these conditions. According to Wright, the injection of vaccines is likely to be followed immediately by a SERUM DIAGNOSIS. 349 decrease in phagocytosis — the so-called "negative phase"; and this feature, in addition to being variable as to degree, also depends, in part, at least, upon the amount of vaccine injected. Next in order follows an increase in pha- goc)d;osis, the so-called " positive phase," and coincidentally with this increase a corresponding improvement in the patient's condition is expected. A low opsonic index is to be expected in cases of chronic infection, and especially is this true when such an infection is more or less completely localized. A high opsonic value is also to be expected in cormection with acute cases that display well-marked systemic manifestations, but such high indices frequently alternate with comparatively low ones. Truly diagnostic values are possible when there is a distinct deviation from the normal value in relation to a special microorganism. Wright has written extensively concerning the diagnostic value of the opsonic index. The following sum- mary of Wright's conclusions concerning the significance of the opsonic index in tuberculosis is taken from Simon: (a) Deductions to be made when one has at his disposal records of a series of blood examinations made from the patient in question : " (1) When a series of measurements of the opsonic power of the blood reveals a persistently low opsonic power with respect to the tubercle bacillus, it may be inferred, in the cases where there is evidence of a localized bacterial infection which suggests tuberculosis, that the infection in question is tu- berculous in character. " (2) When repeated examination reveals a persistently normal opsonic power with respect to the tubercle bacillus, the diagnosis of tuberculosis may with probability be excluded. " (3) When there is revealed by a series of blood examinations a constantly fluctuating opsonic index, the presence of active tuberculosis may be inferred. (&) Conclusions to be drawn from a single blood examination: " (1) When an isolated blood examination reveals that the tuberculo- opsonic power of the blood is low, we may — according as we have evidence of a localized bacterial infection or of constitutional disturbance — infer with probability that we are dealing with tuberculosis — in the former case with a locaUzed tuberculous infection, and in the latter with an active systemic ■ iafection. " (2) When an isolated blood examination reveals that the tuberculo- opsonic power of the blood is high, we may infer that we have to deal with a systemic tuberculous infection which is active, or has recently been active. " (3) When the tuberculo-opsonic power is found normal or nearly nor- mal, while there are symptoms which suggest tuberculosis, we are not warranted, apart from the further test described below, in arriving at a ■ positive or a negative diagnosis." Whenever a certain serum is found to retain its power of inciting phago- cytosis after it has been heated to 60° C. for ten minutes, it is reasonably fair to conclude that "incitor elements" ("immune opsonins") have been produced in the organism either as the result of resistance to autointoxication which took place spontaneously during the course of tuberculosis, or followed the artificial stimulus given through the inoculation of tubercle vaccines. It is the consensus of opinion among workers with this clinical method that diagnostic importance attaches itself only to the results obtained through repeated examinations, and only when there is especially pronounced devia- tion from the normal. It would appear to us from the literature at hand that a single observation is of comparatively trivial importance in the diagnosis of either acute or chronic infections. ' 350 THE BLOOD. At present there appears to be considerable variation in the results attained through the work of different investigators, consequently we find it impracticable to draw deductions as to the actual clinical assistance a knowledge of the opsonins contributes toward the diagnosis of both acute and chronic maladies. Teclinic. — ^The materials necessary for the determination of the op- sonic index are as follows: (1) Patient's serum; (2) normal control serum; (3) washed corpuscles ; (4) bacterial emulsion. The Patient's Serum. — To obtain the patient's serum a few drops of blood (6 to 8) from the peripheral circulation are collected by means of a pipet and transferred to a small glass tube, which is then sealed in the flame of a Bunsen burner. After coagulation has taken place the coagulum is separated from the walls of the tube, and by means of the centrifuge the serum is separated from the corpuscles. The serum should not be more than twenty-four hours old when used. The Normal Control Seriun. — ^The normal control serum is obtained from a normal individual in the same maimer as the patient's serum. It is, however, advantageous to mix equal quantities of sera from three or four persons. There are certain factors which have some influence on the opsonic content of the blood. For this reason the sera of women during menstrua- tion, of hard smokers, and of those who are pale and under weight should not be taken as control. It is preferable to take the blood of the patient and the normal at approximately the same time of day. The Washed Corpuscles. — For this purpose a small amount of blood is collected in a tube containing some substance which will prevent coagula- tion. The fluid is then centrifugalized. The supernatant fluid which col- lects is next removed, and an equal quantity of 1.2 per cent, saline solution replaced. This is repeated, and then the fluid is again removed. The super- ficial layer of corpuscles is opaque and consists principally of leukocytes (leukocytic cream). Wright uses only this layer of corpuscles. Others, however, shake until the cells are thoroughly mixed. Bacterial Emulsions. — Perfectly uniform bacterial emulsions cannot, as a rule, be secured. Wright recommends that the emulsion should be of such thickness that one or two organisms are found on an average for each cell. Emulsions made from the different bacteria require special bacterio- logic technic. (See special works on laboratory methods.) Having obtained the four requisites, we may proceed to determine the opsonic index. For this purpose equal quantities of the patient's serum, washed corpuscles, and bacterial emulsion are mixed together. The control • test differs in no way from that just described, except that normal serum in- stead of the patient's serum is employed. It is then incubated at 37° C. for about fifteen minutes. A drop is next mounted upon a clean slide and stained without previous fixation (except tubercle specimens), preferably with a 1 per cent, aqueous solution of methylene-blue. Tubercle specimens require a different technic. Determining the Opsonic Index. — Before determining the opsonic in- dex we obtain: (1) The bacillary index; (2) the percentage index. To obtain the bacillary index it is only necessary to determine the average number of organisms seen within a series of 50 or more polymorphonuclear leukocytes. The percentage index is obtained by merely noting the percentage number of phagocyting cells. ANEMIA. 351 In obtaining the opsonic index two methods are in use. Wright's method is based upon a comparison of the bacillary index of the patient with that of the normal control serum, the latter taken as one. It may be ex- pressed by the following equation : NBi : 1 : : PBi : x, in which NBi represents the bacillary index of the normal control serum, PBi the bacillary index of the patient, and x the opsonic index. For example, if the bacillary index of the normal control serum was 10 and that of the patient was 5, then — 10 : 1 : : 5 : a; = 0.5 opsonic index. On account of certain fallacies to which Wright's method is open a second method has been brought forth. The opsonic index is obtained by compar- mg the percentage index of the patient with that of the normal control serum, the latter being also taken as one. For example, if the percentage index of the normal control serum was 50 and that of the patient was 70, then — 50 : 1 : : 70 : a; = 1.4 opsonic index. DISEASES OF THE BLOOD. ANEMIA. A condition in which there is a deficiency in the red cells or the hemo- globin, with or without change in the number of leukocytes. Clinically, anemia may be divided into two great classes : Primary anemia, in which the exciting cause is believed to affect the blood-making organs primarily. Secondary anemia, in which the abnormalities of the blood are attributable to some previously existing disease, such as chronic suppura- tion, heart, renal, and gastric disorders. The secondary anemias are of two types : (1) The chloro-anemias, in which there is a moderate reduction of red cells, a greater reduction in hemoglobin, with a low color-index, and little or no change in the leukocyte formula, except a possible increase in the polymorphonuclear neutrophile cells. This variety of anemia is the usual one found in cases of prolonged discharge of pus, cardiac disease, renal disease, malignant disease, etc. (2) The secondary anemias of the pernicious type, in which there is a great reduction in the number of red cells, a less reduction in the hemo- globin, with a high color-index, little or no change in the leukocyte formula, and the presence of nucleated red cells in the peripheral blood. This type IS sometimes seen accompanying carcinoma, sarcoma, after severe mala- rial infection, after hemorrhage, and in cases of infection ^ath dibothrio- cephalus latus. Oligocythemia is a term applied to a diminution of the number of erjd;hro- cytes in a cubic millimeter of blood. It may be inoderate, when the cells number from 4,500,000 to 3,000,000; marked, when they are between 3,000,000 and 1,500,000; and excessive, when they are below 1,500,000. Oligochromemia is a term appUed to a diminution in the hemoglobin per- centage. This may also be moderate, marked, or excessive. 352 THE BLOOD. The histologic study of the stained blood will give important data for diagnostic purposes. The normal erythrocyte is spherical. It varies from 7.2 to 7.8 microns in diameter; stains pale pink with eosin, and presents a pale area in its center, due to the normal concavity of the cell. If the cells are deficient in hemoglobin, this central pale-staining area is larger than normal, and it may be eccentric in position and somewhat distorted in shape. If the cells vary markedly in size, we have a condition known as anisocy- tosis. A red cell which is smaller than normal is called a microcyte ; one which is larger than normal is called a macrocyte. If the erythrocytes are altered in form so that oval, elliptic, pear- shaped, club-shaped, and other irregular forms are seen, we have a condition known as poikilocytosis. The deformed cell is called a poikilocyte. If the erythrocyte, instead of staining pink with eosin, stains purple, on account of taking the methylene-blue stain as well as the eosin, the condi- tion is known as polychromatophilia. Many erythrocytes show small blue dots in their cytoplasm when stained with eosin-methylene-blue combinations. These dots may be uniformly distributed throughout the cell; they may form a ring around its circum- ference; they may be collected into two or three groups, or they may be irregularly distributed throughout the cell. This condition is known as basophilic degeneration, or granular degeneration. Nucleated red cells are often found in the peripheral blood in patho- logic conditions. A nucleated red cell which is normal in size; has a normal staining cytoplasm; and a single, double, or triple nucleus, is called a normoblast. A nucleated red cell, which is larger than a normal erythrocyte;, has a single large vesicular nucleus; and a polychromatophUic cytoplasm, is called a megaloblast. These cells sometimes show karyokinetic figures. A nucleated red cell which does not present aU the histologic char- acteristics of a normoblast, on the one hand, or a megaloblast, on the other hand, is called an intermediate. Microblasts are small nucleated red blood- cells. Clinical Significance. — Anisocytosis, poikiloc3rtosis, polychromato- philia, and basophilic degeneration of the erythrocytes are seen in all of the severer forms of anemia, whether primary or secondary. The most notice- able degrees of poikilocytosis and anisocytosis, however, are found in pro- gressive pernicious anemia. Basophilic degeneration of the erythrocyte is found earliest and in most noticeable amount in the anemia of lead- workers. It has been shown to be present before symptoms are manifested. Normoblasts are found in all severe anemias, most commonly in the post-hemorrhagic cases and in progressive pernicious anemia. They are likely to appear in the peripheral blood suddenly and in large numbers, and to disappear suddenly; such a phenomenon is called a normoblastic shower. Normoblasts are considered by many writers to indicate an attempt at regeneration on the part of the bone-marrow. Megaloblasts may be found in all the severest anemias in small num- bers — one or two to 500 leukocytes. Their constant presence in large num- bers is seen in progressive pernicious anemia only. The absence of megalo- blasts is not conclusive evidence of the absence of progressive pernicious anemia; particularly when all the other features of the blood-picture point to that disease, the failure to find megaloblasts may be disregarded. POLYCYTHEMIA. 353 POLYCYTHEMIA. Pathologic Definition,— A condition characterized by the presence, in the circulating blood, of an excessive number of red corpuscles. Varieties. — In the majority of instances polycythemia is physio- logic, e. g., it follows physical exercise with profuse perspiration, and hot baths; it occurs during pregnancy, and at altitudes above 4000 feet. Pathologic polycythemia is associated with bronchial asthma, emphy- sema, cardiac insufficiency, pneumonia, pleural effusion, ascites, and condi- tions causing obstruction to the return circulation. Again, polycythemia may be either general or local. General polycy- themia of obscure origin is quite common. Anesthesia (chloroform and ether) and the prolonged use of sudh drugs as antikamnia, phenacetin, acetanilid, "headache powders," etc., are followed by general polycythemia. The exact physiologic effect of acetanilid in the production of this cyanosis has not been thoroughly proved, but certain conditions probably take place: first, the heart muscle may be involved, and consequently the organ will have inadequate power to force the blood through the capillaries; second, the capillary system may be relaxed, and the polycythemia at first involve the capillaries, while later, from obstruction offered to the circula- tion, general polycythemia may follow. There are many other theories that might be advocated, among which should be mentioned circulation through the lungs and through the kidneys, either or both of which may be materially interfered with by the use of acetanilid or similar preparations. That the capillary circulation of the brain is materially interfered with, and that there is also a storing-up of some deleterious substance in the brain tissue, is evident from the fact that mental dullness is a common symptom in both chronic and repeated acute intoxications with acetanilid. Infants present normally a polycythemia of from 5,444,000 (Stengel and White) to 7,000,000 (Emerson). Blood taken from a portion of the body which shows cyanosis will contain more than 5,000,000 corpuscles per cubic millimeter, a condition which may be termed local polycythemia. Physical Signs. — On inspection the complexion is often florid, the cheeks are of a bright reddish hue, and the skin in general appears to be too ruddy. In a few instances persons of normal complexion are found to have too many red cells, but such individuals are, as a rule, fat and mus- cular. When cyanosis is general, the skin and mucous surfaces assume a peculiar blueness that is slightly changed by pressure, and which disap- pears gradually when the obstruction to the circulation is removed. In cyanosis the patient's attitude is that of exhaustion; the respirations are shallow and rapid, the lips are separated, and he is often found sitting up or propped up in bed. Epigastric pulsation, due to dilatation of the right heart, and pulsation at the third rib on the left, due to dilatation of the left auricle, are to be seen. The nails of the fingers and toes show a peculiar reddish and at times present a bluish-black hue. Cyanosis often involves but one or two fingers of the one hand, or it may affect but a single extremity. In the majority of instances, however, it becomes general sooner or later, and in such maladies as asthma and valvular heart disease it becomes chronic. Upon palpation the skin is smooth to the feel, and there may be some evidence of edema of the extremities, lips, and eyeUds. I/aboratory Diagnosis.— The laboratory findings in physiologic 23 354 THE BLOOD. polycythemia are quite uniform, and consist chiefly in an increase in the number of red cells. The hemoglobin is likewise increased. While the leukocytes may show moderate increase, in many instances they remain normal in number, and, in fact, cases have been cited in which the number of white cells was subnormal (leukopenia). In the polycythemia of obesity and of plethora the individual red cells are found to contain an excess of hemoglobin, yet the size and form of such cells remain normal. The specific gravity of the blood is increased. Vaquez has found that the total nitrogen content of the blood-serum is increased, a fact probably dependent upon the presence of hemoglobin in solution. The whole blood is also richer in nitrogen than normal, but the red cells when separated from the entire blood display a deficiency in nitrogen. In most forms of polycythemia the urine is of a high color and of high specific gravity, with an excess of uric acid and oxalates. Summary of Diagnosis. — Chronic polycythemia is oftenest encoun- tered in those cases in which there is some defect in the circulation, and it develops after the extraction of a large quantity of liquid from the body, as is seen in cholera, diabetes, etc. Polycythemia, the result of disturb- ances in the arterial tension, is also to be seen after extensive burns of the skin; thus Locke reports an instance in which the red cells increased 4,000,000 in a cubic millimeter following an extensive burn. An increase of 2,000,000 in a cubic millimeter is to be expected in moderate burns. Anesthesia also causes polycythemia, which is, as a rule, local, although it may be general; an increase of 1,000,000 or more red cells in a cubic mil- limeter is often seen after the administration of either chloroform or ether, but at this time the percentage of hemoglobin is reduced. Pathologic polycythemia is to be found after the ingestion of poisons, e. g., phosphorus, carbonic oxid, and during diseases displaying chronic cyanosis. Altitude exercises a decided influence upon the number of red cells in a cubic millimeter, and it is the rule to find the number of red cells above the normal in individuals residing at an altitude above 1000 feet. This increase is proportionate to the rise in altitude, until, at 14,000 feet, the normal number of red cells in a cubic millimeter has been found to be 8,000,000. Certain drugs taken for prolonged periods give a peculiar dull or dusky color to the skin, which is not infrequently accompanied by polycythemia; in a number of cases observed by us there were neurasthenia, anorexia, and insomnia, with a moderate enlargement of the liver and the spleen. In these cases it appeared that the polycythemia and associated conditions resulted from the use of some one, or in many instances of several, of the coal-tar products, particularly from the continued use of headache powders. Polycythemia resulting from the prolonged or excessive use of ace- tanilid may show peculiarities in the hemoglobin, yet the evidence furnished by the literature appears to be conflicting. Blood smeared upon slides and permitted to dry in the air develops a peculiar dull, dusky, lusterless color, which is best demonstrated by preparing a similar film of normal blood and subjecting it to the same treatment. SECONDARY ANEfflA. Definition. — Secondary anemia is a condition that may result from a variety of maladies, which, after a variable period of existence, produce SECONDARY ANEMIA. 355 moderate alterations, and at times destructive changes, in any one or in all the elements of the blood. Varieties and Causes.— For convenience of study, secondary anemias are classified according to their etiologic factors, and they wUl be here considered in the order of their importance and frequency of occur- rence. Hemorrhage is by far the commonest cause of secondary anemia, and since it occurs under a great variety of circumstances, this factor must be considered in conjunction with both physiologic and pathologic proc- esses. _ It would at first appear that hemorrhage the result of surgical operation would constitute, the commonest cause of secondary anemia; this, however, is not the case, but, on the contrary, the vast majority of conditions associated with secondary anemia are in no way dependent upon hemorrhages resulting from surgical intervention. Menorrhagia, metrorrhagia, postpartum hemorrhage, hemoptysis, bleeding from the mucous surfaces, as is seen in gastric and duodenal ulcer, hemorrhoids, and intestinal parasites, e. g., necator americanus, constitute the common sources of hemorrhage. The repeated small bleedings that occur in these conditions eventually so impoverish the blood that hemorrhages from the mucous surfaces become more and more common. Inanition.- — In all instances in which inanition figures prominently there is a decided secondary anemia, which may be due to food which is either insuflacient in quantity or poor in quality. Again, an abundance of nutritious food may be taken, and yet, owing either to defective digestion or to incomplete assimilation or both, the individual may derive but little nourishment therefrom. Grave secondary anemia occurs during the course of chronic gastritis, gastric and esophageal carcinoma, and other conditions that interfere with peptic digestion. Elimination of Albumins. — The discharge of a large amount of albu- min from the system, as occurs in both acute and chronic nephritis, pro- longed lactation, dysentery, chronic suppuration, etc., causes anemia through constant depletion. Toxic Agents. — Poisons, either organic or inorganic, when taken in sufiicient amounts, give rise to secondary anemia. The inorganic sub- stances that commonly , excite secondary anemia are phosphorus, lead, arsenic, and mercur}^. (See Chronic Plumbism.) Anemia is also caused by the toxins of both acute and chronic infectious diseases, and is seen to follow scarlet fever, diphtheria, typhoid fever, acute articular rheumatism, and such chronic maladies as tuberculosis, syphilis, etc. Parasitic Anemia. — When the human economy becomes infected with animal parasites, a variable degree of anemia follows. An extreme type of secondary anemia occurs after infection with the hook-worm (neca- tor), and, in fact, it is this variety that simulates essential or idiopathic anemia most closely. Infection with the tape-worm., particularly the dibothriocephalus latus, taenia solium, and taenia mediocanellata, are also followed by serious blood changes. In children the round- worm and the pinworm often induce anemia, and the condition also results from infec- tion with flagellates and with the Amoeba coli. Protozoa in the blood, as in malaria and trj^anosomiasis, are frequently a cause of extreme anemia. Chief Complaints. — Most prominent are dyspnea, cardiac palpi- tation upon slight exertion, headache, progressive weakness, anorexia, 356 THE BLOOD. indigestion, and mental fatigue. The patient does not feel rested after a night's sleep, and in many instances insomnia forms a conspicuous and troublesome symptom. Hemoglobinemia is occasionally observed ia secondary anemia, and is a condition in which the hemoglobin of the red cells is dissolved and escapes into the serum. In hemoglobinemia the percentage of hemoglobin, as estimated by the hemoglobinometer, is normal, or may, as seen in one of our cases, reach 100 per cent. When the red cells are studied individually, they are found to be de- ficient in hemoglobin, and occasionally erythrocytes that are practically devoid of coloring-matter in their protoplasm are to be seen. The serum into which the hemoglobin has been given off by the red cells is highly stained with blood-pigment, and lends a characteristic appearance to the stained blood. Physical Signs. — On inspection the body usually appears emaci- ated, although it may be well nourished, and the lips and conjunctivae are pale. The skin of the extremities is also pale, but when the anemia is extreme, it may be cyanosed. In secondary anemia in which there is disease of the abdominal viscera or of the suprarenal body, the skin is dark and brownish, but in such cases the conjunctiva serves as a true guide to the degree of pallor. The respirations are rapid on exertion. Auscultation discloses the presence of a soft systolic murmur over the base of the heart. The murmur over the precordium is regarded as hemic, since it is not transmitted, and also disappears as the blood condition improves. I,aboratory Diagnosis.— Upon pricking the finger the drop of blood that exudes is more or less pale and watery, and when smeared between cover-glasses, it does not display the normal adhesiveness (viscosity). Hemoglobin. — There is a corresponding reduction in both the hemo- globin percentage and in the number of red cells, the fall in hemoglobin preceding the reduction in the red cells. In average cases of anemia the hemoglobin may vary between 75 and 40 per cent., but we have found it to be much lower in the anemia following hemorrhage and in that due to animal parasites. Hemoglobinemia, in which the hemoglobin has been dissolved from the red cells by the plasma, is to be seen in certain secondary anemias, and particularly in those due to poisoning by gases. It follows the introduction of snake venom into the system. A drop of fresh blood, when placed under a -j^ oil-immersion objective, will show lowered viscosity, a fact that is evidenced by failure of red cor- puscles to appear in coil-like rolls or piles— the so-called rouleaux forma- tion; on the contrary, however, the erythrocytes are disseminated equally throughout the field. When the anemia is due to the ingestion of mineral poisons, the viscosity may be increased, and instead of appearing in rou- leaux, the red cells are seen to form densely aggregated masses (hyper- viscosity). It is the abnormal degree of viscosity and the specific gravity of the serum in which the corpuscles are suspended that cause the red cells to give up their hemoglobin; hence the earliest changes characteristic of anemia are: Pallor, uneven distribution of the hemoglobin areas, a basic degeneration, and swelling and distortion of the erythrocs^tes. There is also irregularity in the form and size of the red cells, many abnormally large cells (macrocytes) and also extremely small cells (microcytes) being present. The large red cells are greatly distorted and assume various forms and shapes (poikilocytes). PLATE 111 V--''i o-^C'i Various Forms of Erythrocytes (Boston): 1. Normal erytlirocytes; 2, karyokinetic changes in the nuclei of erythrocytes ; 3, pigmentation of the nuclei of erythrocytes ; 4, poly- chromatoijhilia in nucleated erythrocytes; 5, megaloblasts ; 6, microblast ; 7, polychromato- philia of macrocytes ; 8, microcytes ; 9, macrocytes ; 10, poikilocytcs. At tlie lower margin of tlie picture is seen a basophilic leukocyte. (From blood of a child studied at Pennsyl- vania Hospital. Obj. B. and L. one-twelfth oil-immersion.] SECONDARY ANEMIA. 357 Erythrocytes. — The train of events in a secondary anemia is possibly something like the following theoretic outline: As a result of the action of a toxic substance which circulates in the blood from the seat of the disease, or as a result of a continued drain on the body-fluids, the hemoglobin and the number of erythrocytes in the peripheral blood are depressed. In order to compensate this loss the bone-marrow puts out into the peripheral circula- tion a larger number of erythrocytes, each one of which carries a somewhat smaller load of hemoglobin. This would explain those cases in which the erythrocytes are above 5,000,000 with a low color-index. As the deleterious action continues the depression of both hemoglobin and number of erythro- cytes progresses until, finally, the very low cell-counts and hemoglobin percentages are reached. The change in size (anisocytosis), in shape (poi- kilocytosis), and in tinctorial characters (polychromatophilia) go on with theincrease in the action of the pathologic substance. In the severe cases, or in cases of hemorrhage in which considerable blood is lost, nucleated red cells (normoblasts) appear in the peripheral blood, and are looked upon as evidence of an attempt on the part of the red marrow to replace the lost elements. In the severest cases megaloblasts appear in the peripheral streanas, and in some instances this is to be looked upon as evidence of reversion to the fetal type of erythrocyte production, a true degeneration of the bone-marrow. Leukocytes. — In secondary anemia the number of leukocytes may be either normal or greatly increased, and, rarely, they are diminished. An increase in the number of leukocytes (leukocytosis) of from 10,000 to 20,000 is the rule in the secondary anemias dependent upon acute inflammatory processes. Stained Blood. — Some of the large red cells are but feebly stained and may appear as mere shadows. Again, an occasional cell will be stained a purplish hue, taking the eosin red and the methylene-blue stains. This phenomenon results after a portion of the protoplasm of the red cells has given up a liberal percentage of its hemoglobin, but yet retains sufficient to take some of the eosin stain, while the portion from which the hemo- globin has been extracted is stained by the hematoxylin. This peculiarity in staining is termed polychromatophilia, and, with the other features of degeneration of the red cells, is shown in Plate II. Distorted erythro- cjrtes (poikilocytes) are common. Nucleated red cells are an unusual finding in secondary anemia, appear- ing only in the severer types; they are most commonly encountered in post-hemorrhagic anemia, in the anemia of intestinal parasites, and in that of lead workers, although we have repeatedly found them in the anemia of tuberculosis and syphilis. Nucleated red cells which are the size of the normal erythrocjrtes are termed normoblasts. Rarely, one sees an abnormally large nucleated red cell (megaloblast). Nucleated red cells that are smaller than the normal red cells are known as microblasts. It should be further stated that any one or all three varieties of nucleated red cells may appear in a single specimen of blood from a case of secondary anemia. Leukocytes. — ^The proper proportion of the normal varieties of leukocytes is often found disturbed in secondary anemia, yet this is by no means a neces- sary feature. Summary of Diagnosis. — Progressive weakness, palpitation, dysp- nea, pallor of both the skin and the mucous surfaces, with mental hebetude and weakness form the prominent features of secondary anemia. 358 THE BLOOD. Lowered viscosity, the absence of rouleaux formation, with pallor of the red cells, constitute the principal characteristics of the blood of secondary- anemia. Stained blood shows such endoglobular changes as simple decblor- ization, punctate basic degeneration, alterations in shape (poikilocytes) and in size (microcytes and macrocytes), and the presence of nucleated red cells and ring-shaped bodies. Symptomatic oe Secondary Anemia. 1. Symptomatic blood condition second- ary to disease elsewhere. 2. Occurs at any age. 3. Previous or associated history of trau- matic or spontaneous hemorrhage, chronic suppuration, prolonged lacta- tion, chronic Bright's disease, carcin- oma, chronic lead-poisoning, chronic malaria, gastritis, dysentery, or acute infectious maladies. 4. History of overwork and of insufficient food, sunlight, or fresh air. 5. May depend upon intestinal parasites when ova are found in feces, or upon malaria when the plasmodia are in the blood. In the presence of Bil- harzia, the ova are detected in the bloody urine. 6. Blood changes are variable, but steadily progressive in malignant disease. 7- Moderate reduction in both red cells and hemoglobin, the relative pro- portion being maintained. 8. General symptoms and signs usually subordinate to those of the primary malady. 9. Gravity of anemia depends on that of the primary disease. 10. Often responds to treatment, depend- ing on cause; in hemorrhage it is of short duration. Idiopathic ok Essential Anemia. 1. A primary disease of the blood and blood-making organs. 2. Occurs, as a rule, during adolescence and in early middle life. 3. Previous history not clear. Often foUows a profuse hemorrhage or severe mental strain. 4. Negative. 5. Absent. 6. Distinctive blood characteristics and profound 'changes both as to blood- cells and as to hemoglobin. 7. Marked reduction in both the per- centage of hemoglobin and in the number of red corpuscles; there may be a great increase in the number of leukocytes (myelocytes), as in leukemia. 8. General symptoms and signs also more characteristic of the form of anemia in question. 9. Gravity depends on type of blood changes and progressiveness of the condition. 10. One variety (chlorotic) is quite cur- able, but relapses are likely to occur; the other forms are progressive: per- nicious anemia is subject to remissions and relapses. Clinical Course. — This depends — (a) Upon the underlying conditions; (6) upon the degree of anemia present; (c) upon individual surroundings and environment (climate, occupation, city or country life, and age); and (d) on whether or not medicinal and hygienic treatment can be properly instituted. Anemia resulting from intestinal parasites, chronic mineral poisoning, underfeeding, intestinal fermentation, and similar conditions disappears rapidly upon removal of the exciting cause. The anemia of such organic maladies as nephritis, valvular heart disease, hepatic cirrhosis, and malig- nancy is progressive. LEUKOCYTES. During health the number of leukocytes in the adult varies between 8000 and 10,000 in a cubic millimeter. Variation in the number of leukocytes depends upon exercise, digestion, bathing, etc. PLATE IV Via/ ? ^WB^ o o f^rrOo. 5kQ o§ ^;^<-''' ;>A TfK** Blond of Siileniiinediillary Leukemia (PSoston): \. MycLieytes; 2, eosiiKiiibilie myelo- cyte; o, leukocytic .shadows; 4, jiolychrouiatophilic meKaloblas-t ; 5, large mononuclear leu- kocyte; 6, small lymphocyte; 7, eosinophile; 8, megalohlast; 9, polyniorjihonuclear leuko- cyte; 10, small eosinophiles. (Stained with eosin and hematoxj'lin. Obj. B. and L. one- twelfth oil-inimei'si. In the study"^ a "MCT.osfSe ' one can follow a metallic sound down to the constriction, or, much %tter,' one can follow bismuth mixtures which are swallowed naturally By t^;^atient. I first follow a liquid mixture (milk and bismuth), then a thick'^taixture (kefir and bismuth), then the kind of ESOPHAGITIS. 409 food that the patient says he cannot swallow, and give the bismuth liquid on top .untn the location of the stricture has been determined. After this has passed or been regurgitated, one can give various sizes of pills or capsules, until the size of the constricted lumen has been determined. In carcinoma of the esophagus one can usually determine the location, outline, and extent of the constriction. The lumen is irregular, and except in the terminal stage the constriction is not complete. There will always occur trickling of the liquid bismuth mixture through the orifice. The ulti- mate passage of the food will depend upon the degree of stenosis. Additional information may often be obtained by studying the influence of the ingested mixture upon the neighboring structures. Spasm of the esophagus, on the other hand, is more apt to be a complete constriction, which after a time relaxes entirely, allowing the food to pass without obstruction. Occasionally one can see the constriction move upward carrying the bismuth mixture ahead of it. Dilatation of the esophagus and its degree can be determined by filling the lumen above the constriction with bismuth mixture. The amount of dilatation will depend upon the degree of constriction, and the duration. Diverticulum of the esophagus can usually be recognized, but this will depend upon the ability to fill its cavity with the bismuth mixture. One may get it to fUl at one time and not at another. It may vary in size, shape, and location. Its walls will be smooth. The most important evidence, however, is obtained by watching it empty itself. A stenosis empties from the bottom; a diverticulum from the top. The movements of the esophagus are interesting. The peristalsis can be seen to carry solid food down to the cardiac orificei Liquids can usually be seen entering the cardiac orifice by spurts synchronous with the cardiac pul- sations. In a stenosis of the cardiac orifice with dilatation above, I was able to see several bismuth capsules churned about one another in the attempt to force them through the constriction. DISEASES OF THE ESOPHAGUS. ESOPHAGITIS. Pathologic Definition. — An inflammatory condition, either acute or chronic, involving the mucous or submucous or both coats of the. esoph- agus. General Remarks. — The esophagus, owing to the protection afforded by its particular location, function, and histologic structure, is less prone to be attacked by the diseases known to affect other mucous surfaces. When, however, disease of the esophagus occurs and is localized to the mucous or submucous coats, the symptoms will in general be those of similar affections of other mucous surfaces, with this difference, that sooner or later dysphagia is likely to occur. A study of diseases of the esophagus consequently resolves itself into a differentiation of all other conditions in which there is difficulty in swallowing or interference in any way with the passage of food to the stomach. For present purposes the symptomatology of affections of the esophagus in general will be considered here, and we will discuss later, under separate headings, the special symptoms belonging to each particular disease. Principal Complaint. — Pain is by far the most distressing and corn- 410 THE ESOPHAGUS. mon symptom of disease of the esophagus. In acute inflammation the pain is severe, and is distributed over the region of the neck, beneath the upper portion of the sternum, between the shoulders, and for some four to six inches along the vertebral column; a similar pain is experienced in peri- esophageal inflammation. If the esophageal inflammation is acute, the patient complains of a variable degree of stiffness of the neck. Sharp, lancinating pain, burning in character, results from an acute inflammation of the mucous surface of the esophagus, and in many instances is caused by the passage of hot or highly acid foods to the stomach. _ Dys- phagia, while most annoying to the patient, is not always .accompanied by pain. Pressure upon the esophagus may in rare instances excite continuous pain or pain upon swallowing, but it is usually localized and not of an acute character, unless solid food is passing. Progressive weakness and emaciation are among the most constant symp- toms of disease of the esophagus, and are more pronounced when either obstruction or malignant disease is present. Cough accompanies practically all pathologic conditions of the esophagus or of the adjacent structures, from pressure exerted upon the recurrent laryngeal nerve, the bronchi, or the trachea. The conditions that commonly give rise to such irritation and cough are thoracic aneurism, carcinoma of the esophagus, and enlarged mediastinal glands. There is more or less constant annoyance from the accumulation of secretion in the mouth, and the patient expectorates a frothy, viscid mucus. Mucus from the esophagus is not expelled by coughing, but is readily loosened by merely clearing the throat. Generally speaking, the patient complains of profuse expectoration when there is either acute or chronic inflammation of the esophageal mucous membrane. ESOPHAGEAL HEMORRHAGE. Definition. — ^The escape of either arterial or venous blood from the esophageal mucous membrane, which may later be ejected through the mouth or find its way into the stomach. Bxciting and Contributing Factors. — ^The commonest cause of hemorrhage is a varicosity of the veins of the mucous membrane of the esophagus. In this connection esophageal hemorrhage is not readily ex- plained, since it accompanies cirrhosis of the liver, chronic nephritis, and certain diseases in which splenic tumor is present. Minute hemorrhages from the esophagus are highly suggestive of carcinoma, and especially is this the case when a variable degree of obstruction is present. Foreign bodies, either lodged in or while passing through the esophagus, may be the cause of bleeding, and ulceration of this canal may also give rise to hemorrhage. Characteristics. — Blood from the esophagus is bright red in color, and always alkaline in reaction; it is not ejected by vomiting, but is brought up by " clearing of the throat." Physical Examination of the Esophagus. — Inspection of the esophagus is possible only with the aid of the endoscope, and may, in some instances, show evidence of ulceration or of varicose veins. Palpation of the esophagus immediately above the clavicles may be performed from the sides of the neck. From this point the esophagus, when distended or enlarged, will be felt immediately behind the trachea. In peri- esophageal abscess or dilatation of the esophagus a peculiar soft, tumor- like mass can be felt in this region, and in marked dilatation a pear-shaped tumor may be seen in the neck. ESOPHAGEAL HEMORRHAGE. 411 The passing of an esophageal sound furnishes the most valuable evidence as to the condition of the esophagus. Cautions. — (1) The bougie should be protected at its point by an olive- shaped expansion. (2) The instrument should be introduced gently, and should pass through the tube without the operator making any decided pressure. (3) If the question arises as to whether the bougie has entered the esophagus, the patient should be directed to speak, and if he is able to do so, it is evident that the sound has not entered the larynx. (4) The normal constriction of the esophagus corresponds to the level of the fourth thoracic vertebra, and is ten inches from the incisor teeth; therefore all bougies should have an indelible mark at this point in order to guide the operator. It is also well to have the bougie graduated in inches from the olive-shaped expansion to the tip. A mild contraction is noticed when the bougie passes the cricoid cartilage. (5) When the bougie has passed a constriction in the esophagus, it should be removed slowly and with extreme gentleness until it has again passed the point of constriction. (6) The entrance of the esophagus into the stomach corresponds to the level of the eleventh thoracic vertebra. _ General Remarks. — The esophagus may be obstructed at almost any point, either as the result of disease within the canal, from pressure by tumors in the mediastinum or by foreign bodies lodged in the tube. Organic disease usually affects the upper half of the esophagus. In dysphagia due to paraly- sis of the esophagus the bougie passes into the stomach without interruption. In dysphagia due to spasm the tube will be found to pass slowly, and without any decided pressure, into the stomach. In stricture of the esophagus fol- lowing ulceration the bougie will not pass easily. The location of an obstruction possesses a certain value in the diagnosis; e. g., an obstruction of the esophagus located five or six inches from the incisor teeth is commonly of cicatricial origin, whereas an obstruction nine inches from the teeth is highly suggestive of carcinoma. If the passing of the bougie excites pain at any particular point along the esophagus, this is doubtless the seat of disease, and the nature of the pathologic condition is suggested by the point at which the irritation exists. Auscultation. — Hanburger* was the first to call attention to auscultation as a means of diagnosis in constriction of this canal, and this observer has reported in detail sounds heard over both the normal and the diseased esophagus. Method. — Place the stethoscope over the pharjnax, at the side of the neck, over the hyoid bone, or at the left of the spinous process of the vertebra, as low as the first thoracic vertebra. A loud, gurgling sound is heard when the patient swallows liquid. This sound, however, is of short duration. On placing the stethoscope over the left edge of the sternum, or just to the left of the vertebral column, liquids may be heard to pass from the mouth into the stomach. If there is a constriction or decided lessening of the caliber of the esophagus at any part of the canal, a peculiar gurgling sound, resembling that heard when water is poured from a bottle, is audi- ble at a level with such constriction. If there is complete obstruction of the esophagus, the characteristic sound of swallowing is not heard below the point of such obstruction. In dilatation of the esophagus the sound * Jahrbiicher der k. k. Gesellschaf t der Aerzte in Wien, Bd. xviii. 412 THE ESOPHAGUS. produced by swallowing liquids resembles that of rain beating against a glass window-pane. The sound normally audible when the stethoscope is placed along the spine over the course of the esophagus during the act of swal- lowing liquids is best appreciated by listening to this sound. ACUTE ESOPHAGITIS. Predisposing and Bxciting Factors. — These have been alluded to under General Remarks. The condition may, however, result from exten- sion of a catarrhal process from the pharynx; it is not infrequently associated with certain acute infections, e. g., typhoid fever, and is particularly common in diphtheria, scarlet fever, and pneumonia. Practically all diseases arising withia the esophagus are capable of causing an acute or a chronic inflamma- tion of the lining mucous membrane. In a few instances the formation of small pustules has been noted, disseminated over the mucosa of the esophagus. Principal Complaint. — The patient complains of more or less con- stant pain, more particularly upon swallowing either solid or liquid foods. Following deglutition there is at times a dull pain or a sense of weight immediately beneath the sternum. Regurgitation of food is by no means uncommon, and dysphagia is also likely to occur. As a rule, a large quantity of mucus is mixed with the regurgitated food, but pus and blood are rather uncommon findings. Summary of Diagnosis. — Pain localized immediately beneath the sternum, and intensified by the passage of food to the stomach, is highly suggestive of esophagitis. The ejection of blood and mucus also points strongly toward inflammation of the esophagus. Course and Duration. — As a rule, cases of acute esophagitis subside in from a few days to three weeks, but when the condition complicates a pharyngeal or gastro-intestinal malady, the prognosis may be less favorable. In necrotic and in purulent types of the disease the constitutional symp- toms are pronoimced, and death may result. CHRONIC ESOPHAGITIS. Pathologic Definition. — A chronic inflammatory process involving the mucous coat of the esophagus, and following repeated attacks of acute esophagitis. This condition, as stated, may result from repeated attacks of acute esophagitis, or it may depend, in part at least, upon dilatation of the veins of the esophagus, the result of valvular heart disease, myocarditis, chronic interstitial nephritis, or hepatic cirrhosis. The symptomatology of the chronic form differs from that described under Acute Inflammation of the Esophagus only in degree. Bsophagoscopy.— The esophagoscopic findings show paling and mot- tling of the mucous surface of the organ. There is also present a somewhat thick, tenacious mucus, that covers the entire mucous surface. ULCER OF THE ESOPHAGUS. _ Patholpgic Definition.— An acute or chronic inflammatory process, with ulcera,tion, mvolving first the mucous coat of the esophagus, and possi- bly extending to the submucous and muscular coats. ESOPHAGEAL DIVERTICULUM. 413 Predisppsing and Exciting Factors.— Ulcer of the esophagus may follow simple catarrh of the esophageal mucosa, diphtheritic catarrh of the esophagus, and pressure from mediastinal tumors; in bed-ridden patients pressure exerted opposite the level of the cricoid cartilage may give rise to ulcer at this point. Esophageal ulcer may develop during the course of the acute infections, e. g., pneumonia, acute gastritis, acute ulcerative stomatitis, and typhoid fever. There may be ulceration of the esophagus, simulating closely that detected in the stomach, but such ulceration is, as a rule, situated near the cardiac extremity of the tube. Esophagoscopy. — The ulcer may be inspected by means of the eso- phagoscope, and in this way the exact character of the lesion is deter- mined. The esophagoscope should not be employed when ulcer follows the taking of irritating and corrosive substances. Local treatment may also be applied through the esophagoscope. (See p. 404.) Summary of Diagnosis. — Ulcer of the esophagus is difficult to diag- nose antemortem, since practically all the symptoms of acute catarrh of the esophagus are also present in this condition. In addition, ulcer is character- ized by intense pain on swallowing, the pain appearing to be localized im- mediately beneath the upper border of the sternum and along the spine on a level with the lower border of the scapula. It is seldom that esophageal ulcer perforates the tube, but if perforation should occur there is emphy- sema of the surrounding tissues, and particularly of the region of the neck. Emphysema is an almost positive sign of perforation of the esophagus. Complications and Sequelae. — Perforating ulcer usually leads to abscess of the mediastinum and of the tissues of the neck. In rupture of the esophagus complicating carcinoma, ulcer, or traumatism, the symptoms are pain, violent vomiting, a weak, rapid pulse — in fact, the general symp- toms of shock. Doubtless the vast majority of ulcers of the esophagus heal spontaneously, and, as a result of this process, a dense layer of cicatricial tissue is formed that, in time, produces a local diminution of the caliber of the esophagus. ESOPHAGEAL DIVERTICULUM (Pharyngocele). Definition. — A circumscribed sacculation involving one or more coats of the esophageal wall. Varieties. — (a) Pressure diverticula, which may be either congenital or acquired; and (b) the so-called traction diverticulum. Predisposing and ^Exciting Factors. — Excluding those cases of diverticulum of the esophagus that are congenital, the predisposing and exciting factors in pressure diverticula are " localized lesions in the muscular coat of the esophagus," which, in the majority of cases, are produced by rapid eating or by the swallowing of large particles of food — the lodging of foreign bodies in the esophagus, and the like. Sex figures prominently, since males are far more susceptible than females. Age also deserves consideration. The condition is seldom seen in chil- dren unless it is of congenital origin. Location. — ^The sac occurs most often on the posterior wall, at or near the jimction of the esophagus and the pharynx, where the muscular coat of the canal is weakest. When the muscular coat becomes expanded or thin, the mucous membrane tends to protrude forward between the muscular fibers, forming an apparent hernial sac. A characteristic of esophageal diverticulum is the fact that its size increases gradually. 414 THE ESOPHAGUS. Traction diverticula occur only in children, and are situated at a level with the bifurcation of the trachea; they protrude from the anterior wall of the esophagus. Principal Complaint. — ^The patient is at first conscious of the fact that a portion of his food lodges too high, and he describes this peculiar sensation as being relieved when he stretches or makes general pressure upon the neck. He may also observe a small mass or bulging in the neck, which is often relieved by gentle manipulation. Tumor of the neck is a not infrequent symptom, and whenever there is a history of fluctuating tumor in this locality, the possibility of pharyngo-esophageal diverticulum should be foremost in the mind of the diagnostician. In certain cases the patient is able, by pressing upon the neck, to cause a portion of the previously taken food to regurgitate into the mouth — a positive sign of dilatation of the esophagus. When the sac becomes filled with food, pressure exerted exter- nally may excite vomiting, which is accompanied by severe strangling. In those cases in which vomiting is a frequent symptom irritation and soreness of the pharynx and the esophagus are likely to be associated. Soreness may be so marked as to prevent the patient from taking sufficient nourishment, and consequently the symptoms of malnutrition develop. The distended sac may exert sufficient pressure on the nerves of the neck to cause dysphagia and alteration in the voice. Pressure upon either the superior or the recur- rent laryngeal nerves causes paroxysmal coughing, dyspnea, and hoarseness. EsophagOSCOpy. — An esophagoscopic examination enables one to obtain a clear conception of the degree of dilatation existing in a given case. The esophagoscopic findings in diverticulum are quite characteristic, since there is a rhythmic disappearance from view of the esophageal wall with the act of respiration. (See Esophagoscopy, p. 404.) Again, either benign or malignant tumor is frequently found to involve some portion of the esopha- geal wall. Stricture may exist at the lower portion of the sacculation, and in such cases it is possible to estimate the actual caliber of the esophagus at the point of constriction. Summary of Diagfnosis. — A tumor-like mass that appears suddenly in the neck and disappears upon pressure and gentle manipulation or after paroxysmal coughing is highly suggestive of diverticulum. If the esophageal sound may be passed directly into the sac, the instrument is palpable through the neck, and the sensation offered to the operating hand is entirely differ- ent from that experienced when the sound passes into the stomach. Duration. — Most cases are of prolonged duration, and recovery is practically impossible, unless operative interference is employed. In those patients in whom the nutrition remains good the prognosis as to life is favorable. STRICTURE OF THE ESOPHAGUS. Pathologic Definition. — A condition by which the caliber of the eso- phagus is diminished at any given point throughout its length; this narrow- ing may be congenital, the result of disease within the esophagus (ulceration) or of extra-esophageal pressure. Predisposing and Exciting Factors.— It is to be borne in mind that, normally, there is a moderate constriction of the esophagus ten inches from the teeth, and that any decided alteration in the caliber of this tube elsewhere is pathologic. Aside from congenital deformity of the esophagus, stricture oftenest results from epithelioma, and is second in importance only to congenital deformities as a cause of stricture of the esophagus. Less STRICTURE OF THE ESOPHAGUS. 415 often stricture of the esophagus may depend upon an excess of cicatricial tissue produced in_ the process of healing of an esophageal ulcer. Corrosive substances taken into the esophagus may give rise to extensive ulceration and sloughing of the mucosa. A few instances are recorded in which stricture of the esophagus followed typhoid fever, and it is fair to suppose, at least, that typhoid ulceration took place in the esophageal mucous membrane. Certain authors hold that sj^hil- itic ulceration is occasionally responsible for esophageal stricture. True gastric ulcer situated at the junction of the esophagus with the stomach has been reported. Principal Complaint. — ^This will be found to vary greatly with the degree of stricture present. Probably the first complaint is of inability to swallow large morsels of food, or such food may cause the patient some dis- comfort in its passage into the stomach. In practically every case the sufferer notices that this difficulty in the swallowing of solid food increases gradually until finally he is able to take only liquids. The pain, discomfort, or pressure, as the patient is apt to describe it, felt when swallowing solid food is localized to one particular point, immediately beneath the sternum or between the scapulae. It will be observed that as the lumen of the esophagus becomes narrower, increased effort will be required to make the food pass through the tube to the stomach. Spasm of the esophagus may be responsible for temporary esophageal stricture, and has been considered under the head of Neuroses of the Esoph- agus. The degree of pain accompanying stricture of the esophagus will be found to vary greatly with the cause of the stricture. After the lumen of the esophagus has become markedly lessened the patient usually expectorates a large quantity of mucus and regurgitates particles of food that have remained in the esophagus for hours. Food and secretion ejected from the esophagus are alkaline in reaction, and other chemic evidences are also present to show that they do not come from the stomach. Rupture of the esophagus is best considered in connection with dilatation of this tube. (See Esophageal Dilatation.) The patient complains chiefly of progressive weakness and loss of flesh, which in advanced cases is extreme. In persons suffering from stricture of moderate degree malnutrition does not occur. ^SOphagOSCOpy .^ — By means of this method it is possible to determine not only the location of the stricture, but also the actual caliber of the esoph- agus at the point of constriction. The condition of the esophageal wall im- mediately surrounding the stricture is also of importance in considering the treatment, since sclerotic changes might yield to the bougie, whereas in the presence of malignancy such procedure would be contraindicated. The degree of dilatation of the esophagus above the point of constriction is also of interest. (See Esophageal Diverticula.) Diagnosis and I/aboratory Diagnosis. — Regurgitation of food is the most positive sign of stricture of the esophagus, and in cases in which the constriction is located in the upper portion of the esophagus it occurs al- most immediately after eating. If the constriction is situated near the stomach, food is regurgitated in from one to four hours after it is taken. The more marked the degree of dilatation above the stricture, the later does the regurgitation of food occur. Solids and liquids regurgitated from the esopha- gus are alkaline in reaction, and show that they have not been acted upon by the gastric juice, but the changes effected by the mixture of saliva are in evidence. There is an absence of both free and combined hydrochloric acid. 416 THE ESOPHAGUS. Auscultation (see p. 411) is of value in diagnosing the stricture. The most conclusive evidence, however, of the existence of stricture is obtained by the introduction of the esophageal bougie. Diflferential Diagnosis. — Stricture of the esophagus, although ap- parently easily diagnosed, must be differentiated from spasm of the esoph- agus and obstruction the result of external pressure — e. g., from large bron- chial glands, thoracic aneurisms, mediastinal abscess, enlarged thyroid, and large pericardial effusion, in all of which conditions the bougie passes quite easUy into the stomach. In external pressure from glands, or an enlarged thyroid gland, chronic pleurisy with extensive adhesions, caries of the ver- tebrae with spiaal distortion, the bougie may be passed into the stomach, but its passage excites severe pain. If constriction of the gullet is due to neu- roses, the bougie's progress is suddenly arrested, but soon passes the ap- parent stricture without extra force. In neuroses the bougie in its transit meets with obstructions at different portions of the tube. The a;-ray may be of inestimable value in distinguishing between stricture and obstruction due to pressure from thoracic tumors and from bone disease. Caution. — An esophageal bougie should never be introduced when disease of the heart or of the blood-vessels (aneurism) is present, since such procedure is likely to be accompanied by disastrous results. Syphilis and traumatism to the esophagus favor the formation of stricture, and old age and a history of carcinoma likewise point to a similar condition in the wall of the tube. Gastric ulcer, typhoid fever, and dysentery may in- fluence slightly a diagnosis of stricture. DILATATION OF THE ESOPHAGUS. Definition. — A condition in which any portion of the entire esoph- ageal canal becomes expanded. General Consideration. — A variable amount of dilatation practi- cally always follows stricture of the esophagus, and these expansions vary in direct proportion to the degree of stenosis present. (See Stricture.) General dilatation of the esophagus without stricture is certainly a rare condition, and is distinguished from the localized form by the fact that the esophageal bougie passes directly into the stomach. The symptoms of dilatation of the esophagus are practically those of stenosis of the tube, except that pain is less common. SPASH OF THE ESOPHAGUS (Esophagismus). Predisposing and Exciting Factors. — Probably the best ex- amples of spasm of the esophagus are seen in hysteria, epilepsy, and hydro- phobia. In practically all cases the patient is of a neurotic temperament. Less often spasm may be reflex in nature, and secondary to disease of the stomach — e. g., gastric atrophy and dUatation. Spasm occurs occasionally in aged males, and only in those of nervous temperament. Principal Complaint. — Difficulty in swallowing is the only incon- venience from which the patient suffers. As a rule, he is able to take soHd foods except during the spasm, when they cannot pass through the esoph- agus. Pain is much less common and more mild than in true stricture of the esophagus. The patient first complains that he is choking, and this uncomfortable feeling continues untU the food has passed the point at which spasm occurs. In many persons of hysteric temperament a variable degree of choking is CARCINOMA OF THE ESOPHAGUS. 4J7 experienced irrespective of the ingestion of food, and such spasm may be induced by excitement. Diagnosis and DiflPerential Diagnosis.— The facts that hysteric temperament exists and that the attacks are intermittent are positive evidences of the nature of the condition. The freedom from pain and the characteristic vomiting also favor the existence of spasm. Spasm of the esophagus is differentiated from stricture by the fact that the bougie is usually grasped tightly within the esophagus at a given point, but if permitted to remain for a few seconds, it wUl pass the constriction without any special effort upon the part of the operator. Bsophagoscopy. — An esophagoscopic examination shows absence of disease of the organ. In one case studied at the Philadelphia Hospital it was possible, bygliding the bougie through to the esophagus, to excite spasm at different portions of the canal — a positive sign of neurosis. CARaNOHA OF THE ESOPHAGUS. _ Pathologic Definition. — A malignant growth usually developing primarily from the esophageal mucosa, and characterized later by the for- mation of stricture. Predisppsing and Bxciting Factors.— Age is a most prominent factor in carcinoma of the esophagus, the condition being extremely uncom- mon before the fortieth year. Males are more often afflicted than females. The prolonged use of alcohol is believed to exert some influence. An esoph- ageal ulcer forms a favorable site for the development of epithelioma. Principal Complaint. — ^The patient complains of dysphagia, which increases from time to time until it is practically impossible for him to take solid food. Simultaneously with the increasing dysphagia the patient com- plains of progressive emaciation and of weakness, with or without pain. He regurgitates portions of the food eaten, and such ejecta are often blood- stained, containing a large amount of mucus, and in rare instances shreds of diseased mucous membrane. The food is regurgitated either immediately after attempting to swallow or from ten to fifteen minutes later, the length of the interval varying with the location of the carcinoma. In atypical cases the dysphagia may be slight, or the symptoms may subside as the result of disintegration of the carcinomatous growth. Not uncommonly the patient displays other manifestations of carcinoma, e. g., involvement of the cervical glands. BsophagOSCOpy. — It is possible by this method to recognize malig- nancy of the esophageal wall at an unusually early date, and before there are extensive changes in that portion of the esophagus above the lesion. In carcinoma of the esophagus of long standing the employment of the esoph- agoscope is attended with a certain degree of danger, since in these cases ex- tensive ulceration is likely to be present. (See Gastroscopy; also X-Ray Diagnosis, p. 408.) I^aboratory Diagnosis. — ^The ejected material is acid in reaction until stenosis develops, when it becomes alkaline. Lactic acid may be pres- ent, but hydrochloric acid is absent. Mucus is always present. Red and white blood-cells, epithelial cells, yeast-cells, fat-globules, starch-granules, particles of food, and shreds of necrotic tissue are among the microscopic findings. Summary of Diagnosis. — Mediastinal tumors may give rise to symptoms that closely simulate those caused by carcinoma of the esoph- agus, but the degree of emaciation and the anemia are less marked than in 27 418 THE STOMACH AND INTESTINES. carcinoma. The introduction of a stomach-tube may facihtate the making of a diagnosis, since shreds of mucus and particles of carcinomatous tissue may be dislodged by the tube and recovered in the fluid thus obtained. There is always great danger of perforation when either the stomach-tube or the bougie is introduced into the esophagus. Course. — The patient's general condition grows progressively worse, and complications, e. g., bronchopneumonia, pulmonary gangrene, esoph- ageal perforation, and hemorrhage, are likely to occur. The disease is fatal, the majority of cases terminating in from three to twelve months after the first manifestation of symptoms. THE STOMACH AND INTESTINES. EXAMINATION OF THE ABDOMEN. TOPOGRAPHY. Ballance divides the abdomen arbitrarily into regions. He bounds the entire abdomen with a circle, the center of which is the umbilicus. (See Fig. 160.) We have found that this division of the abdomen requires slight Right superior quadrant Right inferior quadrant Fig. IGO. — Arbitrary Regional Division of the Abdomen. rnodification, necessitated by reason of the difference in stature of the in- dividuals examined. Thus in conducting our examinations we make the vertical diameter of the circle extend from the tip of the ensiform cartilage to the pubic articulation (Fig. 160), and the horizontal diameter extend to TOPOGRAPHY. 419 the margins of the abdominal wall, at a point approximately midway between the ensiform cartilage and the top of the pubic arch. This arbitrary outline, in the average individual, will be found nearly to transcribe the circle, whereas in a tall person the vertical diameter will exceed that of the transverse, and, again, in the obese, the transverse diameter will be found to far exceed that of the vertical. In those displaying an abnormal amount of abdominal fat the umljilicus may be found some distance below its normal location, and in such cases our transverse arbitrary division must be taken at a point near the center of the vertical line extending from the ensiform cartilage to the pubic articulation. This circular outline of the abdomen is divided by a transverse and a vertical line into four regions (Fig. 160) : Those above the level of the um- bilicus we speak of as the superior right and superior left quadrant respec- FiG. 161. — Arbitrary Division of Abdomen AXD Mammary Region. Fig. 162 -Special Arbitrary Division of the Abdomen. tively; and of those below the umbilical level as the inferior right and in- ferior left quadrant respectively. It is often necessary to refer to a viscus or tumor as occupying one of these regions, and to qualify this statement Ijy referring to other anatomic landmarks of the abdomen. The advantage of this arbitrary division is further exemplified by sup- posing that a tumor exists in the left inferior quadrant, and that the center of this tumor is three inches from the junction of the transverse with the vertical line at the umbilicus, and one inch below the line drawn between the umbilicus and the left anterior superior spine (Fig. ]fi4). The size may now be readily determined by taking measurements from the center of the tumor. Viscera that are bisected l)y either the transverse or the vertical lines are referred to in a description of them as Ijeing situated in either the median or the vertical line, as, e. g., the bladder. Viscera and tumors are also spoken of as occupying a position a definite number of inches above or below the transverse line or to the right or left of the median line, and a certain num- 420 THE STOMACH AND INTESTINES. ber of inches from the pubis, the ensiform cartilage, or the umbihcus (Figs. 160, 161, 164). Thus, in the case of a growth situated in the right inferior quadrant, this portion of the circle is further divided by a line extending from its center to the right anterior superior spine of the ilium. Again, when locating a tumor or an area of tenderness or of pain in the superior right or left quad- rants, these may be subdivided Ijy a line extending from their center to any bony structure present in this region, c. g., ascertain the co.stochondral articulation, and the exact location of the growth or area of tenderness or resistance may he marked upon this line sul^di^'i^ling the quadrant. It may be that the point in question is a definite distance to one or the other side of Bifurcation of aorta 163. — Landm.^rks of the Abdomen. this subdividing line. Of further diagnostic ser\-ice is it to employ a corre- sponding arbitrary division of the back, deserving the divisions of the abdomen, the normal position of the umbilicus and the fixed bony struc- tures located at or near the periphery of the circle are employed to desig- nate the exact location of a given al)dominal tumor or area of tenderness (Fig. 163). Within the superior right quadrant are t-\^-o layers of organs, a superficial and a deep layer. In the superficial or anterior group are the right lobe of the liver, the gall-bladder, the hepatic flexure and portions of the ascending and the transverse colon, the head of the pancreas, and the pyloric end of the stomach. The deep or retroperitoneal layer contains the greater portion of the right kidney and the suprarenal body. The inferior right quadrant contains a portion of the ascending colon, cecum, vermiform appendix, right ovar}-, right Fallopian tube, and a portion of the uterus and of the Ijladder. At the margin of the arbitrary circular DATA OBTAINED BY QUESTIONING THE PATIENT. 421 boundary is the right inguinal ring. Upon deep inspiration the right kidney IS forced do-noi for about half its length. Withm the superior left quadrant will be found, in the superficial layer, the left lobe of the liver, the spleen, the greater portion of the stomach^ the splenic flexure of the colon, a portion of the transverse colon, the descenduig colon, and the tail and about two-thirds of the body of the pancreas. The deeper layer contains the upper portion of the left kidney, the pelvis of the kidney, and the suprarenal body. In the inferior left quadrant are the left ovary, the left Fallopian tube, a portion of the uterus and of the bladder, the descending colon, and the sigmoid flexure. According to Holden, the left kidney is situated within the left inferior quadrant only upon deep inspiration. Along the bony margin we find the left iaguinal ring. The position of the small intestines is so vari- able that they may be found occupying portions of each arbitrarj^ division of the abdomen. Transverse abdomi- DATA OBTAINED BY -'^'-"^bii.caU QUESTIONING THE PATIENT. This particular class of Radius drawn to lo- SymptOmS wiU be COnsid- 'lerness'^^'^'''' °' ne^~- ered fully under the gen- growths', pains, etc. I eral complaint for each abdominal malady. In- \1mltte?i"^1 quiry should be made as to whether or not the pa- ^^^ 164.-Lr.FT Abdominal Hemisphere. tient suffers from local or general sensations of full- ness, heat, burning, and pain. The local sensation of weight or of an ab- normal degree of fullness in the abdomen is always suggestive of tumor, enlargement of organs, or displacement of a viscus. The sensation of heat, or of a more or less constant burning, with or without pain, is usually associated with the presence of inflammatory affec- tions of the abdomen, e. g., carcinoma, pj'osalpinx. Character of Pain. — Pain may be either localized or general, duh or lancinating, continuous or intermittent. Abdominal pain may begin suddenly, being extremely severe from the start, this being best exemplified by the pain of renal and of hepatic colic; or it may begin with slight sensations of discomfort, nausea, or faintness, and progress steadily until a severe type of pain is experienced — e. g., uterine eolic, inte.stinal colic (lead colic). The sudden development of acute pain points toward inflammation or perforation of some hollow abdominal viscus, although it is often a symptom 422 THE STOMACH AND INTESTINES. of flatulent distention of the abdomen, intestinal obstruction, enteralgia, gastralgia, and all types of colic. Sudden pain developing dunngthe course of gastric ulcer, typhoid fever, and allied gastro-mtestmal conditions points strongly toward intestinal perforation. Chronic pam is indicative of peri- toneal adhesions or of a somewhat acute or chronic inflammatory process. Abdominal pain, chronic in character, is seen to occur in mtestmal neuroses, general neurasthenia, hysteria, insanity, locomotor ataxia, and lead- poisoning. 1 u^ ■ 1 Localized pain is a symptom of gastric ulcer, pyosalpmx, and abdominal affections m which a va- riable degree of localized peritonitis is present. The abdominal pain may be general in diffuse peritonitis, intestinal colic, and rheumatism of the abdominal muscles and fascia, the last-named condition ofttimes caus- ing intense suffering, the muscles being tender and hypersensitive to move- ment, as e. g., in laughing, coughing, and the like. A dull, boring pain is associated with the pres- ence of a large stone in the renal pelvis, carcino- ma of the retroperitoneal glands, and carcinoma of the abdominal organs. Dull pain is seldom re- flected from the seat of its greatest intensity. Lancinating pain is continuous in general peritonitis and in inflam- matory conditions in which the peritoneum shows decided involvement; it is also a symptom of carcinoma involving any of the abdominal organs. The neuralgia and pain ofttimes associated with herpes zoster will be found to follow the distribution of certain spinal nerves. Neuralgic pains are to be distinguished from other forms of abdominal pain by the well- marked areas of tenderness, and by the fact that symptoms of neuritis may be associated. Again, pain may result from affections of the skin and abdominal wall, e. g., traumatism, abscesses, and ulceration. Pain situated in the abdominal wall may be dependent upon disease of its bony structures, as the ribs, ver- tebra, or pelvis. Pain referable to disease of the vertebrae is usually limited to the median line, is intermittent in character, and oftenest described at a definite point between the ensiform cartilage and the umbilicus. We have seen several cases, both in private and in hospital practice, in which this particular type of abdominal pain was excited by pressure of an abdominal aneurism. Fig. 165. — Right Abdominal Hemisphere. INSPECTION OF THE ABDOMEN. 423 Special attention should be called to abdominal pain when present in children. We have considered such pains in the order of their frequency of occurrence : (a) Dysperistalsis of the intestine, including enterospasm, usually excited by irritation. Obstruction or nervous incoordination is by far the commonest cause of abdominal pain in children under one year of age. (&) Disturbance with the motor function of the stomach, together wit'h pyloric spasm, cardiac spasm, and hour-glass contraction are not infre- quent causes of abdominal pain during early life. (c) Spasm of the sphincter of the bladder. (d) Acute catarrhal dysentery. (e) Reflex or referred abdominal pain is rather common in children, and may result from disease of the pleura, pericardium, and lung. (/) Spinal caries. (g) Renal cohc. (h) Appendicitis and peritonitis. INSPECTION OF THE ABDOMEN. One of the most important points to be remembered in making an inspec- tion of the abdomen is that diseases involving extra-abdominal organs, e. g., valvular heart disease, may exhibit among their symptoms an abnormal distention of the abdomen. In such conditions the distention is due to ascites. The reverse condition, i. e., abdominal contraction, is a symptom of meningitis and of systemic poisoning, as seen in lead-workers. Any distention of the abdomen is always suggestive either of unequal muscular development or of disease; in the latter case the form of distention points somewhat directly to the viscus affected. The condition of the skin, whether it be smooth or rough, dry or moist, and the degree of dilatation of the superficial veins should all be taken into consideration in formula- tiag a diagnosis of ab- dominal affections. The superficial veins of the abdomen are dilated to- gether with the general di- latation of the veins of the lower extremities, or such distention may de- pend upon some obstruc- tion to the deeper venous blood in the pelvis or thorax — e. g., organic heart disease, cirrhosis of the liver, adhesive py- elophlebitis, pressure upon the vena cava exerted by tumors of the abdomen or of the thorax. As a rule, the veins are found to be prominent in ascites and in most condi- Midclavicular line Fig. 166. — Arbitrary Division of the Abdomen, Showing Kelatiox of Transverse Colon. 424 THE STOMACH AND INTESTINES. tions causing abdominal distention, regardless of whether or not there has been a decided atrophy of the abdominal wall. A knowledge of the thicloiess of the abdominal wall is also of decided clinical importance. A thin abtlominal waW depends, for the most part, upon an absence of adipose and muscular tissue, and in any given case this may have gone so far as to be due in part to atrophy of the muscular structure. The cause of muscular atrophy should be ascertained, and will be found, in the vast majority of instances, either to depend upon intra-abdominal pres- sure or to be associatetl with nutritional affections in which there is pro- nounced emaciation — c. g., diabetes, tabes dorsalis, paretic dementia. In the first class of cases should be placed frequent pregnancies, large ovarian tumors, and repeated attacks of ascites, all of which conditions tend to produce a variable degree of atrophy of the abdominal muscles, tuberculosis, Umbilical pain. Gastric can- cer where the stomach is prolapsed, extensive gastric ulceration, gastric dilata- tion, intestinal carcinoma, carcinoma of retroperi- toneal glands, cancer of peritoneum, tuberculous peritonitis, prolapse of the transverse colon. Area of localized pain and tenderness in ap- pendicitis. Pubic area. Pain due to dig- ease of the ovarj', uterus, pelvic congestion, acute cystitis, chronic cystitis, cystic calculi, ectopic ges- tation, se.xual excess, and rarely to pyelitis. Pregnancy, uterine disease, dysmenoi;rhea, tumor of the ovaries, psoas abscess, crural neuralgia, appendi- citis (pain raviiating to right leg), rarely due to impac- tion of the colon and rectum and to renal calculi. Fig. 167. — Areas or Pain. and gastro-mtestinal catarrh of long standing. When the abdominal wall is thin, the superficial veins are perceptible and may be abnormal. Further, abdominal distention may result in a separation of the rectus muscles, with hernia-like protrusions between. In several cases seen by us such hernias have followed the exciting contlitions previously named; in one case, that of an Italian treated in the wards of the Philadelphia Hospital, there was pronounced alidominal hernia, the result of enlargement of the liver and of the spleen following malarial infection. Great importance attaches itself to the presence or absence of these hernial projections, and particularly is this true in considering the question of aspiration of the peritoneum. Hernia may be most confusing, as when it appears in portions of the abdomen not commonly affected. A thick abdominal wall may tlepend, in part, upon extraordinary nnis- cular development, upon an unusually heavy deposit of fat, or, lastly, upon edema. In health the abdominal tliiclmess is due to muscular development, the position of the umbilicus remaining unchanged. Excessive abdominal INSPECTION OF THE ABDOMEN. 425 fat causes decided folds in the abdomen below the umbilicus, and the um- bilical depression will be found below its normal position. The skin has a somewhat dull appearance, and there are likely to be numerous strise, but the superficial veins are not prominent. Occasionally, there is an extraordinary dilatation of the veins in the region of the umbilicus, and this mass of dilated veins is referred to as the "caput medusae." Movements of the Abdomen. — ^Under normal conditions the ab- dominal movements may depend upon respiration, vascular pulsation, gas- tric movement, intestinal movements (peristalsis), fetal movements, and the changes of position of floating viscera or tumors coincidentally with the change of the patient's position. Abdominal movement or the abdominal tj^je of breathing is increased by organic disease of the lungs, a large quantity of fluid in one or other pleural cavity, mediastinal tumor, thoracic aneurism, and in conditions that materially inhibit a lateral expansion of the lungs, as, e. g., pleural adhesions and emphysema. Under normal conditions the upper half of the abdomen rises and falls synchronously with inspiration and expiration. The respiratory expansion is diminished by the presence of a large quantity of fluid in the peritoneal sac, tuberculosis of the peritoneum, general or local peritonitis, peritoneal adhesions the result either of disease or of operative interference with the abdominal viscera, and by abdominal tumor. Conditions that interfere with the descent of the diaphragm also lessen the abdominal expansion — e. g., ascites, tumors occupying the upper portion of the abdomen, and enlarge- ment of the liver and of the spleen. In paralysis of the diaphragm a reverse phenomenon occurs with the respiratory movements — e. g., the size of the abdomen diminishes with in- spiration, whereas a feeble degree of expansion takes place during expira- tion. A peculiar respiratory movement of the abdomen is also observed in the presence of obstruction to the larynx and upper respiratory tract, re- sembling somewhat closely that seen in paralysis of the diaphragm. If there is enlargement of either the liver or the spleen, the enlarged organ will be seen to rise and fall synchronously with respiration, and the move- ment of such viscus is usually referred to as "the shadow." Movements of the abdomen are of great value in making a diagnosis of tumors either of the liver or the spleen, since tumors that are not attached to either of these organs are but little, if at all, influenced by respiration. Exceptions to this general rule, however, occur — e. g., when a tumor of the right kidney is seen to fall and rise sjmchronously with respiration, a phenomenon readily explained by the fact that in such cases the kidney is permanently adherent to the liver. Vascular Movements. — Abdominal movement due to vascular pulsa- tion is usually observed in the median line, the exception being in the case of pulsation of the liver, a feature sometimes seen to accompany tricupsid regurgitation. In subjects in whom the abdominal wall is thin, pulsation of the aorta is perceptible; and either locahzed or diffuse pulsation is to be seen when there is aneurism of the abdominal aorta or of one of its branches. Decided pulsation near the umbilicus is suggestive of aneurism of the cehac axis. Tumors of moderate size overlying the aorta may give rise to movement of the abdominal wall, such movements being synchronous with the impulse of the artery. Epigastric pulsation in the median line or slightly to the left may be the result of a dilated right ventricle. (See Cardiac Dilatation, p. 300.) 426 THE STOMACH AND INTESTINES. Gastric Movements.— The movements of both the stomach and the intestines may be seen through the abdominal wall, and are especially marked when there is a high grade of peristalsis. The peristaltic movements are increased in dilatation of the stomach and gastroptosis, in which conditions they appear in somewhat rhythmic succession, and usually extend from left to right. (See p. 440.) Movements of the large intestine wUl be seen_ to follow the course of the colon, and may appear on either side or in the median line, at the top of the abdomen. In coloptosis the movement of the colon may be in the median line, on a level with or below the umbilicus. All movements of the intestines, and even those of the stomach, may be increased by any condition in which obstructive lesions of the lumen of the bowel exist. In complete intestinal obstruction a reverse peristaltic wave is commonly visible, becoming more and more evident until there is re- gurgitation of the contents of the bowel into the stomach, with vomiting of fecal material. Movement of the small intestines may be greatly increased after the ingestion of certain foods — e. g., unripe fruit — and such drugs as jalap, elaterium, sodium phosphate, and magnesium. Contour of Abdomen. — The general contour of the normal abdomen is familiar to every physician, but in order to obtain the valuable knowledge to be gained by inspection, it is necessary for him to get a front, lateral, and three-quarter view of this portion of the body. When there is general enlargement of the abdomen, the increase is nearly symmetric. Uniform enlargement results from ascites, provided the abdom- inal wall is thick and muscular; but if the abdominal wall is relaxed, the contour may be more or less pear-shaped when the patient is standing, and again flattened along the lateral boundaries when the recumbent posture is assumed. The abdomen is pendulous when the enlargement is dependent upon fat deposited in the abdominal wall. Localized enlargement of the abdomen causes the surface to be irregular at some given point, and will be further discussed in conjunction with dis- eases of the abdominal viscera. The abdomen may be uniformly distended in hysteria, and a prominence of the lower portion of the abdomen may be dependent upon retention of the urine. A retracted or scaphoid abdomen is seen during the course of chronic maladies, such as lead-poisoning (Fig. 221), carcinoma, tuberculosis, and diabetes. In these maladies the abdominal wall is found to be very thin, and consequently an undue prominence of the viscera, particularly of the Hver, may produce local enlargement. The size of the abdomen will be found to vary greatly in different persons, this variation depending not only upon the thickness of the abdominal muscles or the deposit of fat in the abdominal wall, but also upon the amount of fat deposited in the omentum, and upon the caliber of both the smaU and the large intestines. The caliber of the small intestine is greatly increased in persons who eat heavily and whose habits are sedentary. Prominence of the abdomen due to the deposit of fat or to enlargement of the intestine is to be distinguished from the enlargement accompanying true obesity, since in the latter condi- tion there is a general deposit of fat throughout the subcutaneous tissues. Abdominal prominence due to new-growths, ascites, pregnancy, and cysts is easily distinguished from the foregoing tjrpes of enlargement, since in the former conditions there are likely to be evidences of a variable degree of emaciation. Causes for general and local enlargement of the abdomen are divided for CHARACTER OF EVIDENCE TO BE OBTAINED BY INQUIRY. 427 clinical study into the following: General enlargement, local enlargement, enlargements due to oversize of solid viscera; to distention of hollow viscera; to fluid; to cystic and solid tumors; to physiologic causes, and to abnor- malities (tumors and overgrowths) in the abdominal wall. General Enlargement. Distention of the bowel and stomach by Ascites (serous), gaS) . Ascites hemorrhagic or chylous, Distention of hollow viscera following Obesity, surgical operation. Adiposis dolorosa. Intestinal obstruction. Local Swelling (Upper Half). Cancer of liver. Leukemic liver, Sarcoma of liver. Malarial hver. Cyanotic liver. Enlargement of spleen, Fatty liver, Aneurysm of abdominal aorta, Amyloid liver, H3T)ertrophic cirrhosis. Local Swelling (Lower Half). Perinephritic abscess, Ovarian cyst, Sarcoma of kidney. Ectopic gestation. Hydronephrosis, MaUgnancy, Pregnancy, Distention of bladder, Uterine fibroid. Enormous dilatation of stomach, Displacement of stomach and intestine. Dilatation of bladder. Abdominal Wall. Phantom tumor, Nodules in adiposis dolorosa. EXAMINATION OF THE STOMACH. General Remarks. — ^The stomach is an expanded portion of the ali- mentary canal, the food being retained in this expansion partly for the pur- pose of effecting solution, and partly in order to become thoroughly saturated by the secretions of the mouth and of the stomach. The stomach-wall is made up of three coats — an interior or mucous coat, a middle or muscular layer, and an external or peritoneal coat. When one or more of these coats become diseased, definite symptoms arise; in many types of gastric dis- order all the coats of the stomach may be involved. It must be remembered that the mucous and muscular coats of the stom- ach-wall are richly supplied with blood-vessels, and that erosion or conges- tion of the wall is likely to be followed by an extravasation of blood into the cavity of the stomach. The stomach-wall is also abundantly supplied with nerves, and its relation to the pneumogastric nerve, as well as to numerous sympathetic plexuses, may give rise to certain symptoms. Disease of remotely situated organs may display, as the most prominent symptoms, those manifestations also referable to disease of the stomach. CHARACTER OF EVIDENCE TO BE OBTAINED BY INQUIRY. Family History. — Heredity is seldom an important factor in diseases of the stomach, except in two conditions, e. g., gastric neuroses and gastric carcinoma. 428 THE STOMACH AND INTESTINES. Social History.— In but few diseases is special inquirjr into the social condition of the patient of such vital clinical importance as in gastric affec- tions. Many stomach disorders have their origia in neurasthenia, or in the various forms of dissipation and overwork, e. g., overeating, improper masti- cation, insufficient exercise, excessive mental strain, overwork, and the abuse of alcohol. They may also arise as the result of the improper functioning of some other organ, as, for example, the liver, pancreas, intestines, kidneys^ heart. (a) The time consumed for the ingestion of a meal andthe character of the food eaten are matters of special importance. Overeating, and particu- larly the ingestion of rich and highly seasoned foods, is one of the commonest causes of gastric disorders. Too frequent eating and the habit of taking food between meals are highly detrimental, since the stomach is not permitted to get sufficient rest. Thorough mastication is also important. Unless the food is well mixed with the saliva, starch digestion is materially impaired. Again, the taking of alcoholic stimulants and the excessive use of narcotics and tobacco tend to inhibit digestion. (6) Exercise and Occupation. — Persons of sedentary habits are es- pecially prone to develop gastro-intestinal disorders; for this reason the amount of exercise taken daily must be carefully ascertained in order to determine the nature of the disease present. Occupations that do not allow sufficient outdoor exercise to be taken, or that necessitate frequent or continuous exposure to such toxic substances as lead, arsenic, mercury, and gases, constitute a common cause of gastric disorders. A history of the ingestion of corrosive substances also points stron^y toward gastritis. Occupation is of further importance to the clini- cian, since cooks, clerks, seamstresses, tailors, shoemakers, and carpenters are particularly subject to gastric catarrh and to gastric ulcer. (c) Mental Strain and Overwork. — Overwork, either mental or physi- cal, interferes with the proper functioning of the stomach; thus the practice of doing heavy work immediately or within an hour after taking a full meal lessens the activity of the gastric glands and consequently diminishes the gastric secretion. Those who do not rest after the ingestion of a full meal sooner or later develop gastric inactivity. (d) Local affections, either intra-abdominal or extra-abdominal, may occur either as a complication of or as a sequel to, disease of the stomach. Impairment of hepatic function of whatever nature gives rise to the devel- opment of a variable degree of indigestion. Pathologic changes in the liver that interfere with the return circulation from the stomach are fre- quent, and are best exempHfied by atrophic hepatic cirrhosis, with ascites. Pancreatic disease may manifest gastric insufficiency as one of its symp- toms, and nephritis and diseases of the intestine may also give rise to the symptoms of indigestion. Organic heart disease, when sufficiently pro- nounced, is a cause of venous stasis of the gastric mucous membrane, which interferes with gastric secretion. (e) Age. — Early adult life — fourteen to thirty years — predisposes to the development of gastric disorders, but such predisposition is probably due to lack of care both as to the character of the food ingested and the regu- larity with which such foods are taken. In women gastric maladies are common at the menopause. (/) Sex exercises but slight influence on diseases of the stomach. (g) Previous Diseases. — Gastric disease may follow certain of the in- fectious conditions, when it is a direct result either of the preceding infection LEADING FEATURES AND THEIR SIGNIFICANCE. 429 or of imperfect innervation. Any prolonged illness, whether acute or chronic, that materially impoverishes the system predisposes to the development of gastric disease. Qi) _ Finally, any abdominal growth that causes pressure upon the sym- pathetic nerve-supply of the abdomen may provoke the symptoms of gastric disease. Relaxation of the muscles of the abdominal wall, by per- mitting displacement of the stomach or of other abdominal viscera, is often followed by symptoms of gastritis; therefore a history of the previous existence of ascites, abdominal tumor, and repeated pregnancies is of great importance to the clinician. LEADING FEATURES AND THEIR SIGNIFICANCE. Disordered Appetite.— (i) Anorexia.— De/imiion.— The appetite is impaired, or there may be no desire whatever for food. Anorexia is an early symptom in nearly all infections, and also occurs during the course of many chronic afebrile and febrile maladies. In disease of the stomach, however, the presence or absence of anorexia is of great im- portance in formulating a diagnosis. Loss of appetite may be present in organic disease of the stomach, and more particularly in carcinoma, and is not infrequent in gastric neuroses with gastric hyperesthesia. When the appetite is greatly impaired for prolonged periods, food is often repugnant, and the patient may go for days or even weeks without sufScient food to provide for the general bodily nutrition, and, as a consequence, the symp- toms of malnutrition develop. Prominent among the causes of anorexia are: Excessive mental strain, mental shock, anxiety, imperfectly prepared foods, and starvation. The use of such drugs as digitalis, strophanthus, the salicylates, opium, the iodids, etc., may be followed by anorexia. (2) Bulimia, also known as Hyperorexia. — Definition. — A symptom characterized by an excessive appetite for practically all kinds of food. Bulimia is nearly always pathologic in origin, although some persons who are apparently healthy consume extraordinary amounts of food both at and between meals. During convalescence from typhoid fever and other prolonged febrile conditions the appetite is, as a rule, excessive. In diabetes meUitus one of the earliest symptoms is overeating, and this usually persists until late in the course of the disease. Bulimia is an occasional symptom in neuroses of the stomach, neurasthenia, and hysteria, and in these conditions epigastric distress and even pain are alleviated by the taking of large amounts of food. A child whose intestinal tract is infested by lumbricoid worms often develops this symptom. An abnormal appetite may develop after hemiplegia, monoplegia, epileptic seizures, or during the course of meningitis, migraine, ataxia, Huntingdon's chorea and other nervous conditions, and in certain types of insanity. In a case of carcinoma of the retroperitoneal glands, recently seen, this peculiar type of appetite persisted for several months. (3) Polyphagia is a condition in which the feeling of satisfaction after a meal is so delayed that there is a constant desire for more food. (4) Parorexia or Perverted Appetite. — (a) Malacia is a condition in which there is a desire for highly spiced and acid foods, e. g., pickles, salads, mustard, pepper, and the like. This symptom is present in neurasthenia, chronic gastritis, intestinal putrefaction, chlorosis, and the secondary ane- mias of young women. 430 THE STOMACH AND INTESTINES. (6) Pica is an abnormal craving for substances other than natural food, such as dirt, crayon, the wood from pencils, blades of grass, straw, and the like. The condition is suggestive of neurasthenia and hysteria, and is seen in children infected with intestinal parasites, and in girls at or near the time of puberty. It is also encountered in chronic gastritis and in anemic in- dividuals. (c) Allotriophagia is a desire for disgusting substances, such as urine and feces; it has been seen in insane persons. Thirst. — An excessive thirst may result from a variety of conditions, many of which are not connected with the stomach. Physiologic thirst develops as a result of free perspiration, and is intensi- fied by the taking of drugs that induce purging, e. g., aloin, elaterium, and magnesia. Pathologic thirst is one of the cardinal symptoms of diabetes mellitus, and follows either acute or chronic conditions in which there are excessive evaporation and combustion, such as t}T)hoid fever and scarlet fever. Thirst also occurs in any condition that causes rapid removal of a large quantity of the liquid elements of the blood, e. g., a hot bath, hemorrhage, diarrhea, dysentery, and vomiting. Thirst is a prominent feature of acute gastritis, and the desire for liquids is increased during the course of chronic gastritis, this symptom becoming markedly intensified whenever an exacerbation of the latter disease occurs. The ingestion of certain substances increases the desire for liquids, e. g., alcohol and alcohoHc substances and highly seasoned foods, particularly salt meats and fish. Taste. — In diseases of the stomach, particularly in acute and chronic gastric catarrh, the taste is abnormal (offensive). An offensive taste is a prominent symptom of the form of acute gastritis known as biliousness. The taste is perverted, dull, or absent during the f astigium of typhoid fever, at the height of acute gastritis, and during acute exacerbations of chronic intestinal catarrh. In practically all febrile conditions in which the tongue is coated the sense of taste is markedly impaired, and the patient desires only highly spiced and acid foods. Chronic diseases of the tonsils, pharynx, esophagus, and posterior nares are usually accompanied by an unpleasant taste upon rising in the morning, although in some instances it may be present throughout the day. In dilata- tion of the esophagus, gastrectasis, pulmonary abscess, pulmonary gangrene, and abscess of the liver that has ruptured into the lung the taste is somewhat sweet, and more pronounced after coughing, vomituig, and clearing the throat. A highly acid taste is suggestive of hyperacidity of the stomach, and is frequently seen in gastric ulcer, and in conditions dependent upon an excess of free hydrochloric acid. In dilatation of the stomach with atrophic gas- tritis and in carcinoma an acid taste is extremely common, and is usually dependent upon increased acidity, due to an excess of lactic and of butyric acid. An alkaline taste is occasionally described by hysteric individuals. Lastly, taste may be modified or absent as a result of disease of the nerves of special sense, particularly those of taste and of smell. Whenever the sense of smell is absent, the taste is greatly modified, and, as a rule, much less acute than in health. Pyrosis and Regurgitation. — Definition. — The eructation of either Hquids or gases, which cause a burning sensation in the esophagus, throatj and mouth. These symptoms are generally associated with some LEADING FEATURES AND THEIR SIGNIFICANCE. 431 pathologic condition of the stomach. There may be eructation of gas, liquids, and particles of undigested food, the condition then being known as pyrosis with regurgitation. There are exceptional instances in which the fluid that rises to the mouth is alkaline in reaction and comparatively taste- less. Pyrosis must be distinguished from vomiting; in the former the fluid is ejected without any effort upon the part of the patient, and without either gastric discomfort or pain. The fluid brought up, when alkaline, may consist of saliva that has accumulated in some sacculation or expanded portion of the esophagus. Saliva when ejected possesses the power of digesting starches. Alkaline fluids are regurgitated during or immediately after the inges- tion of food, whereas acid liquids are more likely to be ejected one or more hours after food has been taken. Pyrosis is a symptom of overeating, acute gastritis, alcoholic gastritis, chronic gastritis with fermentation, gastric ulcer, and other conditions in which there is hyperchlorhydria or hyperacidity of the gastric contents from whatever cause. The regurgitation of foods from the stomach may be accompanied by a burning sensation and the eructation of a variable amount of gas or liquid. At certain times gastric fluid alone is regurgitated, whereas at others large quantities of food are brought up. When the patient chews the regurgitated food and swallows it again, the condition is termed rumination; this is a symptom of neurasthenia, hysteria, and insanity. Hiccough. — Definition. — A peculiar clicking sound that follows spasm of the diaphragm and the rushing of air through the glottis. Hiccough persisting for prolonged periods is of unfavorable prognostic significance. It occurs as the result of overeating, the ingestion of too highly seasoned foods, alcoholic beverages, and unripe or decomposing fruits and vegetables. When it occurs after the ingestion of a full meal, it seldom lasts more than a few minutes. Hiccough is frequently an expression of exhaustion or severe toxemia with marked nervous atony, e. g., uremia and intestinal putrefaction. It is an unfavorable symptom in either local or general acute peritonitis. jL^W-WLy^ Fia. 168. — Tracing of Respiratory Movements in a Case of Hiccough. Hiccough may be an annoying symptom during the course of any variety of nephritis, erysipelas, brain tumor, and myocarditis. Occasionally it accompanies Cheyne-Stokes respiration. (See p. 51.) Nausea usually precedes vomiting, although in many persons vomiting is apparently impossible, whereas nausea may be a most annoying symptom. Nausea is a feature of many extragastric conditions, but it may follow the taking of certain foods or irritating substances. The odor of a certain food or liquid often excites nausea, and many persons are nauseated at the mere sight of certain forms of food. Hyperacidity of the stomach-contents is a frequent cause of nausea, as are also disease of the esophagus, chronic pharjoi- gitis, and chronic postnasal catarrh. Nausea may follow the accumulation of toxins within the stomach, and 4S2 THE STOMACH AND INTESTINES. not infrequently occurs after traumatism to the head, at the sight of blood, or on witnessing an accident. It is a common symptom of chronic intersti- tial nephritis, general arterial sclerosis, organic heart disease with tricuspid regurgitation in which there is an associated venous stasis of the gastric mucosa. Nausea is occasionally seen in cirrhosis of the liver, obstructive jaundice, and chronic enterocolitis. Abdominal or thoracic tumors pressing upon the sympathetic nervous system, e. g., ovarian cysts, abdominal aneu- risms, and uterine fibroids, may excite nausea and vomiting. Whenever the cause of nausea is in doubt, an examination of the external auditory canal should be made, since pressure upon the membrana tympani may give rise to this symptom. Eye-strain, due to defects either in the cornea or in the deeper structures of the eye, may also induce temporary attacks of nausea. Vomiting is a phenomenon due to a coincident, spontaneous contraction of the abdominal muscles and diaphragm, together with a relaxation of the muscles at the cardiac end of the stomach. Spasm of the muscles at the car- diac portion of the stomach serves to explain why many persons are unable to vomit even when there is violent retching, due to contraction of both the diaphragm and the abdominal muscles. The center for vomiting is said by physiologists to be located in the medulla oblongata, contiguous to that for respiration. Nerves from practically all parts of the body, and particularly from the liver, intestine, kidneys, lungs, esophagus, uterus, and bladder, and from the special sense centers, convey impressions to the center for vomiting, and this fact serves to explain why vomiting is so often reflex in character. The vomiting of acute infections, e. g., scarlet fever or small-pox, may be dependent upon a specific irritant circulating through the vomiting center, or upon an associated congestion of some other portion of the body that has direct communication with that center. The latter explanation serves, in a measure, at least,' to explain the vomiting of uremia, auto-intoxication, and allied conditions. The question has arisen as to whether or not the vomiting of hysteria is central in origin. In attempting to determine the actual origin and significance of vomiting careful inquiry must be made into its nature, duration, time of development, the manner in which it began, what is believed to have precipitated the first attack, the quantity of vomitus ejected each time, the character of the ma- terial vomited, the condition of the bowels, and the patient's general health. Types of Vomiting. — (a) The vomiting of acute infections and inflam- mation of the stomach. (&) The vomiting of chronic conditions of the stomach: (1) Chronic gas- tritis. (2) Vomiting of gastric ulcer. (3) Vomiting of gastric carcinoma. (4) Vomiting of atrophic gastritis with dilatation. (c) Vomiting of acute infectious diseases. (d) Cerebral vomiting. (e) Reflex vomiting: (1) Cyclic vomiting. (2) Vomiting of peritonitis. (3) Vomiting of pulmonary tuberculosis. (4) Uremic vomiting. (a) The vomiting of acute gastritis is quite characteristic, since it develops after the free ingestion of indigestible foods and alcoholic liquors; the use of such drugs as opium, the bromids, the salicylates, the iodids, and toxic doses of arsenic and mercury. Nausea is a precursor of the vomiting of acute gastritis, and epigastric distress or pain is usually present. The patient is greatly weakened by the act of vomiting, and often, in addition to exhaustion, his skin becomes cold and covered with beads of LEADING FEATURES AND THEIR SIGNIFICANCE. 433 perspiration. The first vomitus contains particles of undigested food, and after the stomach has been reheved of this, the patient vomits only mucus, to which is added a large quantity of saliva. If the vomiting continues, the patient ejects a greenish-yellow material which owes its color to the admix- ture of bile. After repeated attacks of vomiting the vomitus is not infre- quently streaked with blood. _ The conditions known to cause vomiting of blood are: 1. Acute gas- tritis. 2. Gastric ulcer. 3. Gastric carcinoma. 4. Ulcer of the esophagus. 5. Carcinoma of the esophagus. 6. Varicosity of the esophageal veins. 7. Prolonged vomiting of doubtful cause. 8. Cirrhosis of the liver. 9. Organic heart disease with tricuspid regurgitation. 10. Introduction of corrosive substances into the stomach. 11. Tuberculosis of the stomach. 12. Profound anemias, either primary or secondary. 13. Vicarious menstruation. 14. Blood swallowed and coming from the mouth, throat, or upper air-passages. 15. Extensive cutaneous burns. (6) Vomiting in Chronic Conditions of the Stomach. — (1) ToBvomitus of chronic gastritis differs from that seen in acute inflammation of the stomach in appearance, chemic reaction, and effect upon the patient. "I have re- peatedly found the material vomited in chronic gastric catarrh to be acid in reaction, unless, as occasionally happens, the vomiting takes place several hours after eating, when it is sometimes faintly alkaline or neutral " (Anders). Vomiting does not cause extreme prostration in chronic gastric maladies, and even though marked emaciation is present, it is unsafe to conclude that gastric carcinoma exists without making a chemic analysis of the stomach- contents. If the vomitus of chronic gastritis should display an abnormally high total acidity, special quantitative tests should be made to ascertain the amount of free hydrochloric and lactic acid present. Acid salts, lactic acid, and butyric acid may be in excess, and the amount of hydrochloric acid may be greatly below that of the normal. (See Tests for Gastric Contents, p. 464.) The characteristic vomitus of the different types of chronic gas- tritis will be further considered together with a description of this affection. (2) Vomitus of Gastric Ulcer. — -Vomiting is one of the most constant symptoms of gastric ulcer, and occurs either immediately after or within from one-half to one and one-half hours after the taking of food. It is always preceded by acute pain, which subsides as the vomiting ceases. In ulcer the vomitus contains particles of the food previously ingested, and in approximately 30 per cent, of all cases blood is present. If careful analyses of the vomitus for the presence of blood are repeatedly made, the evidences of minute hemorrhages will probably be found. The so-called characteristic features of the vomitus of ulcer are an excess of free hydrochloric acid and the presence of blood. In contradis- tinction to the vomitus of chronic gastritis, in which the total acidity may also be above the normal, the vomitus of ulcer rarely, if ever, contains lactic and butyric acids in appreciable amounts. (3) Vomiting of Carcinoma. — Gastric carcinoma is almost always accom- panied by vomiting, although it may not occur until the carcinomatous process has attacked the gastric wall; as a rule, however, vomiting takes place early, and continues until a fatal termination occurs. The location of the carcinoma and the degree of ulceration or of sclerosis of the gastric wall materially influence the time of its occurrence and the character of the vom- itus. The macroscopic appearance of the vomitus of carcinoma is not characteristic, as was formerly held. 28 434 THE STOMACH AND INTESTINES. The frequency of vomiting will be found to vary greatly, depending upon the size of the carcinoma and upon its location on the stomach-wall. Vomit- ing occurs a variable time after the taking of food, and is preceded by a deep- seated boring pain, which is not relieved by emptying the stomach. If the carcinoma is situated at the cardiac portion of the stomach, vomiting takes place almost immediately after the ingestion of food, but if the lesion is near the pylorus, it is deferred for some hours. In carcinoma of the pylorus with a variable degree of obstruction dilatation of the stomach fol- lows, and in such instances copious vomiting may occur only once or twice during the week. If there is oozing of blood into the stomach, the vomitus is brownish or bluish in color— the so-called "coffee-ground" vomitus of gastric carcinoma. Chemically, the vomitus of gastric carcinoma shows a deficiency in free hydrochloric acid, and, indeed, in many instances free hydrochloric acid is absent. A still more constant finding is that of lactic acid, which is usually present in large amounts, as is also butyric acid. Caution. — A diagnosis of carcinoma of the stomach cannot be made from an analysis of the vomitus alone, since similar findings are rarely met in the gastric fluids of other chronic conditions in which malnutrition and neur- asthenia figure prominently. (4) Vomiting of Gastric Dilatation. — In this condition the character of the material ejected from the stomach is in many ways characteristic of the pathologic changes that have taken place. In striking contrast to the vomiting of gastric ulcer and of gastric carcinoma, we here find that the patient does not vomit at any stipulated time after the taking of food, nor does the character of food taken in any way influence the time of vomiting. Depending upon the degree of dilatation, an abnormally large quantity (from two to eight quarts) of partially digested food is ejected. The vomitus often contains particles of food that have been taken days before, and that have remained in the stomach without undergoing decided alteration. If the degree of gastric dilatation is great, free hydrochloric acid may be absent from the vomitus, whereas lactic and fatty acids are, as a rule, present. (c) Vomiting of Acute Infections. — Virulent forms of infection, such as small-pox, scarlet fever, yellow fever, or pneumonia, are often ushered in by vomiting, and the severity of the vomiting is directly dependent upon the severity of the type of infection. The vomitus of the acute infections at first contains undigested food, but later it is nearly mucoid in consistence. If the attack of vomiting continues over a period of several hours, blood may be ejected. When the vomitus contains blood, before retching has occurred, hemorrhagic forms of infection are to be suspected. Chemic analysis of the vomitus of the acute infections. shows that the normal quantity of free hydrochloric acid is present, and at times traces of lactic acid are also demonstrable. There is nothing characteristic of the vomitus of acute infections, and it is often with great difficulty that one is able to distinguish this form of vomiting from that caused by dietetic errors. (d) Cerebral Vomiting. — At times the physician encounters severe vomiting that is dependent upon pathologic cerebral conditions, e. g., brain tumor, acute meningitis, chronic meningitis, and early in apoplexy. The vomiting of apoplexy is associated with definite symptoms and signs of cerebral hemorrhage, whereas other types of cerebral vomiting are not accompanied by characteristic symptoms. Vomiting oj Locomotor Ataxia. — During the course of this disease violent LEADING FEATUBBS AND THEIR SIGNIFICANCE. 435 attacks of vomiting and pain occur periodically, which are known as " gastric crises." The vomitus of ataxic crises, in addition to containing particles of undigested food, is highly acid in reaction. If the vomiting should continue for a prolonged period, there are pro- found exhaustion and anuria. In asthenic cases of ataxia circulatory col- lapse frequently follows these gastric crises. (e) Reflex Vomiting. — Definition. — A condition in which vomiting occurs without appreciable pathologic change in the stomach. As previously stated, vomiting may be induced reflexly, and be dependent upon disease in organs remotely situated from the stomach, or it may be caused by the sight of certain substances, as blood and horrible scenes, or by certain odors. Pain of whatever nature is one of the commonest causes of this symptom. In determining whether or not the vomiting is of reflex nature, it is necessary for the physician to ascertain the existence or non-existence of disease or irritation of other organs than the stomach. When it is possible to determine the seat of an irritation, an impression of which is in turn con- veyed to the vomiting center, the removal of such irritation is followed by relief. Probably the best example of reflex vomiting is that occurring in early pregnancy, before the uterus has risen above the brim of the pelvis, while it exerts pressure upon the pelvic sympathetic nerves. It must be borne in mind that any abdominal growth causing similar pressure may excite vomiting. (1) Cyclic Vomiting. — -A pathologic type of vomiting first described by Lyden, characterized by its sudden onset and the severity of the retching. Snow has suggested that the cause of these attacks is probably a gastric neurosis, whereas other writers hold that it is quite difficult to distinguish cyclic vomiting from the vomiting of uremia and that of toxic origin. The vomitus first contains the contents of the stomach, but later becomes mucoid in character. Chemically, the first vomitus is practically normal, but later it may contain no hydrochloric acid. In adults cyclic vomiting is not ac- companied by a rise in the temperature, but in children fever is generally present. Among the symptoms associated with cyclic vomiting are extreme pros- tration, retraction of the abdominal muscles, and a tendency toward circu- latory collapse. After the vomiting has persisted for an hour or more the expression becomes anxious, the cheeks are sunken, and the extremities are beaded with cold perspiration. (2) Vomiting of Peritonitis. — Reflex vomiting may be caused by both acute and chronic peritonitis. The vomitus of peritonitis is likely to contain bile after the stomach has become empty. In persons suffering from renal, hepatic, and uterine colic it is often difficult to determine whether or not peritonitis is present, but the fact that this form of vomiting usually sub- sides with the disappearance of the pain would indicate that the peritoneum is not involved. (3) Vomiting of Pulmonary Tuberculosis. — In pulmonary tuberculosis with cavity formation the patient usually experiences a paroxysmal attack of coughing soon after rising in the morning, and during this attack the throat becomes so irritated that the contents of the stomach are ejected. It must be remembered that gastric ulcer may be present in those suffering from pulmonary tuberculosis, in which case the characteristic features of the vomiting of the latter condition may also be present. (4) Vomiting of Uremia. — This type of vomiting seldom, if ever, occurs 436 THE STOMACH AND INTESTINES. Unless albumin or casts, or probably both, are present in the urine. It should not be forgotten that a urine of low specific gravity may contain neither albumin nor casts, and yet the patient suffers from attacks of uremic vomiting. Again, it is of further interest to note that these patients do, at some time or other, show both albumin and casts in their urine, but the albuminuria is, as a rule, intermittent, and the amount of albumin passed with the urine is slight. Uremic vomiting occurs most often during the morning hours, but may take place at any time during the day or night. Vomiting commonly fol- lows several hours' exposure to cold, and also occurs after partaking of a meal rich in albumins. In practically all persons suffering from uremic vomiting the arterial tension is high, the pulse is slow but wiry, the heart-sounds are forcible, and there is evidence of a variable degree of cardiac hypertrophy. Pain. — Types. — Epigastric pain may be moderate, severe, or intense. The terms cardialgia, gastrodynia, and gastralgia are used to designate these pains. They are all somewhat synonymous, and all are used in a more or less restricted sense by various writers. Cardialgia properly means neuralgia of the stomach, but is sometimes defined as "severe paroxysmal pain in the epigastrium in the absence of gastric lesions" (Anders). Gastrodynia is a term applied to severe, cramp-like pains in the stomach region. The phenomenon may or may not be associated with organic disease of the stomach. Gastralgia means pain in the stomach. Flatulence is a term applied to an accumulation of gas in the stomach and intestines. Attacks of epigastric pain often begin as a mere sensation of discomfort in the epigastrium, which gradually increases until distinct painful sensa- tions of varying severity are experienced. Attacks of pain are seen in atonic dyspepsia, catarrhal gastritis, the gastric neuroses, gastric ulcer, gastric carcinoma, localized peritonitis, etc. During the paroxysm, the patient displays a variable degree of shock, the severity of which is dependent upon the degree of pain and the length of time it has existed. In severe cases the skin becomes cold, clammy, and beaded with perspiration. The expression is anxious, and the pulse is weak and rapid. Pain of Ulcer. — During the active stage of ulcer soreness upon pressure over the epigastrium is a constant finding. Upon taking food the discomfort is immediately aggravated, and localized pain occurs. The pain may radiate from the point of localized tenderness to the back, and is most intense just to the left of the spinal column and along the inner border of the scapula. In atypical cases the pain of ulcer may not develop for from one-half to one hour after food is taken. In uncompUcated cases of gastric ulcer the pain is appreciably lessened, and oftentimes disappears after vomiting. During the course of the disease the. patient may develop gastralgia, when the pain will be reflected for con- siderable distance over the abdomen to the back, and in severe cases down the arm. Pain of Gastric Carcinoma. — Pain is one of the most constant symp- toms of carcinoma, although it is not invariably present. In two autopsies performed by us the patients had never complained of pain during their illness. The pain of carcinoma is less definitely localized than is that of ulcer, LEADING FEATURES AND THEIR SIGNIFICANCE. 437 and may be reflected over the abdomen to the back. It is not increased immediately after the ingestion of food, but becomes most intense in from two to four hours later. Gastralgic attacks are not unknown in case of carcinoma, and vomiting does not tepd to relieve the patient. Pain of Acute Gastritis. — In this condition the pain varies in direct relation to the degree of gastric involvement present. After the ingestion of acids or of other highly irritating substances the pain is acute and is best described as an epigastric burning. If this symptom follows the too free use of rich foods, alcoholic liquors, and tobacco, the patient complains of a dull pain accompanied by nausea. In acute gastritis pain is excited by making deep pressure over the epigastrium. Pain of Gastric Fennentation. — Hyperacidity and excessive fermenta- tion may induce acute epigastric pain with overdistention of the stomach, but tenderness over the epigastrium is seldom present. Epigastric Pain not Connected with the Stomach.— Cramp-like pain, either mild or intense, situated slightly to the right of the median line and radiating to the right shoulder, is highly suggestive of hepatic colic. In severe cases the pain may be reflected over the entire epigastrium, and rarely runs down along the right side of the abdomen, simulating the pain of appendicitis. Hepatic colic is paroxysmal in nature, the attack lasting f rom_ ten minutes to several hours. The pain of gall-stones subsides suddenly, and is usually followed by localized tenderness over the epigastrium. Carcinoma of the common bile-duct or of the liver (with localized peritonitis) may be accompanied by a more or less constant pain, locaUzed to the epi-^ gastrium, and radiating to the back and over the abdomen. In pancreatic disease epigastric pain is one of the chief symptoms. In acute pancreatic hemorrhage the pain is sudden and intense; collapse, followed by death, soon follows. Pancreatic colic is marked by a somewhat characteristic, cramp-like pain, localized in the epigastrium. This pain is to be distinguished from that of hepatic colic by the fact that in the former disease the patient is likely to have diarrhea and often complains of salivation. Carcinoma of the head of the pancreas is often the cause of severe and almost continuous pain in the epigastrium. This pain may be boring or lancinating in character, depending upon the degree of peritoneal involve- ment present. The development of a dull pain in the epigastrium in from two to five hours after the taking of a full meal points quite strongly toward pancreatic disease and intestinal indigestion. The pain of pancreatic disease is not continuous, as is that of gastric carcinoma. Thoracic aneurism and duodenal carcinoma may each cause a distinct boring pain near the ensiform cartilage; and tuberculosis of the vertebra, with necrosis, is not infrequently a cause of epigastric pain. Cardiac Palpitation. — A decided increase in the heart's action, with pulsation over the greater part of the left chest, is at times a symptom of flatulence. Palpitation may follow overeating or the ingestion of improper foods, and is also a symptom of chlorosis, secondary anemia, and hysteria. Overstimulation from the too liberal use of alcohol or narcotics (tobacco) is often the cause of palpitation. Palpitation is a symptom of cardiac disease, and in approximating the actual significance of this symptom, it is necessary for the clinician to exclude practically all the conditions previously mentioned. Dyspnea. — Shortness of breath often follows the too free use of rich 438 THE STOMACH AND INTESTINES. foods or overdistention of the stomach by gas; it is a late symptom in gastric ulcer, gastric carcinoma, and chronic gastritis, in which conditions it is dependent on the associated anemia. Among the extragastric maladies that may cause dyspnea should be mentioned cardiac disease, nephritis, pulmonary disease, and all types of pri- mary and secondary anemia. Constipation.— Constipation may result from disease of the stomach, and not infrequently occurs in gastric ulcer and early during the course of gastric carcinoma. In chronic gastritis, especially when there is dilatation of the stomach, constipation is the rule. New-growths situated in the stom- ach-wall or pressing upon the pylorus and the duodenum are often responsi- ble for obstinate constipation. Constipation may be a precursor of acute gastritis. Diminished motility of the stomach favors the development of constipa- tion. The variety of food and the amount and character of exercise taken are prominent factors in mak- ing definite deductions as to the cause of constipation. Diarrhea may develop late dur- ing the course of gastric carcinoma, gastric ulcer, and chronic gastritis, in which diseases it is probably due to gastric and intestinal fermenta- tion. If the motor power of the stomach is excessive, food is pro- pelled from the stomach into the in- testine l^efore gastric digestion has been completed, and diarrhea results. Gastric neuroses and alterations in the gastric juice, e. g., lack of suffi- cient hydrochloric acid, are followed by diarrhea. Diarrhea may also be a temporary symptom of both acute and chronic gastric catarrh. (See Diarrhea, p. 514.) Drowsiness. — The patient may become extremely drowsy after the ingestion of a liberal meal if chronic gastritis or constipation is present. In all gastric derangements accompanied by constipation mental dullness and a tendency to sleep during the clay, with insomnia at night, are among the symptoms. A marked feature of disordered sleep is that the patient sleeps equally well or Ijetter when sitting than when he assumes the recumbent posture. PHYSICAL EXAMINATION OF THE STOMACH. General Remarks. — Inspection. — The patient should be placed in the recumbent posture. The physician .should sit so that the superior surface of the alDdomen is on a level with his eyes, and then inspect the surface closely from both the right and the left side. He should then stand at the head of the bed and inspect the abdomen from the thorax to the pubes, and, lastly, he should stand at the foot of the bed and view the surface of the Fig. 169. — Sacculated Form of Gastric Dilatation (from clinic , Howard Hospital). PHYSICAL EXAMINATION OF THE STOMACH. 439 body from the pubes to the thorax (Fig. 7, p. 46). These three positions should be taken in all cases when inspecting the abdomen, and if the eye is on a level with the patient's body, any abnormality that may be present will readily be detected. Inspection with the patient in the erect posture is ofttimes of great value. (See Fig. 170.) In persons who have a small amount of abdominal fat, and in whom the stomach is well distended, the outlines of this viscus are readily traced with the naked eye. The first thing to be observed is the lower curvature, noting particularly at what level it is seen, e. g., if the greater curvature is below the umbilicus, gastric dilatation or gastroptosis is present (Fig. 172). If the lower gastric line is above the umbilicus, the stomach is not greatly dilated, and may be of normal size. An abnormal bulging in any portion of the epi- FlG. 170. — Inspection of the Chest and Abdomen. Patient standing. gastrium, and particularly when near the ensiform cartilage, is highly sug- gestive of carcinoma of the pylorus. Gastric dilatation and bulging at the pylorus are two common signs of gastric carcinoma. When a dilated stomach is markedly distended, there is a distinct furrow or groove extending along the course of an imaginary line drawn from the umbilicus to the left nipple; this depression in the abdominal wall corresponds to the lesser curvature of the stomach. A furrow on the abdominal wall below the umbilicus and to the left of the pubes corresponds to the position of the greater curvature. It will be readily understood that the physical signs of gastric dilatation just described are subject to great variation, which depends, first, upon the degree of dilatation; second, upon the rigidity or fiaccidness of the abdominal wall; and, third, upon the degree of gastric distention, Peristalsis. — Peristaltic waves are seen over the epigastrium, and cor- 440 THE STOMACH AND INTESTINES. respond to the movements of the stomach; these waves may be produced by applying either cold or electricity to the abdomen. Normally, the peristaltic waves (Fig. 172) should be seen in the upper portion of the epigastrium, but if there is marked gastric dilatation, they are seen to come from beneath the ribs on the left, and to extend toward the umbiHcus (Fig. 172). If an abdominal tumor is present, the peristaltic waves may be accentuated over the tumor, but if the tumor is anterior to the stomach, the waves are absent at that particular point. The peristaltic waves and, in fact, the position of the stomach, are readily outlined with the naked eye when the stomach is distended by air or gas. (See Gastric Dilatation, p. 505. Also landmarks of abdomen, pp. 418-420.) Ensiform and umbilical line divided into three equal parts. Pylorus. rorresponds to groove seen m gastric dilatation. Fig. 171. — Showing Division of Ensiform and Umbilical Line. Palpation. — The patient should preferably be in the recumbent pos- ture, with his thighs slightly flexed upon the abdomen, in order to relax the abdominal wall. Place the hand upon the abdomen, and let all pressure be made with the fingers pressing equally along their entire length (Fig. 173). It is well to make shght rotary movement of the broad hand, in- creasing the pressure with each rotation, but between the acts of increased pressure the hand should not be lifted from the abdominal wall; in this way deep pressure is made without exciting contraction of the abdominal muscles. To ascertain whether or not an abdominal mass is movable with a change of position of the patient, it is necessary to place the patient upon his side and in the knee-chest position, when, if floating abdominal tumors are present, PHYSICAL EXAMINATION OP THE STOMACH. 441 they will come to the abdominal parietes. Deep palpation will also deter- mine whether or not an abdominal mass moves with respiration. Epigastric pulsation is of great importance, not only in diseases of the stomach, but in cardiovascular derangements, e.g., thoracic aneurism, ab- dominal aneurism, tricuspid regurgitation, and cardiac dilatation. Pulsation of the liver is usually the result of tricuspid regurgitation, but may be seen in hepatic abscess. Epigastric impulse may be transmitted as the result of a solid mass overlying the abdominal aorta. In neurasthenic persons, and in those in whom the abdominal wall is extremely thin and relaxed, a wavy pulsation of the epigastrium is quite common. Increased resistance of the abdominal wall results physiologically from over- development of the muscular coat of the abdomen, and may also be depen- Upper and lower normal wave. I reater curvature in ex- treme dilatation. FiQ. 172. — Upper and Lower Norm.\l Wave of Stomach and Greater Curvature in Extreme Dilatation. dent upon an excess of abdominal fat. Distention of the stomach is marked by a decided increase in the resistance of the upper portion of the abdominal wall, and if the stomach is diminished in size and the abdominal resistance is increased, carcinoma or tuberculosis with a localized involvement of the peritoneum is to be suspected. Increased abdominal resistance is encountered late during the course of atrophic gastritis, in ascites, and in the presence of uterine and ovarian growths. A localized increase in the resistance of the wall of the abdomen, when referred to disease of the stomach, usually occu- pies the upper right portion of the epigastrium, and is suggestive of pyloric carcinoma. Tumors of the stomach, liver, spleen, pancreas, and peritoneum may cause 442 THE STOMACH AND INTESTINES. an increased resistance over the epigastrium. Tumor of the stomach is the only one of the previously named group that is capable of descending en masse as it develops; e. g., carcinoma involving the pylorus may be found a.s low as the umbilicus, and rarely it is seen below this point. The degree of descent of a carcinoma of the stomach-wall depends upon the associated peritonitis, Fig. 173. — Position of P.\tiext and of Oper.\tor for Abdominal Palpation. and upon whether or not adhesii.ms to other epigastric structures exist. If a carcinoma of the stomach is adherent to the tliaphragm, the liver, or the spleen, it will display a variable amount of movement with respiration. Comljined palpation of the stomach with an internal exploratory exami- FlG. 174. — Abdominal Palpation to Detect Change of Position of Abdo.minal Growths WITH THE Change of Position of the Patient. nation may be resorted to in order to determine the actual size of the organ, but this measure is rarely necessary. Palpation and Pain. — Tenderness over the epigastrium is found in acute gastritis, gastric ulcer, gastric and pancreatic carcinoma, malignant disease of the common bile-duct, acute hepatitis, pancreatic calculus, hepatic PHYSICAL EXAMINATION OF THE STOMACH. 443 colic, and in any condition that may have associated localized peritonitis. It is impossible for one to attach too great diagnostic importance to epigastric tenderness or to pain that is excited by deep palpation. In gastric ulcer the tenderness is usually localized, whereas in practically all other conditions in which epigastric tenderness is one of the symptoms it is less markedly localized in direct proportion to the extent of acute or chronic peritonitis present. Percussion. — Normal Position of the Stomach in the Adult. — The position of the stomach will be found to vary greatly within certain limits. These variations, as the}' occur during infancy, childhood, and in early ado- lescence, are shown in the accompanying illustrations (Figs. 176, 177, 178). When food is taken the stomach changes its position, and the greater curva- ture is rotated forward and slightly upward. Involvement of the diaphragm, transverse colon, and splenic and hepatic flexure. Vertical lines outline area of gastric pain. Carcinoma, ulcer, gastralgia, neuroses, acute gastric catarrh, hyperesthesia, duo- denal ulcer. Pancreatic disease causes liain near the center of this area, as do also pneumonia in children and disease of the vertebrae . Abdominal pain. Where the vertical lines cross the transverse lines the pain is ex- cited by conditions named above. Over area of transverse line lead colic, mu- cous colic, flatulency. Dietl's crises (floating kidney), appendicitis (initial stage), intestinal obstruction, intestinal perforation, mercury poisoning, crises of locomotor ataxia, pneumonia (in chil- dren), strangulated hernia, hyperesthe- sia, rheumatism of the abdominal wall, and rarely Loebstein's carcinoma, ab- dominal aneurism Raynaud's disease, and acute pancreatitis. Fig, 17.5, — DiSTRlBTTTroN of Pain. For convenience of study Obrastzow's division of that portion of the abdomen between the ensiform cartilage and the umbilicus is to be recom- mended. An imaginary line extending from the ensiform to the umbilicus is divided into three equal parts. In normal men and women the stomach will be found between the umbilicus and the ensiform, and the lower border of the .stomach will usually correspond to the inferior third of this line.^ The upper border of the stomach is taken at the left parasternal line ; at this point it is normally found at the lower border of the fifth or upper border of the sixth rib, although instances are recorded in which the superior boun- dary of the stomach corresponded to the fourth rib and to the sixth inter- 444 THE STOMACH AND INTESTINES. costal space respectively. The upper border of the stomach is a trifle lower at the left nipple-line than at the parasternal line, but is usually found at the fifth interspace or the sixth rib. In the anterior axillary line the superior boundary of the stomach corresponds to the seventh interspace. Traube's semilunar space is that portion of the left chest overlying the stomach. It is bounded above by the lower border of the heart, the left lung, and the liver; below by the margin of the ribs, and to the left by the spleen. . . . . Tympany.— In outlining the stomach by percussion it is most satis- factory to have the patient in the recumbent posture, with his thighs at right angles to the body, in order to relax the abdominal wall. In infancy the stomach is almost cylindric in outline, and occupies an oblique position, but at the age of one year it will be found in a transverse position (Fig. 176). It is of great importance to ascertain the change in shape of the stomach when the patient suffers from gastric dilatation. Percussion-note. — As the stomach always contains some air, a tym- panitic note is obtained by percussing over this hollow viscus, and while this note varies greatly, depending upon the degree of distention of the stomach by gas, etc., it is always elevated in pitch, but lower than thatof the colon, metallic in character, and displays a certain distinctive quality known as " stomach tympany. " _ . . Auscultatory percussion (Fig. 179) may be employed in determming the exact outline of the stomach, although this diagnostic measure is of far greater value for outlining the solid abdominal viscera and new-growths. Conditions That May Increase the Area of Stomach Tympany.— A. Those depending upon alterations in the size and shape of the stomach. B. Pathologic conditions not directly connected with the stomach. A. 1. Overeating. 2. Gastroptosis. 3. Dilatation of the stomach. 4. Starvation. 5. Cardiac stenosis. B. 1. Fibroid induration of the left lung. 2. Adhesive pleurisy (left side). 3. Contraction of the liver. The area of stomach tympany is diminished in — 1. Left-sided pleural effusion. 2. Fibroid induration of the stomach- wall. 3. Hour-glass contraction. 4. Left pyopneumothorax. 5. Enlargement of the liver. 6. Enlargement of the spleen. 7. New-growths of the mediastinum. 8. Abdominal tumors, e. g., ovarian cyst, uterine fibroid, carcinoma of the left kidney, echinococcus cyst, preg- nancy, and ascites. Auscultation. — Auscultation is of value in determining whether or not stenosis of the esophagus or disease of the stomach exists. (See Esopha- geal Stricture, p. 416.) The gurgling sound, audible when the patient swal- lows liquids, and heard only by placing the stethoscope over the esophagus, is always followed, in from five to ten seconds later, by a second sound, which is caused by the escape of the fluid from the esophagus into the stomach. This second sound is usually referred to as the "deglutition gurgle," or mur- mur. If there is obstruction to the cardiac portion of the esophagus, the "deglutition gurgle" takes place later, and is materially modified. By placing the ear over the stomach, either anteriorly or at the back, it is possible to get a decided splashing sound when the patient is shaken PHYSICAL EXAMINATION OF THE STOMACH. 445 Lower border of stomach tympany in poorly nour- ished chil- dren. Lower normal position of stomach. rapidly from side to side. The presence of the siiccussion splash is positive evidence that the stomach is partially filled with liquid, but it must Ije re- membered that the splash alone is to be taken only as corroborative evidence of other physical signs and symptoms. The succussion splash may be elicited by external manipulation of the abdominal wall; this is accomplished Ijy placing the left hand over the pylorus and the right hand just at the costal margin in the anterior axillary line, when, by alternating pressure at these points, the succussion splash i's produced. Percussion along the margin of the ribs and over the left superior abdominal quadrant is often sufficient to cause a splashing sound. The succussion splash over the abdomen is at times veiy loud, and may be heard for some dis- tance from the patient, although the best means of eliciting this sound is for the operator to place his ear against either the abdomen or the back. Sign ifica?icc. — U n d er normal conditions, when 100 cubic centimeters of water are taken before re- tiring, the succussion splash cannot be elicited in the morning. If the succussion splash is pres- ent under such conditions, an atonic condition of the stomach-wall exists. The succussion splash should be audible during diges- tion, and the sounds are of pathologic significance when they are present thxee hours after the in- gestion of an ordinary meal. If the splash is present five to seven hours after liquid food has been taken, it is posi- tive evidence that there is gastric dilatation or defective gastric motility. Under normal conditions the splash is heard above the umbilicus. In dilatation of the stomach and in gastroptosis it is audible Ijelow the umbili' cus. In children who are poorly nourished a splashing sound is also audible below the tran.sverse umbilical line. The exact location at which the suc- cussion splash is heard is of value in determining the lower boundary of the stomach, and this is be.st attained after inflating the organ. Caution. — Great care should be exercised in differentiating the succus- sion splash caused l.iy fluid in the stomach from that the result of air and fluid in the left pleural sac. (See Pyopneumothorax, p. 166.) Fig. 176. — Lower Normal Position of Stomach in Child. 446 THE STOMACH AND INTESTINES. GASTROSCOPY. Definition.— Gastroscopv is a clinical method of inspecting the interior of the stomach by means of tubes that serve as specula. Orchnanly, the natural passage (esophagus) is chosen for conducting this method of exami- nation, although occasionally abdominal wounds and fistula are utilized. Instruments for Gastroscopy.— The Gastroscope.— In order to examine the stomach, an 80 cm. tube is frequently required, although in many cases a 70 cm. by 10 mm. one is sufficient. It is impossible to illumi- nate well the field of view by any form of light projected through the proximal Fig. 177. — Showing High Normal Posi- tion OF Stomach in Child. Fig. 178. — Lateral Area of Stomach Tympany in the Child. end, since there is too great a loss for practical work. With .lackson's gas- troscope (Fig. 180) the length of .the tube is immaterial — the view is as good at the end of an 80 cm. tulje as is that of a 45 cm. esophagoscope of the same diameter. The tubes are illuminated by a small "cold" lamp carried down to the extremity by a light-carrier. The chief advantages of this form of illumina- tion are: The light being in the tube, the object is always illuminated, regardless of the movements of the patient or of the operator. The lamp may occa- GASTROSCOPY. 447 sionally become smeared with blood, which necessitates withdrawing the light-carrier and cleaning the lamp. The illumination is as powerful and the view as clear through an 80 cm. gastroscope as through a shorter tube. A great advantage is gained by oblique light, due to the location of the lamp at one side of the orifice of the tube. "The darker shades of red do not throw back rays strongly, so that in case of a long tube, with the light at one end and a dark-red object at the other, the light traveling twice the tubal length, the greatest skill and the utmost perfection of every detail of apparatus are absolutely essential for results" (Jackson). A small object or an instrument introduced into the tube does not cut off any light, as the light is beyond the instrument. Each tube is fitted with a handle, which is a time-saver as compared to attaching a handle each time a different tube is inserted. Fig. 179. — Method of OrTLiNiNG the Stomach by Auscultatory Percussion. "The tubes for general use are fitted with an auxiliary drainage canal which maintains a dry, clean condition at the distal end of the tube. Occa- sionally a tube is needed without this auxiliary drainage, but only rarely, as in the ca.se of passing a narrow stricture. " The secretion is removed by pressure maintained in a bottle, by aspirating syringe, the bottle being con- nected at intervals with the outer end of the drainage canal. If the drainage canal becomes obstructed, an extra drainage-tube may be inserted and re- moved as needed. The extra drainage-tubes are especially u.seful for blowing in medicaments or bismuth for Roentgen-ray localization. A number of accessory instruments have been devised, and for a description of these the reader is referred to Jackson's monograph. In the wall of the gastroscope, as in the esophagoscope, there are two small auxiliary tubes or canals. Both of the.se canals open into the main tube, close to the distal end. One canal ends near the handle, in a tip for the 448 THE STOMACH AND INTESTINES. attachment of rubber tubing connected with the aspirating apparatus previ- ously referred to, and this l^eeps the field clear of all fluids and prevents smearing of the lamp. In some cases quantities of fluid must be pumped out of the stomach. The other canal is for the light-carrier, already alluded to, which is a small, removable, douljle conductor, carrying the lamp to the distal end of the instrument, where it sheds its light at close range at the point where needed, leaving every object iDetween it and the oljserver's eye in darkness. The exterior of the tube is not graduated, and the depth is to be measured with a sterilized steel rule by noting the distance between the proximal (outer) end of the tube and the upper teeth. An obturator or mandrin with a projecting conic end is fitted to facilitate the passing of the inferior pharyngeal constrictor, especially for those un- familiar with esophageal work. Teclinic of Gastroscopy. — In order to introduce the gastroscope with any degree of ease and safety to the patient, complete anesthesia is essential. Certain writers recommend that , in heroic patients, local anes- thesia, by means of cocain, may be used, but in no case does cocain prevent retching and spasm of the diaphragm, which temporarily interrupts the examination. Ether anesthesia has been employed extensively l^y Jackson and others, and it is suggested that chloroform should be an ideal anesthetic in this particular work, although it does not seem to have been extensively Fig. ISO. — Chevalier Jackson's Bro.nchoscope, Esophagoscope, and Gastroscope. employed. Irrespective of which anesthetic is selected, morphin adminis- tered hypodermically will be found of assistance. Preparation of the Patient. — It is desirable to have the gastro-intesti- nal tract, as nearly empty as possil^le, and no solid or semisolid food should be allowed for at least twelve hours before the gastroscope is introduced. When the gastroscope is to be introduced in patients having no evidence of pyloric stenosis, liquids, e. g., black coffee, may be allowed by mouth eight hours before the introduction of the instrument. Position of the Patient. — Place the patient upon an ordinary operating table, and lower his feet approximately fifteen inches. This position will be found to assist the operator greatly, and the only objection to it is that the aspirating bottle must be attached to the instrument in order that any excess of fluid may be drained through the gastroscope. After the instrument has been pas.sed into the stomach, the entire plane of the table is again changed, so that the head is aljout 30 cm. higher than the feet. Passing of the Gastroscope. — The operator must be gentle in all his movements, and if the tube does not pass readily, it is not in the right posi- tion, not rightly directed, or not sufficiently well lubricated with vaselin. The proximal end of the instrument should be held lightly between the fingers of the right hand, and the handle directed horizontally to the right. (See Fig. 181.) The forefinger of the left hand should be introduced into the right glosso-epiglottic fossa posteriorly to the lateral glosso-epiglottic fold, and, GASTROSCOPY. 449 if possible, into the right pyrifoi'm sinus. Guided Ijy the finger the instru- ment is forced to foUow the siune route, and naturally glides toward the median line. The cricoid cartilage may be reached in children, and pressure made directly upon it. (See Fig. 182.) In the adult traction is made upon the tissues in the right epiglottic fossa. Certain authors recommend passing the esophagoscope by threading it over an esophageal bougie. Position of the Patient's Head. — The neck of the patient is bent backward (Fig. 183) in order to straighten the cervical curva- ture, or rather to laring the axis of the oral cavity to that approxi- mately parallel with the esophagus, and it is also possible, with the head in this position, to pass the superior teeth more readily. When bending the neck of the patient, the angle should be as much as possi- ble at the upper cervical vertebrse, thus straightening the oropharj'n- geal angle. If the position of the patient 's head appears to cause op- pression, it may be found neces- sary to elevate it. The exact posi- tion of the patient's head is one of the most difficult features in the introduction of the gastroscope. Directions for Assistant. — In all this work safety demands that the mouth, pharynx, and esophagus be brought into a straight line, not by a leverage-like action of the instrument, but by holding the head steadily in extreme extension with the mouth widely open. Not only does lateral pressure add to the operator's difficulty, but it also prevents him from Fig. 181. — Position of the Right Hand for In- troduction OF the Gastroscope. View from Above by the Operator Looking Downward (Jackson). Fig. 1S2. — Position of the Left Hand in Starting the Gastroscope or Esophagoscope (Jackson"). determining what the point of the instrument is touching. No mouth- gag is always self-retaining, and a slight slip while the tube is in position may have serious consequences. Therefore, a second assistant should be detailed to hold the head and steady the mouth-gag. In order that the assistant be out of the operator's way, it is necessary that he shall hold the head at arm's length. (See Fig. 183.) The patient is drawn forward 29 450 THE STOMACH AND INTESTINES. until the tops of his shoulders clear the table four to six inches, and the mouth-gag is inserted on the left side. The assistant's left foot is supported on a stool (Fig. 183), 26 inches lower than the top of the table; his right forearm is passed beneath the patient's neck, supporting it; his right hand grasps the mouth-gag, drawing it strongly backward. " His left hand rests on the left knee, grasps the head strongly at or in front of the bregma, bend- ing it backward and exerting a certain degree of upward pressure. The exact proportion of backward and upward pressure cannot be described, but is readily appreciated on trial, especially if the assistant has actually experienced the difference in sensation when the hand hangs free and when it is properly supported in extreme extension" (Boyce). Fig. 183. — Position of Patient and Second Assistant for Bronchoscopy (Jaclcson). After the introitus is passed, the obturator is removed, the cord is attached to the light-carrier by the bayonet fitting, which, by rotation, is used as a switch to turn the current on and off. The rheostat on the battery is to be regulated to full illumination when the instruments are prepared. Turning the bayonet fitting lights the instrument, and the passing from this point is under the guidance of the eye. The sense of touch is used to note resistance, which, if felt, means that such resistance must be overcome by skill, since the application of force is dangerous. Once started, the passage of the in- strument down the esophagus is comparatively easy if the following impor- tant points are observed : GASTROSCOPY. 451 (a) The instrument must have been well lubricated before starting. (6) The tube must be guided by the eye, so as to follow the esophageal lumen. (c) The pinching of the tube by the teeth must be avoided, in order that the tube shall be free to move as needed to follow the axis of the esophageal canal as it is seen. Fig. 184.- -Diagram Showing Occlusion of the Trachea by Faulty Direction of the Gastro- scoPE (Jackson). After passing the introitus, care must be taken to raise the head of the patient slightly to prevent the tube pressing upon the trachea (Fig. 184). This is readily noticed if the passing is done Ijy sight. In finding the lumen, the normal respiratory movements are of great assist- ance. The way often seems to be completely lilocked ahead by what appears to be the esophageal wall, but with the next inspiration a lumen appears in one or other quadrant of the tube, where a few bubbles are seen. "The introitus passed, only two points will give any trouble. The first is at the hiatus dia- phragmaticus, the second, the bend of the abdominal esophagus to the left. The hiatus is passed by placing the long axis of the elliptic cross-section of the tube from the right posteriorly forward toward the left anteriorly. This is easily done by placing the handle of the gastroscope in the direction of the visual axis of the patient, if he were looking forward ("if erect) to the left (see Fig. 157)" (Jack- son). Passage of the abdominal esophagus is facilitated by mov- ing the head to the right (Fig. 185), and the lumen is carefully watched and followed. If serious diffi- culty is experienced in passing the hiatus, it will be found that anesthesia is not complete. After the tube has entered the stomach a systematic plan of exploration is to be fol- lowed. An area of from one to six centimeters of gastric mucosa is vis- ible at one time, so that a systematic plan of tube travel brings all por- tions of the explorable mucous membrane into view. Fig. 18-5. — Head and Neck Moved to the Right to Reach the Left Limit of the Explorable Area (Jackson). 452 THE STOMACH AND INTESTINES. "There are two plans of exploration, both of which should be carried out. First, the gastroscope should be passed down carefully and gently to the greater curvature, inspecting the anterior and posterior walls. At times these walls do not seem to be fully collapsed ahead of the tube, and one will have to l^e examined first, then the other. Then the tube is withdrawn, inclined slightly laterally in the same plane, then pushed gently downward again in a new series of folds. This is repeated until the extreme pyloric limit is reached. To reach this limit, the head and neck of the patient are moved to the left, with the tube below the cardia. " After the whole possible range has been covered in this way, we pro- ceed to the second plan. The tul^e is passed down until the extremity touches the wall of the greater cur- vature in the extreme left of the possible field. Then the tube is moved slowly along the greater cur- vature, but not in close contact therewith, until the extreme right is reached. Withdrawing the tube a centimeter or two, the field is slowly swept again in the same plane, but at a higher level, and so on upward to the cardia. Next the deft fingers of one skilled in ab- dominal palpation are called upon to manipulate the unexplored por- tions over in front of the tube. This is sometimes l^etter accom- plished iDy turning the patient upon the side." Caution. — During the process of turning the patient from side to side the tube must be withdrawn within the esophagus. When the stomach is in its new position, the gastroscope is again pushed down- ward, and the newl}^ available sur- faces are explored. If retching su- pervenes while the gastroscope is in the esophagus, no harm will result, but when the tube is in the stomach, retching is the signal for immediate withdrawal of the instrument until the distal end is above the diaphragm. The tendency is for the gastric walls to be dragged along with the tube when the tul^e is moved, but if the tube is withdrawn slightly liefore changing its position, the tul^e then changed, and the instrument reinserted to its original depth within the stomach, the gastric wall will have assumed its normal position and a new field is brought into view. Explorable Area of Stomach. — This varies with the position of the stomach — the more horizontally the organ is placed, the less of its surface can be viewed by the gastroscope (one-third to one-half). The degree of anesthesia is also an important factor in governing the extent of the explora- FiG. 186. — Showing Extreme Right and Left Positions of the Gastroscope (Jackson). DESCRIPTION OF PLATES IX and X. Gastroscopic Views (Chevalier Jackson). 1.— Thoracic esophagus. Expiration. Note lumen not entirely closed. Man aged 40. 2, 3, 4, 5, and 6.— Normal stomach. Folds in various positions as seen separating and collapsing ahead of the tube as it is inserted and withdrawn. In Fig. 4 is shown a horseshoe-shaped position of a fold often seen near the cardia, usually to the right. At times seen elsewhere. Compare Figs. 16 and IS, Plate X. 7 aha 8.— Stomach. Normal wall of inferior curvature flattened by pressure of the tube-mouth. 9.— Gastritis. Fold in lower right-hand corner is capped by secretion simulating ulcer, before . being, wiped away. lO.^Gastritis. All folds sponged but one, which shows thick tenacious s^retioni U.— Gastric ulcer seen on edge. • Not sponged. Man aged 32. Patient of Dr. Finkelpearl. 12.— Same patient. Scar after healing of the ulcer. Scar shows yellow by 6ngraver's error ; it should be grayish, nearly white. 13.— Carcinoma of cardia. Infiltrated, but not ulcerated, hard mass to right of view. Man 38 years. Referred by Dr. Haworth. 14. — Same patient. Further to right than Fig. 13, on lesser curvature. Fungating portion of mass. 16.— Carcinoma of pylorus. Left border of the tumor. Man of 44 years. Referred by Dr. Haworth. 16.— Normal stomach. Three cm. below the cardia. Note horseshoe-shaped fold to the right. Maid of 19 years. Patient of Dr. Lichty. 17 .^Normal stomach, farther down, same patient. (Views are never twice alike, no form is meant as typical of locality.) M.— Normal stomach. Four cm. from cardia. Woman of 33 years. 19.— Normal stomach. Woman of 19 years. Showing diversified forms of folds. 20.— Normal stomach. Transverse trend of folds as greater curvature is approached. Folds are rarely seen as straight as the central one in this view. 21.— Approaching the. pylorus. Gastroptotic stomach. (View probably not abnormal.) Woman of 33 years. Jleferred by Dr. Dranga. 22. — Gastroptotic stomach. (Same patient.) Pylorus hidden by folds. 23.— Folds at fundus (not typical). ' 24.— Approaching the pylorus. Folds disturbed by tube-mouth. Same patient as Fig. 21. 25.— Same patient, same location, about one minute later. 26.— Same patient, same location, about one minute later. Annular folds of pylorus surrounding prolapsed duodenal folds. Brownish fluid was regurgitated into stomach. 27.— Cancerous (?) infiltration near pylorus. Fluid exuded from triangular slit. Woman aged 26 years. Referred by Dr. Montgomery. 28.— Gastric nicer filled with secretion, and seen on edge. Man aged 59 years. Referred by Dr. Goldsmith. - - 29.— Same ulcer wiped clean. Looking into bed of ulcer, 30.— Cicatrix (?) of stomach, in a man 59 years of age who had a specific history. 31.— Carcinoma of esophagus. Man of 60 years. Referred by Dr. Sanes. 32.— Carcinoma (?) of pylorus. View not at but near the pylorus on greater curvature. Color should be much darker Woman aged 25 years. Referred by Dr. Montgomery. j33.— Carcinoma of pylorus. View at left border. Other portions of growth jf ere spotted with dark brown. Man 46 years of age. Referred by Dr. Walton. Afterward operated upon by Dr. MacClelland, and diagnosis as to size, shape, position, and nature verified. 34.— Another portion of same growth. Mucosa normal, but foldless and hard: (Right in view.) 35.— Cardiospasm. Abdominal esophagismus. Man aged 59 years. Referred by Dr. Goldsmith. PLATE IX '**r O '^^ 8 o o 10 11 12 o 9 e 13 14 15 PLATE X 17 18 22 X-RAY EVIDENCE OF DISEASES OF GASTRO-INTESTINAL TRACT. 453 ble area, absolute anesthesia increasing this area materially. A full range of the upper thoracic aperture is available by shifting the head and neck laterally, and Fig. 186 will also explain the results to be obtained by vary- ing the position of the instrument. Moderate anterior and posterior rotation of the patient's head and of the instrument wiU be found to facilitate the bringing of both the anterior and the posterior walls into full view. Unless the caliber of the esophagus is normal, difficulties are en- countered, all of which materially lessen the explorable area of the stomach. Gastroscopy should not be regarded as an unusually difficult procedure, although considerable skill is necessary in order to attain the best results. The training necessary successfully to use the gastroscope has been compared to that needed for mastery of the ophthalmoscope. The eye soon becomes educated, and if the directions previously given for both patient and assistant are followed closely, but few difficulties wiU arise. Contraindications. — Pott's disease and other pathologic changes of the vertebrae may render gastroscopy impossible, and, indeed, are contra- indications to the use of the instrument. Gastroscopy is also attended with great danger when there is extensive atheroma of the blood-vessels, and especially when aneurism exists. In our opinion, the procedure is also contraindicated in all pulmonary conditions, for the following reasons : (1) Prolonged anesthesia is in itself dangerous. (2) Because extensive adhesions to the esophagus and other mediastinal structures may follow pulmonary disease. Maladies characterized by dysp- nea would also contraindicate the use of the gastroscope. In the profound cachexia accompanying malignant and other chronic maladies the instrument should not be used, because here the percentage of hemoglobin is already low, and at least 20 per cent, or more of this vital substance would be lost as the result of profound anesthesia. Those who ■ have suffered at some earlier date from luetic infection take ether badly ; in such cases some risk would attend the introduction of the gastroscope. Valvular heart disease in which any of the symptoms of failure of compensa- tion are present should also be considered. Gastroscopic Findings. — The accompanying illustrations (Plates IX and X) were prepared by Dr. ChevaUer Jackson, who, in addition, suggests that these should not be regarded as the average appearance, but are illus- trative of individual cases. The amount of gastroscopic work done is not sufficient to warrant us in drawing any definite deductions as to what repre- sents an average finding in any given type of disease. X-RAY EVIDENCE OF DISEASES OF THE GASTRO-INTESTINAL TRACT. By George E. Pfahler, M.D. It is difficult to cover this subject thoroughly and yet briefly. In general, the gastro-intestinal tract is rendered visible by means of bismuth mixtures, which give an added density of shadow to this canal. The bismuth subcar- bonate may be mixed with water, milk, kefir, gruels, or other food (1 oz. to 12 oz. of kefir). Both fluoroscopic and photographic studies are necessary. The fluoroscopic work is unfortunately dangerous to the operator. One must be familiar with the normal stomach and the variations under normal conditions before much of value can be determined pathologically. The filling of the normal stomach in the standing posture takes place as 454 THE STOMACH AND INTESTINES. follows: the upper pole is outlined usually by a small collection of gas, just beneath the left dome of the diaphragm. The remainder of the stomach is collapsed. Along the right border of the collection of gas the bismuth mixture may be seen entering and giving the appearance of a dark streak. This collects below the gas, making a funnel-shaped shadow. One or two swallows may be retained here for several minutes. Gradually this funnel- like shadow becomes elongated until it reaches the lower pole, curving slightly to the right. At the lower pole the shadow is broadened with the ~'>^ Loft superior quadrant Left inferior quadrant Fia. 224. — Aebitrary Regional Division of the Abdomen. the right half of the abdomen, radiating to the right thigh and to the testicles. Dyspnea may be aimoying. In acute appendicitis the patient is loath to change his position, as the movement aggravates the pain. A symptom that is often overlooked is diarrhea, and it should be remembered that it may precede the initial pain in acute catarrhal appendicitis. Thermic Features. — The patient is usually flushed, and the tempera- ture rises somewhat abruptly to 102° to 104° F., mild cases fluctuating be- tween 99° and 101° F. The "degree of fever is no guide to the severity of the condition. In severe and fatal cases the temperature may be subnormal throughout the entire course of the disease, and if diffuse or gangrenous changes develop, the temperature may also be subnormal. Physical Signs. — Inspection. — The patient sits or inclines toward the right side, and the right thigh is usually flexed upon the abdomen. Re- 538 THE INTESTINES. traction of the right testicle is common. According to the degree of pain, the face will first be pinched or anxious, pale or blanched. When peritonitis develops as a complication the abdomen is distended. The tongue is coated and moist, and in modei-ately severe cases the lips are often fissured. In advanced cases the tongue may be brown and deeply fissured, and the buccal mucous membrane dry and harsh. Palpation.— The pulse is rapid (90 to 100'), out of proportion to the fever, and in severe cases it may reach 120 or more a minute. It is strong and wiry at first, but later it frequently becomes weak, dicrotic, and compressible. Fig. 225. — Method of Determining the Degree of Abdominal Tension, which is Increased Over Enlarged Solid Visci, Prolapsed Stomach, Various Abdomin.al Tumors, Flo.ating Kidney, AND Over the Muscles Overlying Acute Inflammatory Processes. TeDaion is universally increased in general peritonitis, ascites, and tympanitis. Firm pressure over the site of the appendix (Tig. 224) will elicit a varial^le degree of tenderness, and often excite pain. Fixetl tenderness is practically constant on pressure over a limited area at the center of a line between the anterior superior iliac spine and the umbilicus, and is a very valualjle sign in appendiceal inflammation. Fixed tenderness at the right of the umbilicus is extremely unusual, although it has been observed. Tenderness may be distributed at different points of the abdomen (Fig. 224), but within a few hours after the onset it becomes localized at McBurney's point. Palpation also elicits unusual rigidity over the right rectus muscle, a sign that is present early, even before actual tenderness is evident. The degree of tension of the two rectus muscles should be compared in every questionable APPENDICITIS. 539 case of appendicitis, and although increased tension is not an infallible sign, it is to be regarded as one of great significance in formulating a careful diagnosis (Fig. 225). Circumscribed induration manifests itself about the second day, and is soon followed by swelUng and obliteration of the' normal curvatures about the ihac spine. Percussion over any portion of the abdomen discloses the greatest amount of tenderness or pain to be present in the right inferior abdominal quadrant and at the site of the appendix. I/aboratory Dias:uosis. — The urine is scanty, of high specific gravity, rich in indican, and in about 40 per cent, of cases contains a trace of serum- albumin. Frequent urination is by no means uncommon, but the twenty-four- hour quantity seldom equals 50 fluidounces. There may be an increase in the colloidal coefficient. Leukocytosis is the rule — 10,000 to 25,000 cells in a cubic millimeter. If a differential leukocyte count shows over 75 per cent, of polymorpho- nuclear elements, pus is probably present. We have observed both private and hospital cases when the number of leukocytes per cubic millimeter ap- proximated normal. Pus when encapsulated may exist without exciting leukocytosis, therefore the blood findings are not constant in subacute or in chronic forms of appendicitis. Illustrative Case of Acute Appendicitis. — J. R., female, aged nineteen years; height, 5 feet, 8J inches; weight, 142 pounds. Family History. — Father living at the age of forty; mother, at thirty-eight, and both enjoy good health. An older brother died of organic heart disease at the age of sixteen, and a younger sister of scarlet fever at the age of twelve. No history of tuber- culosis, mahgnancy, or inherited disease in ancestors. Previous History. — Had the diseases of childhood, including measles complicated by catarrhal pneumonia at the age of fourteen. Has enjoyed good health during the past five years. Social History. — A pupil in the senior class at high school. For the past year parents have noticed that she finds her school work unusually difficult. Her appetite is good, and she takes a fair amount of outdoor exercise daily. Present Illness. — While in the mountains during her summer vacation she ate more than usual, and upon one occasion suffered from a severe attack of abdominal pain, accompanied by nausea, vomiting, and later by obstinate constipation. She complained chiefly of soreness over the right inferior abdominal quadrant, the soreness being in- creased by exertion. The character of food taken did not appear to exercise any in- fluence upon her general condition, although her discomfort was more pronounced when constipation existed. Ten weeks later, and following the original seizure, she experi- enced a severe attack of abdominal distress, accompanied by violent vomiting, which compelled her to take to her bed. Paroxysmal -pain was situated midway between the anterior-superior spine of the right ilium and the imibiHcus, was cramp-like in character, and aggravated by move- ments and by pressure over the involved area. Pain radiated to the right thigh and down the right leg as far as the knee; there was also distress in the right lumbar region. Acute pain lasted for about twelve hours, and subsided after purging with citrate of magnesia. During the first thirty-six hours the temperature fluctuated between 99° and 101.4° F., when it fell gradually to the normal. Physical Examination. — General. — During the interval between the attacks the patient showed a decided tendency to incline toward the right side when standing, she also bent slightly forward, and there was moderate drooping of the right shoulder. The complexion was normal, the body well nourished, and the general appearance showed but little evidence of disease. Local Examination. — Palpation. — The muscles of the right abdominal wall were distinctly rigid as compared with those of the left side of the body, and upon firm pressure over this area tenderness was elicited for several days following the paroxysmal attack. Laboratory Findings. — The quantity of urine voided during the twenty-four hours approximated the normal, and was free from albumin and glucose, although it gave a decided reaction for indican. Microscopic and ohemic examinations revealed noth- ing of pathologic interest. 540 THE INTESTINES. Diagnosis by Induction from the Clinical Data. — The occurrence of an attack similar to the present one ten weeks previously was suggestive. The history of an acute onset of intestinal pain develoning in a young and previously healthy indi- vidual, and the additional fact that such pain was locaUzed to the inferior right abdomi- nal quadrant, aroused a strong suspicion as to the nature of the disease. Extreme tenderness at McBurney's point and rigidity of the muscles of the right abdominal wall were confirmatory of the existence of appendicitis. The patient's attitude, flexing the right thigh upon the abdomen and inclming sUghtly toward the right side, was also significant. Again, the thermic changes pointed to appendicitis. Differential Diagnosis. — The acute onset of the first attack, following dietetic error, strongly suggested the possibility of acute gastritis or intestinal coUc, since vomiting and abdominal pain were among the conspicuous symptoms. The con- dition was distinguished from the two last-named maladies by the following: First, the pain was soon definitely referred to the region of the appendix; second, there was circumscribed tenderness at McBurney's point, and rigidity of the right abdominal muscles was present; third, localized tenderness existed for a period of three days. Course of the Disease. — The patient came under our care during the second attack of abdominal pain; she was kept in bed for a period of eight days following the initial symptoms, and was then removed to the hospital for operation. The appendix was found considerably congested, and there were many adhesions about that organ, the colon, and the right ovary. She made an uneventful recovery, and returned to her home at the end of the third week, since which time she has been in good health. Summary of Diagnosis.— This is based, first, upon the presence of abdominal pain, which eventually becomes more or less strictly localized to the region of the appendix, the history of previous attacks, the presence of persistent vomiting, and the position. of the patient, e. g., he inclines toward the affected side, and the right thigh is flexed upon the abdomen. Careful palpation is also invaluable in formulating a diagnosis, since rigidity of the right rectus muscle and localized tenderness at McBurney's point are among the important signs of this affection. Moderate fever, when present, should be regarded as an important symp- tom, yet the absence of fever and the presence of the other essential features of the disease are at times observed. The character of the attack, e. g., sudden onset, gradual increase in pain, which eventually becomes localized, vomiting, and constipation, is to be considered in formulating a diagnosis of acute appendicitis. DiflFerential Diagnosis. — See' differential table, as follows. TABLE SHOWING THE DIFFERENCES BETWEEN ACUTE RENAL COLIC, EXTRA-UTERINE HEPATIC COLIC. 2. Appendicitis. 1. History of previ- ous attacks common. Pain over the right half of the abdomen, be- coming local- ized later at Mc- Burney's point. As the disease ad- vances the pain becomes circum- scribed at Mc- Burney's point. Renal Colic. 1. History of prev- ious attacks common. 2. Pain may be lo- calized at either side of the abdomen, along the course of the ureter. 3. Patient can feel the pain get- ting lower and lower until stone escapes into the blad- der. PREGNANCY WITH extra-utbrine Pregnancy with Rupture. 1. History of ster- ility. 2. Pain low and at the center of the abdomen. APPENDICITIS, RUPTURE, AND 3. Pain disappears in a short time, and is followed by the symp- toms of inter- nal hemorrhage. Hepatic Colic. 1. History of pre- vious attacks. J. P a i n in upper right abdominal quadrant. Pain radiates to right shoulder. APPENDICITIS. 541 Appendicitis. — (Continued.) [. Vaginal hemor- rhage absent. ). Temperature, 99° to 102° F. or, rarely, higher. 6. Frequent mictu- rition ; urine rich in indican. Renal Colic. — (Continued.) 4. Vaginal hemor- rhage absent 5. Temperature may be sub- normal, fol- lowed by rapid rise, and then drop by crises. 6. Frequent mictu- rition; urine bloody. 7. Localized tender- ness at Mc- Bumey's point, and pressure here intensifies the pain. 8. Distention of the right inferior abdominal quad- rant within the first twenty- four hours. 9. Negative. Extra-uterine Preg- nancy WITH Rup- ture. — (Continued.) 4. Vaginal hemor- rhage present. 5. Temperature subnormal for several hours. 6. Negative, urine blood-stained by vaginal flow. 7. Localized ten- 7. Pressure derness not tive. constant. Pres- nega- sure exercises but slight in- fluence. No distention of 8. May be abdomi- the abdomen. nal distention due to hem- orrhage. 9. Negative. 9. Negative. Hepatic Colic. — • (Continued.) 4. Vaginal hemor- rhage absent. 6. Temperature may rise abruptly to 102° to 105° F., and fall by crisis. 6. Urine contains bile twelve to twenty - four hours after the initial pain. 7. Tenderness in the epigastrium and over the gall- bladder. 8. No abdominal dis- tention. Jaundice twenty- four hours after the attack. Among the conditions that may be mistaken for acute appendicitis, acute indigestion occupies a prominent place. Fixed pain in the region of the appendix and localized tenderness are two of the strong clinical points in favor of appendicitis, and in the absence of these symptoms, with intestinal derangement, acute indigestion with colic is highly probable. Cholecystitis, with Distention. — ^This gives rise to a superficial mobile, pear-shaped tumor, with or without jaundice — all of which features are not encountered in appendicitis. The tumor in appendicitis is generally below the umbUicus, but when the appendix extends upward, the tip may touch the gall-bladder, making an accurate diagnosis impossible. Acute Peritonitis due to Pelvic Disease. — When the diseased ap- pendix occupies the pelvic fossa, the differentiation between right-sided salpingitis and appendicitis is difficult. Right ovaritis, owing to the presence of pain, tenderness in the right iliac fossa, and fever, often closely simulates appendicitis. In ovaritis, however, tenderness is less pronounced, and the organs of generation show certain disturbances (menorrhagia, etc.). A complete history, coupled with a careful pelvic examination, will usually enable one to distinguish between these two conditions. The following table shows some of the distinctive features between pyosalpinx and appen- dicitis. Pyosalpinx. 1. History of gonorrhea, puerperal sep- sis, or of long-standing leukorrhea. 2. Pain most marked at or near the men- strual period. 3. Escape of purulent discharge from the cervix uteri. Periodic discharge of a large quantity of pus from the vagina. Appendicitis. 1. Negative. 2. Not appreciably influenced by men- struation. 3. Absent. 542 THE INTESTINES. Pyosalpinx. 4. Digital examination shows swelling in the region of the ovary and tube, and a soft, sausage-like tumor may- be present. 5. Progressive secondary anemia the rule. 6. Vomiting unusual. 7. Micturition undisturbed. 8. Temperature irregular (septic) in char- acter. 9. Chills, followed by fever and sweats, quite common. 10. There may be constipation or diar- rhea. Appendicitis. 4. Tenderness upon digital examination, but a tumor mass is not common. 5. Less conspicuous. 6. Vomiting common. 7. Frequent micturition early during an attack of appendicitis. 8. Temperature 99° to 102° F., and of an irregular type. 9. Unusual. 10. Obstinate constipation the rule. Perinephritic Abscess. — A diagnosis is made either from the history of previous attacks of nephritic colic or by exploratory incision. Analysis of the urine may be of service if perinephritic abscess communicates with the pelvis of the kidney. Acute Tuberculous Peritonitis. — In both appendicitis and tuberculous peritonitis there are pain, tenderness, and fever; in the latter condition, however, the onset is more gradual, and the signs of tumor and increased resistance in the ileocecal region are absent. Movable dullness may be pres- ent in a tuberculous affection of the peritoneum. Acute hemorrhagic pancreatitis simulates appendicitis with gener- alized peritonitis. The deep-seated epigastric pain and shock present in pancreatic hemorrhage are absent in appendicitis. Dietl's Crises. — -In movable kidney all the symptoms may point toward appendicitis. A history of similar attacks, following which the patient voids large quantities of urine, renders the diagnosis clear. In patients who have suffered from Dietl's crises the kidney is readily palpable. (See differential table, p. 540.) Acute Intestinal Obstruction. — Here tumor, if present, is not likely to be situated in the right inferior quadrant. The portion of the bowel below the obstruction is at times thoroughly emptied, and the discharges are fre- quently serous and bloody. Stercoraceous vomiting develops somewhat early in intestinal obstruction, and is an extremely uncommon symptom in appendicitis. Neurasthenia may also simulate acute appendicitis. (See Fig. 226.) Chronic Appendicitis. Clinical Definition. — A condition in which repeated attacks occur at intervals of weeks or months, each relapse being characterized clinically by the symptoms and signs of acute appendicitis. General Remarks. — During the intervals between attacks the patient may be free from symptoms of acute appendicitis, although many patients constantly complain of a sense of discomfort and of moderate soreness about the region of the appendix. Relapses appear to be brought about by muscular effort, indiscretions in diet, acute gastritis, and constipation. Nervous Manifestations.— When the patient has been told that he is suffering from appendicitis, and when two or more attacks have occurred, APPENDICITIS. 543 he becomes extremely nervous. Neurasthenia and hysteria may develop, and the general health may become impaired. Summary of Diagnosis. — The diagnosis of chronic, as of acute, ap- pendicitis rests largely upon the foUowing factors: (1) The historj^ of local- ized tenderness; (2) pain at McBurney's point, (3) the existence of fever, which is often slight during each relapse. Diflferential Diagnosis. — Chronic appendicitis must be distinguished from carcinoma of the cecum and from tuberculosis of the cecum. Typhlitis has been considered conjointly with and as resulting from chronic appendicitis. Carcinoma of the cecxmi presents certain points of similarity to chronic appendicitis. The amelioration of all the symptoms for a period of weeks or months favors the existence of appendicitis, for in carcinoma there are no distinct intervals of remis- sion. Fever is also a feature of chronic appendicitis, and is, as a rule, unknown in carcino- matous disease of the colon. Emaciation and progressive weakness are more pronounced in carcinoma than in appendi- citis. Appendicitis is a disease of youth and early adult and mid- dle life, whereas carcinoma of the colon is rare before the for- tieth year. Tuberculosis of the cecum does not resemble chronic ap- pendicitis until a variable de- gree of localized peritonitis is present. In tuberculosis there Fin. 226.— Localized Area of IIypehsensitiveness I'c ri^ ri;o+;>TO+ n'n+Q,.m;o.j;/^,i r^( SEKN IN NEURASTHENIC INDIVIDUALS AND LlvBLE lb nu aiSlinci mieiimbSlon Ui rj,Q ^^ Mistaken for Abdominal Disease. symptoms, fever is usually ab- sent or mild, and diarrhea is more common than constipation. The detection of tubercle baciUi in the stools makes the diagnosis of tuberculous enteritis positive. Recurrent Appendicitis. Clinical Definition. — A condition in which successive attacks of acute appendicitis occur in the same individual at intervals of from several months to one or more years. General Remarks.— Severe attacks may follow comparatively mild ones, or, on the other hand, each successive attack may be more and more mild for an indefinite time. The severity of the previous attack is no guide to the grade of the inflammation of the next recurrence. Clinical Course.— Mild forms of catarrhal appendicitis tend to go on toward recovery in the majority of instances, although these comparatively mild cases may cause the formation of peritoneal adhesions. Severe cases of catarrhal appendicitis, and particularly those occurring after the patient has had one or more previous attacks, may teiminate fatally unless surgical treatment is instituted. There is no means by which it is possible to estimate satisfactorily the danger in any case. The temperature and general condition 544 THE INTESTINES. of the patient may be confusing, and, in fact, in selected cases of appendicitis, may be misleading. Irrespective of how mild the symptoms may be, the tendency is for an acute appendiceal process to become more and more general in its distribution, and such extension may take place without ma- terially influencing the pulse, the temperature, or the degree of pain. Suppuration may follow in those cases that apparently run an insidious course, and it must be remembered that fever is not a coiistant finding in appendiceal suppuration. It must also be emphasized that in this condition a subnormal or normal temperature may be present in cases that are as serious as those displaying a temperature of 101° or 102° F. Complications. — Complications of any kind materially increase the danger in aU types of appendicitis. Among the more frequent complications are abscess, perforation of the colon followed by general peritonitis, perfora- tion of the colon with localized peritonitis, and localized peritonitis with the formation of adhesions and consequent lessening of the lumen of the intestine. Mortality. — Collectively speaking, Fitz estimates the mortality for appendicitis at 14 per cent., but in our experience a much lower mortality rate has followed early surgical treatment. The more chronic the type of appendicitis, judging from the symptoms and frequency of attacks, the more uncertain is the prognosis. In our opinion, the mortality rate in all forms of appendicitis is greatly reduced by prompt surgical treatment, except in those cases in which other conditions make surgical interference impracticable. CHOLERA INFANTUM. General Remarks. — A type of diarrhea seen in young children, in which the general symptoms bear a striking resemblance to those of Asiatic cholera, but develop after the ingestion of impure milk or improper food. Characteristic Features. — The onset is sudden, and is characterized by the passing of an unusually large quantity of feces. A distinctive feature between cholera infantum and the other types of diarrhea previously out- lined is that no diarrhea or intestinal trouble antedates cholera infantum. Gastric Symptoms. — Vomiting is an almost constant symptom, de- veloping early and continuing throughout the attack. There is complete anorexia, and even ice is ejected almost immediately after it is taken. In- tense thirst is present. Thermic Features. — The temperature rises early to 103°, 104°, or 105° F., and may reach 106° or 108° F., but with the approach of the general symptoms of collapse the fever soon falls to normal. Eventually, the ex- ternal temperature is subnormal in severe cases. Nervous Manifestations. — ^The child may be extremely nervous at the onset, but later, as the vomiting subsides, he falls into a semicomatose state and coma finally develops. I^aboratory Diagnosis.— Within a few hours after the onset the stools become watery, and yellowish-green in color, and as the condition progresses the dejecta become watery. To the naked eye the stools contain shreds of mucus and small floccuh. The stools may not emit a distinct odor, although occasionally an odor of musk is present. The frequency of stools varies greatly, numbering from 12 to 50 a day. The vomitus at first contains the contents of the stomach, but later it is often bile-stained and of the consistence of water. Summary of Diagnosis.— The diagnosis is based upon: (1) The history of the ingestion of decomposed food; (2) the copious evacuation of the bowel and the character of the bowel movements; (3) the rapidity of the ENTERALGIA. 645 heart's action and high temperature that prevail early during the attack; (4) the great tendency toward collapse ; (5) the character of the vomitus. Clinical Course and Duration. — In practically all cases of cholera infantum the prognosis is guardedly favorable. In those instances in which judicious treatment is instituted early, convalescence may be established in from one to four days, or later by the end of the first week. The intestinal symptoms commonly assume a subacute course between the first and fourth days, after which convalescence may not be established for several days or even for weeks. NERVOUS DIARRHEA. General Remarks. — A peculiar condition in which no true pathologic lesions are foimd, but in which there is an increased motor power of the bowel that results in diarrhea. Generally speaking, nervous diarrhea should be regarded as reflex, since it frequently develops after fright, attacks of hys- teria, mental strain, and psychic influences. The number of stools may vary from three to twenty a day, but such stools do not present anything charac- teristic. Patients afflicted with this condition are, as a rule, well nourished, but of a neurasthenic temperament. Diflferential Diagnosis. — Nervous diarrhea is to be distinguished from chronic dysentery, the latter condition being characterized by its pro- longed duration and by the character of the stools. (See p. 734.) The fact that the diarrhea always follows nervous excitement differentiates nervous diarrhea from that due to dietetic errors. (See Summer Diarrhea of Children, p. 544.) ENTERALGIA (Intestinal Neuralgia). General Remarks. — Neuralgic pain of the intestine may be localized or general, and in those cases in which there is associated enterospasm, the condition may be sufficiently severe to constitute intestinal colic. Predisposing- and ISxciting Factors. — Enteralgia is usually the result of a neurosis, occurring in debilitated and neurasthenic individuals. At times it results from the ingestion of certain foods or from excitement. Enteralgia may be reflex in character, and follow the taking of indigestible or metallic substances into the stomach, infection by intestinal parasites, obstinate constipation, and the like. Enteralgia the result of organic disease is best seen in the crises of loco- motor ataxia, and may be due to toxic poisons, as evidenced by the intense abdominal pain of lead workers. (See Enterospasm.) There is unusual sensitiveness of the intestine in pei'sons suffering from chronic appendicitis and from peritonitis of long standing. Principal Complaint. — Enteralgia may develop suddenly, or it may set in less abruptly, and is then attended with eructations of gas and flatu- lence. In the fully developed attack the pain may be so violent as to cause the patient to faint. The pain is described as boring, tearing, or lancinating in character. It is not localized at any particular portion of the abdomen, but, on the contrary, is likely to be diffuse. Attacks may be brief, or less often they are prolonged for hours or even weeks. Sudden subsidence of the pain is quite characteristic. Recurrences are the rule, but the intervals during which the patient is free from pain vary both in different cases and in the same patient. Hypogastric Neuralgia. — When neuralgic pain is limited to the epigas- trium, it is usually termed " epigastric neuralgia." Examples of this type are seen in locomotor ataxia and in rectal and ovarian diseases. 35 546 THE INTESTINES. Clinical Course and Duration.— The prognosis depends entirely upon the etiologic factors. As a rule, when the patient's general condition is good, improvement follows. CARaNOMA OF THE INTESTINE. General Remarks. — Carcinoma of the bowel may be either primary or secondary in nature. Primary carcinoma of the intestine, however, is rare in comparison with the great frequency with which carcinoma occurs elsewhere. Carcinomatous involvement of either the large or the small in- testine is a common cause of chronic intestinal obstruction. The occlu- sion is effected both by direct pressure and by intrusion of the growth upon the lumen of the gut. Predisposing and i^xciting Factors.— Age— after forty— and heredity stand as prominent predisposing factors. Gastro-intestinal ca- tarrh and intestinal ulceration render the patient especially susceptible to carcinomatous disease. Principal Complaint. — Clinically speaking, carcinoma of the lower portion of the intestine, especially when it involves the rectum, belongs to a special field of surgery, namely, proctology. The chief symptoms are distress, which increases progressively until there is intense pain, which may radiate from the rectum. The first discomfort experienced by the patient occurs during defecation, but with the progress of the disease the pain be- comes almost constant, although it is always increased during and after defecation. Diarrhea usually alternates with constipation, and when a con- siderable portion of the rectal mucosa is involved, blood and bloody mucus are passed with the feces. As in carcinoma in other portions of the body, there are progressive loss of strength and emaciation, together with anxiety. If the carcinoma is situated above the rectum, the patient's symptoms are often vague, and, in fact, there is no definite group of symptoms character^ istic of carcinoma of this portion of the bowel. Progressive emaciation and weakness are, however, constantly present. Irregular attacks of lancinating abdominal pains usually occur, generally some hours after eating or after defecation. Nausea, vomiting, and anorexia are the rule. When carcinoma involves the duodenum, the vomiting of bile and jaundice is common. Physical Signs. — Inspection. — The patient is emaciated and ca- chectic. When the neoplasm involves the sigmoid flexure of the colon, a peristaltic wave is often seen above the site of the obstruction. In selected cases it may be possible to detect an irregular enlargement of the abdomen. Palpation. — By means of palpation it is often possible to outline a dis- tinct mass in the abdomen, and the portion of the intestine involved is quite readily approximated by the situation of the tumor. A nodular abdominal growth is almost invariably carcinomatous in nature. Location of the Growth. — To determine the site of a palpable, supposedly carcinomatous abdominal tumor, the following points may be of service: (a) A hard, nodular mass situated near the median line, between the ensi- form and the umbilicus, would suggest a gastric or duodenal lesion. If jaundice is present, the lesion is most probably duodenal. (6) A tumor situated in the right iliac region, probably has its origin in the lower portion of the ascending colon or the cecum. (p) A mass in the left iliac region, or even slightly above the brim of the pelvis, is suggestive of involvement of the sigmoid flexure or descending colon. (d) In neoplasm of the splenic flexure the colon may be drawn from its CARCINOMA OF THE INTESTINE. 547 normal position and the tumor be detected to the left of the median line and possibly as low as the brim of the pelvis. ' Percussion is of value when the tumor mass is large, revealing, as it does, an area of dullness of variable size. By distending the colon with air or water, it is possible, on making percussion over the distended portion, to determine the exact extent of the carcinomatous involvement, and this means of diagnosis may enable the clinician to distinguish between tumor of the colon and tumor extending from adjacent structures. I/aboratory Diagnosis.— The quantity of urine voided during the twenty-four hours is approximately normal, except during the attacks of diarrhea, when it is decidedly lessened. In those cases suffering from chronic obstruction the feces are passed in small nodular masses, or there may be the so-called thread-like or ribbon-like stools, which are quite characteristic. Summary of Diagnosis. — In the majority of instances the diagnosis rests largely upon the age of the patient, the nature of the pain, and the fact that it increases progressively from day to day. The character of the bowel movements and the presence of blood and mucus in the stools are also of great importance in formulating a diagnosis. Differential Diagnosis.— The following conditions may be mistaken for carcinoma of the intestine: (1) Early during its course carcinoma of the rectum is frequently confused with chronic dysentery, on account of the blood and mucus that are passed with the stools. Much stress should be laid upon the presence of an abdominal tumor and the detection of the peri- staltic wave through the abdominal wall. Progressive emaciation and ca- chexia, although always present in carcinoma elsewhere, are also present, though in a lesser degree, in other diseases in which starvation is evident. (2) Fecal impaction may be dependent upon carcinomatous stenosis of the colon, and therefore the distinction between these two conditions may be made largely upon the presence or absence of pain, cachexia, and emacia- tion, all three of which symptoms are less marked or entirely absent in simple fecal impaction. (3) The tumor resulting from intussusception differs from carcinoma in that it develops abruptly, the pain being acute, instead of boring, as in carcinoma. Intussusception is of short duration, whereas carcinoma is chronic. (4) Carcinoma of the head of the pancreas differs from carcinoma of the intestine in that the tumor mass is not movable. Jaundice is common. (5) Carcinoma of the gall-bladder may result in stenosis of the com- mon bile-duct, when distention of the gall-bladder may be confounded with tumor of the colon, and here the differentiation is at times possible after in- flating the colon. (6) Hydronephrosis and floating kidney are differentiated from neoplasm of the colon by the fact that these tumors are freely movable when the patient is turned from side to side. The tumor does not interfere with distention of the colon by either gas or water. A fact to be borne in mind is that neoplasm of the abdomen, developing outside the colon, may, by pres- sure or by the formation of adhesions, lessen the lumen of the colon, and in this way produce the signs and symptoms of carcinoma of the bowel. Clinical Course. — As a rule, carcinoma of the intestine pursues a rapid course, terminating fatally in from a few weeks to six or even twelve months. When the pathologic changes in the colon are cirrhotic in nature, the disease may run a course of two or more years. 548 THE INTESTINES. Complications. — Among the complications the most serious is per- foration of the intestine, which is usually followed by acute suppurative peri- tonitis. Carcinoma of the rectum is likely to form fistulous openmgs mto the vagina and bladder. Owing to stenosis of the rectum, mstances have been reported in which overdistpntion of the colon was followed by general pen- tonitis. CHOLERA MORBUS (Cholera Nostras; Acute Dyspeptic Diarrhea). Pathologic Definition.— An acute self-Hmited disease, excited by the eating of large quantities of indigestible food. Predisposing and Exciting Factors.— Age.— Children and young adults are most prone to this disease. When it develops in infants the con- dition is usually referred to as cholera infantum. (See p. 544.) Season. — During the summer months this disease is quite common, the greatest number of cases being seen during July, August, and September. Unhygienic surroundings without doubt contribute toward the production of cholera morbus, although the disease develops among the well-to-do classes quite as frequently as among the poorer. The theory has been ad- vanced that this disease is probably microbic in origin. The variety of food taken certainly plays an important role in its production, since the eating of unripe fruits and of vegetables, such as string-beans, peas, egg-plant, cucum- bers, etc., is often followed by an attack. Principal Complaint. — A history of gastro-intestinal catarrh con- tinuing for several days is quite common, and the patient wUl usually admit having eaten some indigestible substance or unripe fruit and vegetables. The onset is, comparatively speaking, sudden, and is ushered in with acute abdominal pain, followed by violent vomiting, severe diarrhea, and a tendency toward faintness. In addition to intestinal cramp there are also cramp-like pains in the calves of the legs, thighs, and at times in the muscles of the forearms. In severe cases there is intense thirst, and the patient is unable to retain either liquids or solids taken by the mouth. Thermic Features. — ^The temperature rises abruptly to from 100° to 104°, 105°, or even 106° F., remaining high during the acute stage of the disease; when the symptoms of collapse appear, the cutaneous temperature may be subnormal, whereas that of the rectum may be above 104° F. Physical Signs. — Inspection. — ^The patient usually assumes a re- cumbent posture, with the legs well flexed upon the abdomen; the expression is anxious, the face is pale, the cheeks are sunken, the lips are cyanosed, and the abdomen is scaphoid in shape. Palpation. — ^Tenderness upon deep pressure over the stomach and colon may be elicited. The skin soon becomes cold and clammy, and is often beaded with drops of cold perspiration. The hands, feet, and nose are ex- tremely cold. The pulse soon becomes weak, the beats numbering from 110 to 140 a minute, and unless treatment is instituted early, it may become irregular and dicrotic. I,aboratory Diagnosis. — The number of stools voided during the early stages is extremely high. At first they contain only the contents of the bowel, generally partially digested food, each movement being accom- panied by the passage of a large amount of flatus. Later the stool may be almost watery, and finally it becomes serous in character. The vomitus at first contains the contents of the stomach, with some ACUTE GENERAL PEHITONITIS. 549 of the food that has been previously taken, but later it may be made up of watery material. A bacteriologic study of the vomitus and of the feces will reveal the presence of a number of bacteria, many of which are non-pathogenic. Finkler and Prior describe a spirillum which they found present in a large percentage of cases, but since streptococci and staphylococci are also occasionally present, it is quite difficult to estimate the pathogenicity of any one special organism cultivated from either the vomitus or the dejecta. The urine is diminished in quantity, high in color, rich in indican, and often contains a trace of albumin. Stunmary of Diag'tLOSis. — A history of the ingestion of a large amount of indigestible food, and particularly of unripe fruits, is highly important. Violent vomiting, together with purging, intestinal colic, and cramps in the muscles of the extremities, are in themselves quite characteristic of cholera morbus. The appearance within the course of a few hours of extreme pallor, subnormal temperature, a weak, rapid pulse,, and the fact that the patient's face is beaded with perspiration, all further substantiate the diagnosis. Diflferential Diagnosis. — The general clinical picture of cholera morbus is quite similar to that of Asiatic cholera, but the geographic loca- tion and the absence of an epidemic, together with a clear history of the eating of certain unripe fruits, will be of great value in making a differentia- tion. A bacteriologic study of the feces and of the vomitus will enable one to distinguish positively between these two conditions, since the comma bacillus is always present in those suffering from Asiatic cholera. Great care should be exercised in obtaining a careful clinical history, as this will serve to exclude the possibility of ptomain poisoning and of poisoning by drugs (e. g., arsenic). Clinical Course and Duration. — In the majority of cases of cholera morbus that tend to terminate favorably all the alarming symptoms sub- side in from three to six hours. In severe types of this condition the acute may be followed by a series of subacute symptoms, which may continue for from twenty-four to forty-eight hours. When cholera morbus develops in indi- viduals who were previously healthy, a fatal termination is rare, and, in fact, the vast majority of all cases terminate favorably when judicious treat- ment is instituted early. The element of danger is that of profound collapse, and with this in mind, the physician is usually able to apply the treatment necessary to ward off this fatal symptom. Complications and sequelae are rare. DISEASES OF THE PERITONEUM. ACUTE GENERAL PERITONITIS. Pathologic Definition. — A disease characterized by an acute inflam- matory process involving an extensive portion of the peritoneum. Predisposing and Exciting Causes.— Age.— Acute general perito- nitis occurs oftenest between the fifteenth and forty-fifth years, developmg at a time in life when all the abdominal organs are most active. _ General peritonitis has been said to exist even in intra-uterine life, although it is quite uncommon in infants. Holt having found it but four times in 726 consecutive autopsies. In an analysis of 187 cases of acute general peritonitis occurrmg in children. Holt found 25 per cent, to have occurred in the new-bom, 21 per cent, between the first and fifth years, and 54 per cent, between the fifth and 550 THE INTESTINES. sixteenth years. The high percentage of cases found to affect the new-born is attributed to direct infection through the umbilical cord. Sex serves as predisposing factor by reason of the great frequency of suppurative processes along the genital tract, and particularly in the uterus, ovaries, and Fallopian tubes. Again, young females are more likely to suffer from gastric perforation due to ulcer than are males. Gall-stones contribute toward the production of general peritonitis in older subjects, but this con- dition is usually followed by a local inflammation of the peritoneum, and un- less rupture occurs, a general involvement of the serous sac is not to be ex- pected. It is generally believed that peritonitis may be a primary disease, but it is found to occur more often as a terminal complication of gout, general arteriosclerosis, rheumatism, and chronic Bright's disease. _ In the vast majority of all cases acute peritonitis develops as the result of infection from an adjacent viscus the surface of which is covered with peritoneum, or from rupture of one of the hollow abdominal viscera, e. g., the colon, appendix, or stomach, tuberculous ulcer of the colon, or carcinoma of the intestine. Ab- scesses in this region may either rupture into the peritoneal sac or infect the peritoneum by the spread of their infection by contiguity. Acute peritonitis follows abscess, perinephritic abscess, empyema, or hepatic abscess. Perito- nitis occasionally occurs as a sequel to septicemia and pyemia. Bacteriologic Causes. — ^Many microorganisms are capable of produc- ing acute general peritonitis; among these are Bacillus coli communis. Staph- ylococcus pyogenes. Streptococcus pyogenes, the bacillus of Friedlander, the pneumococcus, and Bacillus pyocyaneus. In one case seen by us acute general peritonitis was due to Micrococcus tetragenus. The peritoneal sur- face appears to be well adapted for the development of most pyogenic bac- teria. (a) The peritoneum is highly sensitive to the absorption of ptomains, a fact that serves to explain the high mortality rate in this affection. (6) Peritonitis may result from the application of chemic irritants when these are placed directly upon the serous surface. (c) Mechanical irritation, such as that produced by hernia, may give rise to a localized peritonitis that, in turn, may become diffuse. Secondary peritonitis may follow the introduction of certain toxic substances into the intestine, or may be the result of a slight inflammatory process involving the pleura. (d) Rheumatic peritonitis is believed to follow exposure to cold and wet, and to be slightly influenced by season and by climate. Principal Complaint. — This will be found to vary widely, such variations depending upon the character of the onset and the presence or absence of a preexisting suppurative process covered by some portion of the peritoneum, with rupture of this abscess and the discharge of its purulent contents into the peritoneal sac. If general peritonitis follows a localized peritonitis due to an inflammatory process of one of the adjacent viscera, the onset is insidious, extending gradually over the entire peritoneal surface. If pus containing pyogenic bacteria is set free in the peritoneal cavity, the onset is sudden, and the height of the clinical phenomena is reached within a few hours. The early symptoms of peritonitis may be masked by those of the local inflammation that exists within the abdomen, and it is only by the exercise of great care that the clinician can arrive at an accurate interpreta- tion of the clinical features. Pain. — Pain constitutes the chief feature of diffuse peritonitis, and may ACUTE GENERAL PERITONITIS. 551 be of equal intensity over all parts of the abdomen, or, as is common, an acute pain may be localized. It is generally conceded that the area of in- tense pain corresponds to the site of the initial infection of the perito- neal surface — e. g., intense pain in the region of the epigastrium and re- flected toward the back and shoulder points somewhat strongly toward gastric ulcer. In one case seen by us in consultation there was rupture of the stomach, probably the result of an ulcer of long standing; in this case the extreme tenderness and intense pain were in the epigastrium, near the median line, and reflected over the right half of the abdomen, becoming most intense in the right inferior quadrant — McBurney's point. At operation, twenty-four hours after rupture, the peritoneal sac was found to be distended with the contents of the stomach, the appendix was normal, and there was no appreciable disease of the liver or of the intestine other than the diffuse peritonitis. Following rupture of a gastric ulcer the pain may be most intense in the lower half of the abdomen, and cases are recorded in which the reflected pain was limited to the bladder. After general peritonitis is well established it is practically impossible for the patient to inhale deeply, on account of the intense pain. The pain of peritonitis is continuous, although in asthenic patients it may be remittent or intermittent. _ The abdomen becomes tympanitic within the first twenty-four hours, the pain appearing to be exaggerated by such distention. The abdominal mus- cles are spastic, and the movements of the abdomen are restricted. The patient complains that he is unable to take a deep breath, and that he must flex his thighs well upon the abdomen and lie upon his back in order to get relief. Hiccough. — In patients whose strength has been well conserved prior to the onset of peritonitis, hiccough occurs early, and is apt to recur at intervals of but a few minutes, or at longest from one to two hours. Between attacks of vomiting hiccough is an annoying symptom, and is suggestive of extensive peritoneal involvement. In the case previously cited vomiting was not an annoying symptom, whereas hiccough was more or less constant after the first twenty-four hours following gastric rupture. Thirst is absent during the early stages of acute general peritonitis, but develops with the progress of the disease. The patient complains that his mouth and throat are dry and parched, and that his tongue appears to stick to the surface of his lips, teeth, and cheeks. In advanced peritonitis there may be deep fissures of the tongue and lips, from which blood-stained serum may ooze. Again, the tongue may be somewhat rolled together in the back of the oral cavity, and the patient be unable to protrude it. Vomiting is produced by the taking of food and by increased peristalsis, although in many instances the vomiting is more or less continuous. At first the material ejected from the stomach may contain particles of food; later it is yellowish or greenish in color, and contains shreds of mucus. As the disease progresses the vomitus may be brownish in color and emit a fetid odor. Constipation is a fairly constant feature of acute general peritonitis, and may be attributed either to spasm or to paralysis of the muscular coats of the intestine. Occasionally a case may be seen in which diarrhea is present throughout the entire course of the disease. Such diarrhea is attributable to a catarrhal infection (possibly septic) of the intestinal mucosa. Thermic Features. — Peritonitis developing in the robust and prev- iously healthy is likely to be ushered in with a decided rigor or a series^ of chills; even in the asthenic chilly sensations are experienced. Following 552 THE INTESTINES. the chill, provided there has been a rupture of one of the hollow abdominal viscera, there may be shock, which is accompanied by all the nervous and circulatory phenomena of this condition, as, e. g., a subnormal temperature, cold, clammy skin, anxious expression, and a weak, rapid pulse. A few hours later the symptoms of shock subside and the temperature rises steadily imtil it reaches 100° to 101° or 102° F., at which point it remains with mod- erate remissions. An intermittent temperature is occasionally seen. Acute general peritonitis due to infection with the bacillus coli communis may be accompanied by but slight elevation of temperature, the average being from 99° to 101° F. Generally speaking, it should be stated that hy- perpyrexia is unusual in general peritonitis, and when present, is probably due to an acute purulent process outside the peritoneum (puerperal sepsis, for example). In the last type of case, and occasionally in peritonitis af- fecting the previously healthy, the chUl may be followed by a rapid rise in temperature, which may reach 104° or 105° F. within a few hours. In these septic cases the temperature assumes the continued type, reaching 104° or 106° F. by the third or fourth day of the disease. In sthenic subjects the temperature may rise abruptly, but during the first twenty-four hours fol- lowing it may remit, reaching about 101°, and continuing at or near this point throughout the course of the disease. " Rectal temperature is often relatively high" (Anders). Cardiovascular Peculiarities. — If the patient is seen during the stage of shock,ithe heart action will be extremely rapid, the pulse feeble and easily compressed. With the advance of general peritonitis the pulse be- comes rapid, ranging between 120 and 160 beats a minute, and later it will be found to be intermittent, dicrotic, and compressible, the general evi- dences of circulatory collapse occurring, as a rule, between the fifth and twelfth days of the malady. Owing to a general loss of cardiovascular tension and to extra muscular effort on the part of the heart there is often a decided pulsation of the vessels of the neck. The heart's apex impulse may be at the fourth and even the third interspace in the nipple-liue. The heart displacement depends upon the elevation of the diaphragm due to abdominal distention. The area of relative cardiac dullness is seldom greatly increased, whereas the area of absolute cardiac dullness is increased and slightly elevated. Respiratory Symptoms. — The respirations are rapid, varying in num- ber from 25 to 45 a miaute; the expansion is limited to the apex of the chest (superior thoracic t}rpe), although there is an apparent increased lateral expansion at the base. Owing to absence of the movements of the diaphragm, abdominal respiration does not occur. The patient is unable to take a fuU breath, and the acts of sneezing and coughing are accompanied by intense abdominal pain, which is likely to be followed by vomiting. The breath- sounds are decidedly altered and numerous rales are audible. Nervous Manifestations. — In the majority of uncomplicated cases of general peritonitis these are not pronounced, and, in fact, it is customary for the mind to_ remain clear throughout the entire illness, except, say, for a few hours during the night. In certain instances delirium may be mild or extreme, and late in the disease it may terminate in coma. The fact that the patient states that he feels comparatively well except for the abdominal pain shouldbe regarded as a grave symptom. There may be hypersensi- tiveness to light and sound, and the shghtest jar of the bed causes agony. Physical Signs. — Inspection of the abdomen reveals a general symmetric enlargement; the transverse diameter of the abdomen is increased ACUTE GENERAL PERITONITIS. 553 in proportion to the amount of fluid present. Abdominal distention is also influenced by the degree of relaxation of the abdominal muscles; conse- quently in the strong there may be but moderate enlargement. Generally speaking, however, the more decided the abdominal distention, the more virulent is the type of infection. The entire abdomen is immobile. Palpation. — Rigidity of the abdominal wall is more or less pronounced, and is usually extreme after perforation of a hollow viscus. There is marked tenderness at every point overlying the peritoneal sac. After peritonitis has existed for some days, a friction fremitus may be detected over the abdomen. When there is great distention, the edge of the liver is not palp- able, and at the upper portion of the abdomen there is a decided paramesial bulging between the tip of the sternum and the cartilages of the ribs. Percussion over any portion of the abdomen causes great pain, and the note elicited is decidedly tympanitic. We have examined a number of cases in which liver dullness was absent, except in that portion occupying the posterior part of the superior right abdominal quadrant. This absence of liver dullness may be present irrespective of whether or not perforation of the stomach or colon has occurred. We have found at autopsy on sub- jects dead of acute general peritonitis that absence of liver dullness de- pended upon the fact that portions of the intestine had been forced between the surface of the liver and the- abdominal wall. It may be difficult, and at times impossible, to outline the area of splenic dullness in advanced peritonitis. Movable dullness due to the presence of free fluid in the peritoneal sac is at times detectable, yet in the majority of instances the fluid present does not change rapidly with the position of the patient, or the quantity may be too small to give rise to definite physical signs. Late in the course of acute general peritonitis adhesions may form that will materially inhibit the change of position of the abdominal fluid. We have seen cases at postmortem in which several pints of thick, tenacious fluid occupied the peritoneal sac. The lung resonance does not extend as low as normal, and the margin of the lung is elevated in proportion to the degree of abdominal distention. As previously stated, the area of cardiac dullness is elevated (see Cardiac Fea- tures), as shown in a case reported by one of us. Auscultation of the heart has been referred to under Cardiac Phenomena. Decided gurgling, due probably to intestinal fermentation as well as to peri- stalsis, is heard over the abdomen. When peritonitis has existed for a few days, it is possible to detect peculiar friction murmurs that resemble in character those heard over the pleura, but they are less Ukely to be rhythmic, •although in a few instances we have found such murmurs to be synchronous with respiration. I/aborato_fy Diagnosis- — Fluid obtained from the peritoneum will be found to contain pathogenic bacteria, the bacillus coli commimis, the strepto- coccus, and the staphylococcus being the organisms most commonly encoun- tered; any pus-producing bacterium is, however, capable of causing acute peritonitis. The peritoneal fluid is rich in albumin, and microscopically is seen to contain many pus-cells, leukocytes, red blood-cells, and bacteria. The urine is diminished in quantity during the entire course of the malady, but this diminution is commonly in direct proportion to the quantity of liquids taken. After the disease has progressed for forty- eight hours or more, albuminuria frequently develops, and the urine may contain hyaline and granular casts. In one of our cases the urine con- tained blood-casts and red blood-cells in large number. Indicanuria 554 THE INTESTINES. develops early during the course of peritonitis and continues throughout, fluctuating in more or less direct relation to the degree of tympany present. The blood displays decided evidence of suppurative infection, the number of leukocytes rising abruptly to from 10,000 to 20,000 in a cubic millimeter, and a much higher count may be observed. A differential count of the leu- kocytes shows the iacrease to affect chiefly the polymorphonuclear elements (which normally comprise 65 to 72 per cent, of the total number of white cells), which may equal 85 to 95 per cent, of the total number of leukocytes present. In selected cases leukocytosis is absent. The number of red blood-cells in a cubic millimeter is but sHghtly, if at all, altered until peritonitis has advanced for several days, when there may be a corresponding decrease in the number of red cells and in the percentage of hemoglobin (secondary anemia). If the patient has been greatly depleted from hemorrhage or purging, the number of red cells in a cubic millimeter and the percentage of hemoglobin may both be above the normal limit, owing to concentration of the blood. Summary of Diagnosis. — ^The presence of diffuse abdominal tender- ness, which results in extreme pain when the patient moves or when pressure is made over the abdomen; marked tympanites, with rigidity; anxious expression; together with an elevation of temperature (which is governed by the type of infection), and leukocytosis with an abnormally high per- centage of the polymorphonuclear cells are the cardinal symptoms of acute general peritonitis. Clinical Course and Duration. — ^When acute general peritonitis develops in young subjects who have previously been in good health, the duration will vary from four to eight days, according to the predominant microorganism causing the infection. Infection by the bacillus coli com- munis is somewhat longer in duration, ending fatally between the eighth and fourteenth days. If the type of infection is highly virulent and the amount of purulent material that has escaped into the peritoneal cavity is large, the patient seldom survives such infection longer than forty-eight hours. The asthenic forms of diffuse peritonitis, while they display less pro- nounced local symptoms at the onset, are equally as fatal as those of the sthenic type. Acute general peritonitis resulting from intestinal per- foration, appendicitis, gastric ulcer, duodenal ulcer, etc., is severe from the onset, and tends rapidly toward a fatal issue. Rheumatic peritonitis may occur during the course of, or during convalescence from, acute articular rheumatism, and is the only type of acute general peritonitis that is amen- able to medicinal treatment. ACUTE LOCALIZED PERITONITIS. Pathologic Definition. — An acute, circumscribed inflammation of some portion of the peritoneum that overlies an organ known to be the seat of an inflammatory process. Varieties. — Localized peritonitis is often referred to as pelvic, in which caseit arises from extension of an inflammatory process affecting the uterus (perimetritis), ovaries (peri-ovaritis), bladder (pericystitis), or appendix. If the circumscribed inflammation is located in the superior right abdominal quadrant, it is designated as perihepatitis or subdiaphragmatic peritonitis; when the peritoneum covering the spleen is involved, the condition is known as perisplenitis. Circumscribed areas of inflammation may arise at any ACTJTE LOCALIZED PERITONITIS. 555 portion of the peritoneum as the result of carcinoma, tuberculosis, or rheumatism. Predisposing and Exciting Factors.— Puerperal sepsis, gonor- rhea, pyosalpinx, appendicitis, gall-stone, abscess of the liver, ovarian ab- scess, tuberculosis of one of the glands of the abdomen or of either the hollow or the solid abdominal viscera, primary carcinoma of the peritoneum or secondary carcinoma. Principal Complaint.— Localized tenderness of the abdomen with acute lancinating pains upon movement or upon deep pressure over the tender area, constitute the chief complaint in connection with localized peritonitis. The degree of pain and of discomfort varies in direct correlation with the area of peritoneal surface involved and with the amount of movement com- mon to the abdominal wall overlying the inflamed peritoneum. These symptoms are milder than those seen in acute general peritonitis, and are often entirely concealed for a time by the symptoms referable to the organ known to be the primary seat of the infection. If the acute localized peritonitis becomes general, all the symptoms of acute diffuse peritonitis previously described (p. 550) appear within the first twenty-four hours. There is often a tendency for acute localized peritonitis to subside gradually between the third and tenth days, and to continue for an indefinite period, running a subacute course. Constitutional symptoms, as seen in acute general peritonitis, vary in direct proportion to the extent of the peritoneal inflammation present. Thermic Features. — The temperature in localized peritonitis varies with the character of infection from which it has arisen — e. g., in pelvic peritonitis following puerperal sepsis the temperature may be high — 102° to 104° F. — and of the continuous type, although we have seen cases in which the temperature did not exceed 101° F. In perihepatic and localized peri- tonitis the temperature is more likely to be lower (100° to 101° F.) than when the peritoneum of the pelvis is involved, this peculiarity probably de- pending upon the fact that pelvic peritonitis is likely to be excited by vir- ulent pus-producing organisms — e. g., streptococcus and staphylococcus. There is no appreciable elevation of the temperature in acute localized peri- tonitis resulting from carcinomatous or tuberculous infection, and, in fact, these forms of peritonitis are frequently accompanied by a subnormal tem- perature during the morning hours. I/aboratory Diagnosis. — ^Usually, when acute localized peritonitis follows suppuration of some of the pelvic organs, leukocytosis is present with the other evidences of secondary anemia. (See Laboratory Diagnosis of Acute Peritonitis.) The urine generally contains indican, even when the area of peritonitic involvement is small. Summary of Diagnosis. — The presence of localized abdominal ten- derness and pain, which are increased by deep inspirations and by pressure over the abdomen, serves as the cardinal symptom of acute localized peritonitis. The temperature is also an important factor, but is in no way charac- teristic, being controlled largely by the degree of fever resulting from the initial infection. Duration. — Acute localized peritonitis rims a course of varied duration. It usually begins abruptly, and continues until the inflammatory process that has extended to the peritoneum from one of the adjacent tissues has abated. In a great many instances localized peritonitis is amenable to sur^ gical treatment. 556 THE INTESTINES. SUBPHRENIC PERITONITIS (Subdiaphragmatic Abscess). Pathologic Definition. — An acute inflammation of the peritoneum, which may or may not be suppurative in nature, limited to the right or left lobe of the liver, or at times to the lesser peritoneal cavity and the adjacent peritoneal covering of the diaphragm. Subphrenic abscess may contain air. Rarely, abscess of the liver due to infection with the bacillus coli communis may extend to the subphrenic peritoneum and cause a similar abscess, the walls of which are distended by gas. The Bacillus aerogenes capsulatus is also capable of producing abscess formation and of generating gas. Predisposing and i^xciting Factors. — Extension of inflamrnation from: (a) Perforating gastric ulcer; (6) the appendix; (c) perforation of the intestine; (d) perforating duodenal ulcer; and (e) from extension by contiguity from abscess of the liver or the pancreas. Principal Complaint. — The patient complains of symptoms referable to the preexisting pathologic condition of the abdomen — e. g., gastric ulcer, appendicitis, hepatic abscess, duodenal ulcer, etc. He usually states that the condition occurred somewhat abruptly, with extreme pain and the vomiting of a large quantity of bile-stained or of bloody material. He de- clares that his breathing was difficult at the time this pain occurred and that there was a tendency toward faintness. Within the first forty-eight hours the patient experiences a chill or a series of chilly sensations, which are fol- lowed by profuse drenching sweats; night-sweats are likely to continue. The appetite is poor, there is great prostration, and at times the fever is that characteristic of suppuration. Instances are recorded in which subdiaphragmatic abscess has ruptured through the diaphragm and communicated with the bronchi; in such cases the patient expectorates a portion of the contents of the abscess. One of us has reported a similar case, in which abscess of the liver following amebic dysentery communicated with the lung, and the patient expectorated large numbers of Amoeba histolytica. Pneumothorax may be produced by rup- ture of an abscess into the pleural cavity, and it also occasionally results from a gastric ulcer perforating the diaphragm. Cardiovascular Peculiarities. — If subdiaphragmatic abscess fol- lows rupture of the stomach or duodenum, the pulse will become weak, rapid, and irregular at the onset; but after the symptoms of shock subside, the pulse remains full and strong, with but moderate acceleration, imtil the symptoms of sepsis — e. g., chill, fever, sweats, etc.^ — appear. Following the appearance of these last-named symptoms the pulse increases in frequency and later becomes weak, rapid, compressible, and dicrotic. In one instance, seen at the Philadelphia Hospital, the pulse remained at 140 for a period of twenty-eight days, when a fatal termination occurred. If a large subdia- phragmatic abscess causes pressure upon the thoracic sympathetic system, unilateral flushing, unilateral sweating of the face, and inequality of the pupils are prone to occur. Physical Signs.— Inspection. — There is usually bulging of the upper portion of the abdomen, and if the abscess is situated between the liver and the diaphragm, there is a bulging below the costal margin, due to the liver having been pushed downward. In one case, studied at the Philadelphia Hospital, the outline of the margin of the liver could be readily seen through the abdominal wall, and reached a point almost on a level with the umbilicus. The epigastric angle may be bulging in subdiaphragmatic abscess, and there may be prominence of the chest on the affected side. Movements of the SUBPHRENIC PERITONITIS. 557 affected portion of the abdomen are limited, and if there is extensive peri- tonitis, the respiratory movements of the abdomen are decreased. Palpation elicits more or less extensive tenderness in the region of the diaphragm, its extent depending upon the degree of involvement of the peritoneum. The upper portion of the abdomen is tense, owing to distention from the abscess and to peritonitis (muscular spasm) . The liver or the spleen may extend for some distance below the costal margin. Percussion. — In the presence of an abscess that does not contain air, the upper margin of the liver dullness will be found to extend to the fourth rib, above which there will be pulmonary resonance in the nipple line. If the abscess contains air or gas, there is a distinct area of tympany between the upper margin of the liver and the lower border of pulmonary resonance. Again, the area of liver diollness will be found to change sHghtly with the po- sition of the patient, and its upper border will be far below the lower margin of the fifth rib. If the abscess is situated at the left of the median line, a zone of tympany will be found between the splenic dullness and the lower border of lung re- sonance. In one instance in which a large subphrenic abscess was present, the area of cardiac dullness was displaced upward. Rarely, the lesser cavity of the peritoneum becomes filled with pus, when there is dullness in the left superior quadrant of the abdomen. If the lesser peritoneal sac is distended by gas, percussion will elicit a tympanitic note in the particular area affected. It is highly important to differentiate between the tympanitic note due to gas in the peritoneum or in the abscess, and the note obtained over the transverse colon. Tympany or dullness depending upon subdiaphragmatic abscess involving the lesser peritoneal cavity is always above the area of the colonic note. When the abscess is well distended by air, tympany may be elicited as high as the fourth rib in the left mammary line. Auscultation. — ^There is an absence of breath-sounds over the affected area, whereas the normal respiratory murmur is heard above the abscess. Vocal resonance is also absent over the involved area, unless adhesions to the pleura have been formed and there is a direct communication with the lung, in which case voice-sounds are feebly heard. In the case of a large abscess, the lung may be decidedly compressed, and the respiratory sounds and voice-sounds over such lung are markedly intensified. Friction murmurs due to pleuritic or to peritoneal adhesions are not uncommon. In two cases of subphrenic abscess studied by us the diaphragm on the right side of the thorax had been elevated to the lower border of the third rib, and in both of these cases the physical signs closely simulated those of pyopneumothorax, the distinctive feature being that voice-sounds were not weU transmitted to the lower level of the chest. It is usually stated that subdiaphragmatic abscess of the left side simulates pyopneumothorax more closely than does the same condition when situated to the r^ght of the median line. Further, the distinction between subdia- phragmatic abscess and pyopneumothorax can be made only after a guarded analysis of the symptoms obtained and the physical signs elicited has been made. I/aboratory Diagnosis. — Aspiration of .the abscess may be of great value in the diagnosis, since the fluid recovered will usually contain albumin, many pus-cells, few red blood-cells, and various forms of bacteria, among which the colon bacillus, the streptococcus, and the staphylococcus deserve^ special mention. (For complete laboratory diagnosis see Empyema, p. 160.) 558 THE INTESTINES. Summary of Diagnosis.— A history of the existence of disease of the stomach, duodenum, or Hver, with the sudden development of acute pam m the upper abdomen, followed by the general symptoms of shock. _ Gradual onset may terminate in a decided tenderness along the diaphragmatic margin and beneath the diaphragm. Later, characteristic features appear— e.g-., temperature (septic in type) and the general symptoms of pyemia. Leuko- cytosis, indicanuria, and, less commonly, albuminuria are present. _ The physical signs of subphrenic abscess are of great importance m formu- lating the diagnosis. (See Physical Signs.) The table below sets forth the most prominent features that will enable the clinician to distinguish between subdiaphragmatic abscess and pyo- pneumothorax. Differential Diagnosis.— The accompanying table is designed to show by comparison the distinctive clinical features of pyopneumothorax and subphrenic abscess. Pyopneumothorax. 1. History of pulmonary tuberculosis or of traumatism to the chest. 2. Develops suddenly with severe pain in the side, followed by the symptoms of shock. 3. Cough accompanied by free expector- ation. 4. Practically no expansion on the af- fected side of the chest. 6. Clavicle elevated and neck appar- ently shortened on affected side. 6. The voice and breath-sounds may- show a metallic quality over the af- fected side. 7. Normal breath-sounds absent over affected side. 8. Succussion splash audible when the ear is placed over any portion of the chest on the affected side. 9. High tympanitic note is heard over the entire pleura on affected side. 10. Bell tympany (coin test) present over entire pleura on affected side. Subdiaphragmatic Abscess. 1. History of gastric or hepatic disease or traumatism to the abdomen or base of the chest. 2. Develops insidiously. 3. Dyspnea with cough, and when ex- pectoration is copious, it is apt to be bloody and to emit a fetid odor. The breath may also be foul. 4. The expansion limited at base of chest on affected side. 5. Not a conspicuous feature. 6. Absent. 7. Absent at base of thorax on affected side. Exaggerated at apex of same side. 8. Heard at base. 9. Tympanitic note over base of affected side seldom extending above the level of the nipple. 10. Present over base of chest on affected side and not infrequently indistinct. Clinical Course and Duration. — ^The duration is usually from ten days to twelve weeks, and this condition should be regarded as a purely surgical one. CHRONIC DIFFUSE PERITONITIS. Pathologic Definition. — An extensive chronic inflammation of the peritoneum involving both the lesser and the greater sac. Predisposing and Exciting Factors. — Infection with the tubercle bacillus is the most common cause, although general chronic peritonitis may result from infection extending from a previously localized peritonitis, as, e. g., in carcinoma or inflammatory disease of the liver, uterus, intestine, kidney, or retroperitoneal glands. CARCINOMA OF THE PERITONEUM. 559 Principal Complaint. — In addition to that volunteered by the patient, there are general abdominal soreness and tenderness, which are increased upon movement of the abdominal muscles and upon deep inspiration. The patient always complains of a variable amount of discomfort that he cannot well describe — a sensation of fullness, or as though something were pulling in his abdomen. After general peritonitis has existed for some months or even years, numerous adhesions of the peritoneum have formed, and the intestines are everywhere bound together by both fine and coarse filamentous bands. In many instances the parietal and visceral layers of the peritoneum are united, and small sacculations filled with serous fluid may be formed. During the early stage of chronic diffuse peritonitis ascites may be present, but later there is little if any abdominal fluid. Physical Signs. — Palpation. — Rigidity of the abdominal muscles is an early symptom, but becomes less decided with the progress of the dis- ease. A tumor-like mass is often palpable in the region of the umbilicus, and is due to a roUed-up condition of the omentum. In other cases a similar mass is felt between the umbilicus and the transverse colon. There are no definite physical signs known to chronic peritonitis, and the exact significance of dullness and tympany is often misleading, on account of the decided mis- placement of the viscera by peritoneal adhesions. From the last-named cause marked irregularity in the contour of the abdomen is likewise mislead- ing, and demands most judicious consideration. Clinical Course and Duration. — The disease usually lasts over a period of one or more years, although at no time does the patient enjoy per- fect health. CARCINOMA OF THE PERITONEUM. Remarks. — ^Primary carcinoma of the peritoneum is not common, but secondary involvement of the peritoneum by extension from contiguous structures is often seen — e. g., extension from carcinoma of the liver, stomach, uterus, gaU-bladder, ovaries, and rectum. During the course of carcinoma of the peritoneum the patient, in addition to carcinoma of the organ primarily affected, develops ascites. We have foimd it possible, in a few instances, before ascites develops, to palpate small nodules through the abdominal wall, and after ascitic fluid has been removed, these carcinomatous nodule masses are readily palpable. The general fea- tures of carcinomatous peritonitis are very similar to those described under Chronic Diffuse Peritonitis (p. 558). Metastatic involvement of the other glands, inguinal and axillary, generally occurs. I/aboratory Diagnosis. — Fluid obtained from the peritoneal sac is likely to be blood-stained and to contain the usual amount of albumin present in sanguineous serous fluids. Microscopically, the fluid shows red blood-cells, white blood-cells, and occasionally small sheets of desquamated, peritoneal endothelium — ^the so- called "carcinoma cells." Since microscopic sheets of cells are to be found in the peritoneal fluid in tuberculosis of the peritoneum, it is not wise to formulate a diagnosis of carcinoma of the peritoneum upon a microscopic study of the sediment alone. Summary and Differential Diagnosis. — Carcinoma of the peri- toneum is readily diagnosed when it is known that carcinoma of some one of the adjacent structures existed. It is extremely difficult on many occasions 560 THE INTESTINES. to distinguish between carcinoma and tuberculosis of the peritoneum. Age serves as the most distinctive feature, tuberculosis being more likely to at- tack the young and carcinoma the aged. A nodular condition of the abdo- men may be due to the presence of small cysts, and in two cases of chronic peritonitis believed to be due to tuberculosis it was foxmd that the condition depended upon a number of hydatids that occupied the omentxmi. (See table, p. 562.) Clinical Course. — CarcLaoma of the peritoneum goes from bad to worse, terminating fatally in from a few weeks to two years. TUBERCULOSIS OF THE PERITONEUM. Pathologic Definition. — A subacute or chronic affection excited by the bacillus tuberculosis, and characterized by miliary tubercles of the peri- toneum. Varieties. — (a) Primary miliary involvement of the peritoneum with ascites; (p) tuberculosis of the peritoneum with the formation of a fibrous exudate and numerous adhesions; (c) ulceration of the peritoneum, tuber- culous in character; (d) a localized tuberculosis of the peritoneum due to direct extension from the mesenteric glands; and (e) locaHzed tuberculosis of the peritoneum from direct extension from a tuberculous focus in the liver, kidney, ovary, or a retroperitoneal gland. Predisposing- and Bxciting Factors. — Among the predisposing factors should be mentioned pulmonary tuberculosis. Phillips' analysis of 107 cases showed 99 of them to be secondary to tubercvilosis of the lung; in 60 of these cases he found the pleura involved, and 80 of them showed tuber- culosis of the kidney. Tuberculosis of any one or more of the abdominal viscera materially increases the danger of infection. The ingestion of un- cooked beef or pork and the drinking of large quantities of mUk that has not been sterilized favor general infection. Age figures prominently in tuberculosis of the peritoneum, as is shown by Holt's collection of 156 cases, 71 of which were imder three years, 26 be- tween the third and eighth years, and 23 between the eighth and tenth years. In 119 autopsies upon the bodies of children under three years of age this author found that 8.5 per cent, of them showed tuberculosis of the perito- neum. The frequency with which tuberculosis attacks children after the third year is further substantiated by the statistics of Ashby, who found that in 105 autopsies on children dead of tuberciilosis 36 per cent, showed the peritoneum to be involved. Biedert analyzed the reports of 883 autopsies made upon children, and found that 18.3 per cent, of them showed tuberculosis of the peritoneum. The greatest number of cases of the condition are to be foimd between the tenth and fortieth years, whereas after the forty-fifth year it is decidedly uncommon. Sex appears to exert little, if any, influence on children, whereas adult females are more prone to be attacked than are adult males. The ratio based upon sex is as 3 is to 2, in favor of the female. The condition often extends from the Fallopian tubes and ovaries. Race and Nationality. — ^The American Indian is more susceptible to tuberculosis of the peritoneum than members of any other race, yet the negro and the Mongolian (Chinese and Japanese) are far more susceptible than the Caucasian. TUBEBCULOSIS OF THE PERITONEUM. 561 Close contact with persons known to be suffering from pulmonary tuber- culosis occupies the front rank in the etiology of tuberculosis. We have in mind the case of a cook suffering from pulmonary tuberculosis who was em- ployed in a hospital, and in a period of two years five physicians in this hos- pital developed pulmonary tuberculosis. This cook's sputum was found to contain great numbers of tubercle bacUli, yet he had comparatively few gen- eral symptoms or signs of pulmonary tuberculosis. Not infrequently it is found that the mother of a large family is suffering from a chronic type of pulmonary tuberculosis; her sons and daughters in turn contract the disease, while she survives her family for many years. As an illustration may be cited the case of a family who came to Philadelphia about ten years ago; the mother was suffering from a cough with profuse expectoration, and her sputum was found to contain many tubercle bacilli; at that time three daughters and two sons were healthy. Within a period of eight years all five children had succumbed to tuberculosis, whereas the mother was but slightly, if at all, worse than when she first came under our care. There is no more rapid method of spreading tuberculosis than for persons infected with the disease to be occupied in either the kitchen or the dining-room. Principal Complaint. — The chief complaint of patients suffering from general miliary tuberculosis of the peritoneum will be found to vary with the virulence of the type of infection, and will depend upon whether or not the patient has suffered from tuberculosis of some other portion of the body for an indefinite time. If the onset is sudden, the patient complains of such severe symptoms and constitutional disturbances as nausea, vomiting, pain and tenderness over the abdomen, and either diarrhea or constipation. As tuberculosis of the peritoneum progresses the pulse quickens and the general symptoms of secondary anemia appear — i. e., palpitation, shortness of breath, and vertigo. The condition progresses rapidly until the patient assumes the so-called typhoid state, when the tongue is parched, the lips are fissured, there is intense thirst, and there may or may not be ascites. Pus in the peritoneal sac is uncommon, yet it may be found, and at this time or even when there is tuberculosis of the lung with cavity formation night-sweats are prone to occur. In those cases that' do not display ascites, tuberculous nodules may be felt through the emaciated abdominal wall, and the other symptoms and signs of general peritonitis (see p. 553) are present. A child may complain of nothing that would lead one to suspect that there is any involvement of the peritoneum, and ascites is unusual. Cutaneous Manifestations. — Pigmentation of the skin of the abdo- men is not unusual, and may appear in the form of blotches localized near the median line, or in the form of a general pigmentation of the skin of the ab- domen and back. Thermic Features. — ^The patient complains of feeling feverish, and the temperature will be found to vary between 101° and 104°, although we have seen cases in which the temperature did not exceed 100° F. I/aboratory Diagnosis. — ^The blood changes of secondary anemia (p. 356) are found after the disease has progressed for but a short time; thus the hemoglobin falls to below 70 per cent., with a corresponding decrease in the number of red cells in a cubic millimeter. Leukocytosis is commonly found in those suffering from tuberculous peritonitis, although leukopenia is the rule before suppuration is present in some other portion of the body._ The urine gives a reaction for indican, and may contain albumin (febrile albuminuria, p. 643). In three cases studied at the Philadelphia Hospital 36 562 THE INTESTINES. in which tuberculosis of the peritoneum followed an initial tuberculosis of the kidney tubercle baciUi were found in the urine throughout the entire course of the illness. Summary of Diagnosis. — The recognition of tuberculosis of the lung or of some one of the abdominal viscera, together with the characteristic symptoms described above, points somewhat conclusively toward tuberculo- sis of the peritoneum. In many instances it is practically impossible to determine the exact nature of the peritonitis without opening the abdominal cavity. In a number of cases following operation upon the uterus and ovaries we have seen tuberculosis of the peritoneum develop in from three to five years, but in none of the cases observed was a careful pathologic study of the tissues removed from the uterus or ovaries carried out. In two cases diag- nosticated as uterine fibroid, tuberculosis of the peritoneum developed five years later. In children it is often very difiicult to recognize tuberculosis of the peritoneum, and when the condition is only a portion of a general involvement, the peritoneal surface shows but little evidence of tuberculous infection at autopsy. Diflferential Diagnosis. — See table below. TABLE SHOWING THE DIFFERENCES BETWEEN CHRONIC GENERAL PERITONITIS, GENERAL TUBERCULOSIS OF THE PERITONEUM, AND CARCINOMATOUS PERITONITIS. Chronic Generalized Peritonitis. 1. History of rheumatism or of tonsillitis. 2. Social history negative. Occurs most often in the obese and in those displaying a gouty tendency. May develop at any age, but is oftenest seen between the thirtieth and fiftieth years. 5. Sex appears to exercise but little influence. 6. Ascites absent. Generalized Tuber- culosis OP the Peritoneum. 1. Family history of tu- berculosis or of some chronic infec- tion of the lungs common. 2. In many instances the patient has been more or less intimately associ- ated with a person suffering from pul- monary tubercu- losis. 3. Develops in slender and ill-nourished subjects. 4. Common in children and during early adult life. The greatest number of cases appear be- tween the sixteenth and thirty-fifth years. 5. More common in adult females. In children both sexes are equally af- fected. 6. Ascites the rule. Carcinomatous Peritonitis. 1. Family history points toward carcinoma, and there is usually evi- dence favoring carci- noma of the stomach liver, or rectum. 2. Social history negative. 3. Seldom develops until the patient shows de- cided emaciation. 4. Rare before the fortieth year, although we have seen one case in a female aged thirty- three years. 5. Slightly more common in the female, due to extension from carcin- oma of the uterus. 6. Develops after a fairly large surface of the peritoneum has become involved. SARCOMA OF THE RETROPERITONEAL GLANDS. 563 Generalized Tuber- Chronic Generalized culosis of the Carcinomatous Peritonitis. — {Continued.) Peritoneum. — {Continued.) Peritonitis. — {Continued.) 7. Abdominal tenderness 7. Tenderness constant, 7. Unaffected by treat- appears to be uninflu- and not influenced ment. enced by climatic by treatment, changes. Symptoms are materially les- sened by medication. 8. Disease advances 8. Progresses rapidly 8. Terminates fatally in slowly, and may re- from bad to worse, from three to eighteen main stationary for a fatal termination months, years. ensuing within from a few weeks to one year. Clinical Course. — Tuberculosis of the peritoneum runs a somewhat rapid course, progressing steadily from bad to worse, and terminating fatally, as a rule, in from three months to one year. SARCOEIA OF THE RETROPERITONEAL GLANDS (LOBSTEIN'S CANCER). Pathologic Definition. — A sarcomatous growth in the retroperito- neal glands near the attachment of the mesentery. It develops somewhat rapidly from a growth the size of a goose egg to that of a human head. There is comparatively little pain, but slight constitutional symptoms, and no fever is present. Predisposing and Exciting Factors.— Sex.— So far as we know J. Button Steele's analysis of 65 reported cases furnishes the only tangible data regarding the etiology of retroperitoneal sarcoma, and shows that males are more susceptible than females, in the ratio of 12 to 8. A pathologic analysis of the 65 cases showed that 39 per cent, were of the spindle-celled variety; 34 per cent, of the round-cell variety; and 14 per cent, were lympho- sarcomata. A history of traumatism to the abdomen and spine is occa- sionally obtained. Age. — In Steele's analysis retroperitoneal sarcoma was shown to develop more commonly during the first decade, and between the fourth and fifth decades, of life. Principal Complaint. — The onset is insidious, and the patient first becomes conscious of his condition when he detects a hard, hall-like mass in the abdomen. The tumor is not tender, and he often states that he is able to move the mass to various portions of the abdomen. Again, he may state that the tumor falls from side to side of the abdomen with change of posture. After the tumor has attained suSicient size to interfere with the circula- tion of the abdominal viscera, the following symptoms may be described: nausea, anorexia, constipation, and intermittent cramp-like pains. Accord- ing to the size of the tumor, the patient will suffer from a decided draw- ing or pulling sensation in the back and loins, and a sensation as of a weight in the abdomen. As the tumor increases in size it is likely to interfere mater- ially with the venous return blood-currents, and edema results. Pain. — As the result of pressure upon the nerve-filaments and nerve- trunks, the patient suffers from intense neuralgic pains in the lower extremi- ties, abdominal wall, lumbar region, and genitalia. After retroperitoneal sarcoma has continued for several months, the patient becomes anemic, and then complains of palpitation, marked pros- tration upon exertion, and a general feeling of malaise. 564 THE INTESTINES. Physical Signs. — Inspection. — In patients in whom the abdominal wall is thin a peculiar irregularity, due to the presence of the tumor, is at once apparent. In selected cases the tumor mass may be seen to rise and fall sUghtly with the respiratory movements. In a case now under our observa- tion the tumor is not affected by respiration, and in a series of cases studied by us the tumor was firmly adherent to the peritoneal tissues. Palpation. — Early, the tumor is not tender to the touch, and it may be apparently moved by forcibly pressing over the mass. The growth is always hard, more or less irregxilar in outline, and situated at one or the other side of the median line, a portion of the mass commonly resting over the spine. After there has been extreme pressure upon the abdominal nerve-trimks, there may be marked tenderness over the lower extremities, and in one case seen by us hypersensitiveness of the left testicle was an early and annoying feature. When there is decided interference with the circulation through the spermatic veins, the testes will be found swollen and soft to the feel, with the general signs of varicocele. Percussion tends to confirm palpation. The size and shape of the tumor are readily outlined, and surrounding it the normal tympanitic note due to the presence of the intestine may be demonstrated. Ascites frequently develops late during the course of retroperitoneal sarcoma. (See Ascites, below.) IVaboratory Diagnosis. — ^The blood changes are those of secondary anemia. The urine becomes pale, and later, after the development of as- cites, it may contain indican and albumin. Summary of Diagnosis. — A nodular growth in the abdomen, of less than two years' duration, which is not decidedly painful, and may be palpated without any inconvenience to the patient, is highly suggestive of retroperi- toneal sarcoma. Duration. — The disease terminates fatally in from six to eighteen months after the patient discovers the presence of the tumor. ASQTES. Pathologic Definition. — An accumulation of fluid (serous, sanguin- eous, purulent, or chylous) in the peritoneal sac, with consequent distention of the abdomen. General Remarks. — ^This symptom is considered separately, since it displays so wide a variety of physical signs and aggravates an equally large number of other annoying symptoms. The conditions capable of causing an accumulation of liquid in the peritoneal cavity are : (1) Cirrhosis of the liver. (2) Pulsating liver. (3) Echinococcus cyst of the liver. (4) Peri- hepatitis. (5) Peritoneal adhesions binding down the portal vein as it enters the liver, and general peritoneal adhesions, both of which conditions interfere with the return blood-current from the mesentery. (6) Tubercu- losis of the peritoneum. (7) Carcinoma of the peritoneum. (8) Retro- peritoneal sarcoma or Lobstein's cancer. (9) Sclerosis of the mesentery. (10) Tumors of the uterus — fibroma, myoma, and carcinoma. (11) Tumors of the ovaries — sarcoma, tuberculosis, and abscess. (12) Tumors of the kidneys — sarcoma, hypernephroma, and hydronephrosis. (13) Enlargement of the spleen (malarial, leukemic). (14) Perisplenitis. (15) Essential an- emias, leukemia, and less often pernicious anemia and chlorosis. (16) Sec- ondary anemia, as is seen in ankylostomiasis, pernicious malaria, and chronic mineral poisoning. (17) Chronic parenchymatous nephritis and late in ASCITES. 565 chronic interstitial nephritis. (18) Valvular heart lesions with tricuspid insuflaciency. (19) Cirrhosis of the lung. (20) A large pleural effusion. (21) Tumors of the abdomen pressing on the ascending vena cava or portal vein. The following table may serve in classifying the causes of ascites under their respective subheadings: a. Diseases op the Pbhitonetjm: Tuberculous peritonitis. Carciaomatous peritonitis. Non-suppurative acute peritonitis. Peritoneal adhesions. "Simple" chronic peritonitis. Hydatid cysts in the peritoneal cavity. b. Obstruction to the Main Poktal Vein: Non-suppurative thrombosis. Peritoneal adhesions. Aneurysm. c. Tumors and Enlargements of Adjacent Organs: Liver. Duodenum. Pancreas. Colon. Kidney. Suprarenal capsule. Stomach. Retroperitoneal sarcoma. d. Hepatic Causes: Atrophic cirrhosis. Carcinoma. Hypertrophic cirrhosis. Sarcoma. Perihepatitis. Cyanotic liver with enlargement. SyphUis. Pulsating liver (chronic). Hydatid disease. Any condition accompanied by extensive enlargement of the hver may, from obstruc- tion by tortion or pressure of the portal vein, be accompanied by ascites. (See causes of hepatic enlargement, p. 586.) e. Obstruction of the Inferior Vena Cava: Thrombosis. Congenital cysts. Obstruction of thoracic duct. Filariasis. Rupture thoracic duct. Stenosis by chronic mediastinal adhe- Rupture of the receptaculum chyU sions. (chylous ascites). Occlusion by mediastinal growth. Chronic adhesive pleurisy. /. Chronic Valvular Heart Conditions Usually Accompanied by: Tricuspid regurgitation. Mitral stenosis. Mitral regurgitation. Aortic stenosis. Aortic regurgitation. f Fatty degeneration. Fibroid heart. Myocarditis -j Fatty infiltration. Primary alcohohc heart. (. Fatty superposition. Adherent pericardium. g. Nephritis: In Bright's disease ascites may be caused in different ways: Part of a general dropsy. Secondary to hypertrophy and dilatation of the heart, followed by failure of com- pensation and tricuspid regurgitation. h. Essential Anemias: SplenomeduUary leukemia. Aplastic anemia. Lymphatic leukemia. Splenic anemia. Hodgkin's disease (rare). Pernicious anemia. 566 THE INTESTINES. Varieties.— In the vast majority of all cases fluid obtained from the peritoneal sac will be found to be serous in character; and when studied microscopically, it will be seen to contain white blood-cells, endothelial cells, and an occasional red cell. This tj-pe of ascites is usually considered under the head of serous or true ascites, and results from mechanical causes or a mild inflammation of the peritoneum. In still other cases we encomiter a more dense exudate — e. g., in tuber- FlG. 227. -Position' of the Patiext and Method of Employixg -a Binder ix .\spiratiox of the Abdomex for .Ascitic Fluid. culosis of the peritoneum and carcinoma of the peritoneum, while a san- gitineous exudate is by no means mrcommon. Ruptured ectopic gestation also causes the peritoneal fluid to be bloody. In certain mstances the fluid is merely a transudate, c. g., following valvular heart disease, renal insuffi- ciency, and leukemia. Purulent ascites may follow a chronic suppurative process involving a portion of the peritoneum, and occasionally there is a purulent infection of the entire peritoneal surface. Pus from caries of bonj' structures rarely enters the peritoneum. Chylous ascites is the name applied to two rare conditions in both of which milky fluid collects in the peritoneal cavity. Principal Complaint. — The patient states that his abdomen has been enlarged, and that his clothing has been uncomfortably tight for a period of weeks or months. He also complams of a sense of weight in the lower part of the abdomen, and usually suffers from such gastro-intestinal disturbances as nausea, anorexia, vomiting, and hemorrhoids. Since the majority of symptoms due to ascites are more or less common to many of the pathologic conditions from which it arises, it is considered unnecessary at this point to discuss at great length the symptomatology- of this condition. ASCITES. 567 Physical Signs.— Inspection.— When the patient is resting in a supine position, the abdomen bulges laterally between the ribs and the crests of the ilia, and there is a varialile degree of flattening at the umliilicus. When there is a large amount of fluid and the distention is extreme, there is but little change in shape as the result of position, except when in the stand- ing posture, when the anterior portion of the abdomen below the umbilicus is somewhat pendulous. The skin overlying the aljdomen becomes shiny, and the veins are prominent. There is often seen at the umbilicus a network of dilated veins — the so- called " caput medusfB." There is swelling of the lower extremities and the genitalia, and edema of the pre- puce and scrotum may be most an- noying. Palpation. — If the amount of peritoneal fluid is small, palpation is negative; Init when there is a liberal quantity of liquid in the sac, it is possible to obtain a wave of fluctua- tion, which is elicited by placing the palm of the left hand against one side of the abdomen, and then tap- ping the opposite side of the ab- domen with the right hand while an assistant holds his hand upon the ab- domen at the median line, in order to break any jar that may he conveyed through the abdominal wall. The abdominal wall may be hard and lusterless, owing to the general effusion of the serum into the alveolar tissue, and a characteristic sensation is detected by palpating over the "caput medusa^." The lower portion of the abdominal wall, particularly in the region of the hips and loins, pits upon pressure and is rarely sensitive. Percussion. — When the patient is resting upon his back, there is a vary- ing area of flatness in both flanks, and above and anterior to this area a tym- panitic note is obtained (Fig. 229). The area of liver dullness is, as a rule, approximately that of the normal, but a large collection of ascitic fluid may force a portion of the bo\vel lietweeu the sui-face of the liver and the anterior abdominal wall, making it impossil)le for the examiner to outline the lower border of hepatic dullness anteriorly. Posteriorly, the level of liver dullness will be found to be from one-half to one and one-half inches higher than nor- mal. The area of splenic dullness is changed by the presence of a large ac- cumulation of ascitic fluid. The area of cardiac dullness is higher in cases in which a large amount of peritoneal fluid is present, and after ascites has existed for some time, the area of cardiac ckillness is often found to be in- creased as the result of an effusion into the pericardium. (See Hytlroperi- cardium, p. 243; also Fig. 112.) Upon change of posture — e. g., on sitting or standing — the area of flat- ness due to the presence of fluid will occupy the lower portion of the abdo- FlG. 228. — Lines Indicate Area of Flatness DiTE TO Distention op the Bladder or THE Uterus. Dotteif area indicates that portion of the solid mass where intestine is interposeil between it and the abdominal wall, and over which area modified tj-mpanitic note is obtained. 568 THE INTESTINES. men, whereas the area of tympany wiU be transferred to the upper portion. Again, on turning the patient from side to side the area of fiatness disappears from' the superior side, to be replaced by a corresponding area of tympany. Upper area of flatness Fig. 229. — Ascites and Pleural Effusion, Areas of Tympany, Etc. Lastly, the level of flatness will be found to change perceptibly while the patient is sitting merely by tilting him backward or forward. Summary and Differential Diagnosis. — Distention of the ab- domen with the presence of an area of flatness that changes its position with Fig. 230. — Ascites. the change of posture of the patient is positive evidence of the presence of free fluid in the peritoneal cavity. The detection of a wave of fluctuation is further confirmatory, but by no means infalliljle, evidence of the existence of ascites. The accompanying table is designed to set forth the definitive features of ascites, etc. (See also Fig. 229.) Jl ASCITES. 569 s 1^ J. ^T3 a a (B 2 © C8 rt-a 3 a g, '3'" 3«*H ai S s':^ ° S O «15 o a o a ^■g ' a ° a o a «T3 •s-S-g is . ill's ■-+3 t.c^ fl+J 1= ."I po5s> ^ a to Eh^ -^ sa;|j > o 11^ 52g . a-" o a o ^^ aSg ■a.aa-J, ■^ cd © U gs-i-s a a'S'O ■_. « a) .23°'S-g|:S| ■S ^ 2 » !>..a -^ ^ 3 p,bo.ri.4l u u ^1 i'"a §5 ^■g; ^n =3-2^ h-2^ &.„o ° 9 Si tea-s CO 3g o J °oa° •?g1fe| [K 3 aS eS "2 o 03 ™, <" ■3 2 ^-' ^ eS ^ IIP •3 k< O c o.ao-3J3 o o S.s-^.B g o-2"sl"? s'm -2 § » a i §'Si® - ■alisoSfs ;S oi CI 3 o-s S3 gogsga-- S d ° 2« 2S gS"g-2?5| ^ 3 •Sb.S a >S2«-! I ll sis a * to d -^ O — " 5 CD— 1 O 03 ; o ' extend but a short distance below the right costal boixler, Init in advanced cases it has been found at or even some distance below the level of the umbilicus. Carcinomatous hepatic enlargement appears to affect mostly the right lobe, conseciuently the degree of enlargement may, comjjaratively speaking, be moderate. We have examined patients in whom the lower margin of the Fig. 243. — EIere the P.^tient Kests the Kight I'Yiot Uro.w a S-mall I'.nx. which Gives Ide.n- ncALLY THE Same Result as St.anding with but .v Small Portion oe His Weight on the Right Toe (Boston, New York Med. Jour., Nov. 1, 1913). liver extended lielow the umbilicus, and yet no nodules were present upon the surface of the organ. The spleen is usually palpable in those cases in \\hich ascites tlevelops as the result of extension of the carcinomatous process to the peritoneum, and the physical .signs of ascites are also to be expected. (See p. 567.) The heart impulse is extremely weak, and a distinct pulsation is felt over the right carotid. Edema of the feet and of the hands is a late finding. Percussion gives positive findings as to the degree of enlargement of the liver and the spleen, and regarding the presence or absence of peritoneal fluid (moval)le alidominal flatness). It is not uncommon to find the degree of liver dullness extending from the lower border of the fourth rib to the crest CARCINOMA OF THE LIVER. 583 of the ilium in the anterior axillary line, although, as a rule, the superior border of dullness is found at the fifth rib or the fifth interspace. I^aboratory Diagnosis. — The blood changes are those of secondary anemia, the red blood-cells falling to 3,000,000 or below, while the hemoglobm displays a corresponding decrease, except in those cases in which jaundice is present, when the estimation of hemoglobin is difficult. The presence or absence of leukocytosis is of but little importance in connection with hepatic carcinoma, since it is impossible to estimate to what degree the peritoneal surface is involved, and also what other modifying conditions coexist. The character of the urine is influenced largely by the nature of the food taken and by the condition of the digestive tract ; evidence of kidney dis- ease is rare. If jaundice is present, the urine is highly colored and its or- ganic sediments are also_ colored by bile-pigment. It is to be remembered that jaundice, when continued over a long period, produces the inflammatory renal changes indicated by the presence of albumin and renal casts in the urine. Illustrative Case of Carcinoma of the Liver. — M. J., female, aged fifty-six; height, 5 feet 6 inches; normal weight, 155 pounds; present weight, 120 pounds. Family History. — Father died of epithelioma of the lip at the age of fifty-two; mother died of pneumonia at the age of sixty-four. Two young brothers and a sister are Hving and are in good health. One paternal uncle died of carcinoma of the stomach, and a haK sister of pulmonary tuberculosis. Previous History. — Thinks she had the diseases of childhood. Had influenza at the age of forty-five, and another attack at fifty. Has had four children, and all are in perfect health. Social History. — She was married at the age of twenty-two. She has been com- pelled to attend to her own household duties since she married, but she has also been permitted to get a fair amount of outdoor exercise. Menopause at fifty-two; uses no intoxicants, but tea and coffee in moderation. Present Illness. — States that during the past year she has had considerable annoyance from what she termed stomach trouble, which included occasional attacks of nausea, moderate anorexia, some abdominal pain, and obstinate constipation. Three months ago the pain in her abdomen became appreciably increased, and she then con- sulted her physician with reference to this particular symptom and obtained consider- able relief. When first seen by us she was markedly emaciated and weak, unable to take nutriment, and complained of a constant sense of weight in the region of the liver. She also stated that she became readily exhausted upon slight exertion, and that on ascending a single flight of stairs she was compelled to rest for a few minutes. She experienced a variable degree of vertigo after exercise, and was constantly annoyed by eructations of gas. She slept poorly, especially during the night hours, although there was mental hebetude during the day. Delirium was not present early, but later low muttering dehrium was more or less continuous. The pain was constant, and was always situated in the right hypochondrium, but occasionally, when it became severe, it radiated to the back and right shoulder, and less often was reflected over the anterior surface of the abdomen. A peculiar dull headache was annoying early during the illness, but later this symptom disappeared. The temperature was approximately normal until the last three weeks of the disease, when it rose during the evening to 101° to 103° F., whereas the morning temperature was at or near the normal level. Physical Examination. — General. — The skin was markedly jaundiced, the ex- pression was dull, there was slight puffing beneath the eyes, and evidences of emaciation were general. At first the patient's gait was feeble and tottering, but later she was unable to leave her bed, and she rested in the supine position, complaining when asked to turn from side to side. Local Examination. — Inspection. — The conjunctivae were markedly jaundiced, the tongue was heavily coated, and the breath was foul. The abdomen showed distinct bulging in the region of the liver, and there appeared to be some restriction in the expansion at the right base of the chest. Palpation. — Even moderate pressure over the liver at the costal margin excited 584 THE LIVER. severe pain, and it was possible to palpate the lower edge of the liver at a distance of 2§ to 3 inches below the costal border. Careful though fairly firm palpation also revealed the existence of nodular masses upon the palpable surface of the Uver. The pulse was fuU at first and fairly strong, the beats numbering 50 to 60 a minute, a clinical feature probably explained by the early development of jaundice, but late during the disease the pulse became weak, rapid, and thready, and the beats numbered 120 to 140 a minute. Percussion. — This confirmed palpation with reference to the size of the liver. Laboratory Findings. — The quantity of urine voided -during the twenty-four hours varied between 20 and 3.5 ounces a day; its specific gravity was 1.025 to 1.030. Chemically, albumin was present, and microscopically numerous hyaline and granular casts were seen, both of which were more or less deeply stained by bile. An examina- tion of the blood showed the red cells to number 2,380,000, whereas the white cells numbered 7400 in a cubic millimeter. Owing to the existence of extreme jaundice, an accurate estimation of the percentage of hemoglobin was impracticable. Diagnosis by Induction from Clinical Data. — The duration of the present illness, the fact that it was accompanied by increasing weakness and rapid and progressive emaciation, and the presence of a sense of weight and pain in the region of the liver were considered to be clinical points decidedly favoring the existence of carcinoma. The family history and the age of the patient also supported this view. The later develop- ment of jaundice suggested that either the gall-bladder or some of the larger bile-ducts were involved in the process. Pressure over the liver always excited severe pain, and the detection of nodular irregularities on the surface of the liver was considered to be of great importance in establishing the diagnosis. Differential Diagnosis. — Certain features in the case somewhat resembled hyper- trophic cirrhosis, from which disease it was differentiated by — (a) The presence of nodu- lar enlargements on the surface of the liver; (6) the occurrence of continuous pain in the region of the liver; and (c) the fact that the pain was intensified by making firm palpation over the organ. Course of the Disease. — In approximately one year from the time the patient consulted a physician with reference to pain in the region of the liver the case terminated fatally, catarrhal pneumonia complicating the condition in its last stages. Autopsy revealed the presence of multiple carcinomatous growths disseminated throughout the substance of the liver; a fistulous communication between the gall-bladder and the transverse colon, which was completely surrounded by dense peritoneal adhesions and had doubtless resulted from a softening of the carcinomatous mass, was also found. The common duct was patulous, but there was extensive evidence of inflammation of most of the surface of the gall-bladder. Summary of Diagnosis. — The age of the patient (after forty years), the history of carcinoma existing elsewhere in the body, the character of the pain, the presence of cachexia, and the fact that the patient has lost from twenty to sixty pounds in weight, point strongly to hepatic carcinoma. The detection of nodular enlargement of the liver makes the diagnosis prac- tically certain. Differential Diagnosis. — Carcinoma of the pylorus may be mis- taken for hepatic carcinoma, yet a point ever to be borne in mind is that the latter is frequently secondary to pyloric involvement; consequently by the time the patient consults the physician, and when the symptoms are well marked, there is likely to be a primary carcinomatous process in the stomach, with secondary involvement of the liver. Carcinomatous tumor limited to the pylorus displays but a single nodule, which nodule differs from those of hepatic carcinoma in that it is depressed by deep inspiration, but is not elevated by forced expiration. If firm adhesions bind the stomach to the liver, palpation is negative. Gastrectasis, if present, points to involvement of the pylorus, and the diagnosis can often be confirmed by associated gastric symptoms. Carcinoma of the Colon and Omentum. — Here carcinoma is, as a rule, secondary. Carcinoma of the intestine involves most often the sigmoid flex- ure, and is characterized by the symptoms of chronic intestinal obstruction (p. 525) without jaundice or ascites. In carcinoma of the liver the pain is HEPATIC SARCOMA. 585 higher in the abdomen, there is hepatic enlargement, and there may be jaundice. Carcinomatous growths developing from the colon and omentum can, as a rule, be shown to be differentiated from those involving the liver by auscultatory percussion — an invaluable sign. Carcinoma of the Suprarenal Body. — Rarely, carcinoma involves primarily the suprarenal body, and spreads by direct extension to the in- ferior surface of the liver. We have observed two such cases, but in both the symptoms of hepatic carcinoma were obscure, and symptoms referable to adrenal disease were present early — e. g., paia, tenderness, a mass in the region of the right kidney, and bronzing of the skin. Hypertrophic cirrhosis can be mistaken for that unusual form of car- cinoma only when the carcinomatous nodules are equally disseminated throughout the liver, with uniform enlargement of the organ, thereby giving a rounded edge to that portion of the liver projecting beneath the costal margin. The age of the patient, the character of the pain, and the late development of fever, together with extreme emaciation, will indicate carcinoma. The distinctive features between hepatic carcinoma and hepatic abscess are shown in the accompanying table (modified from Anders) : Hepatic Carcinoma. 1. May be hereditary. History of car- cinoma elsewhere in the body^rec- tum, stomach, etc. 2. Occurs after middle life. 3. Fever present only during the latter stage of the disease. 4. Cachexia a constant feature. 5. Pain dull and constant. 6. ChiUs unusual. 7. Increased area of hepatic dullness ex- tends downward. 8. Aspiration negative. Hepatic Abscess. 1. History of dysentery, traumatism, gall-stones, or suppuration elsewhere. 2. Commonest in early adult life. 3. Septic fever throughout. 4. Absent. 5. Pain sharp, boring, and paroxysmal. 6. Chills and profuse sweating prominent symptoms. 7. Extends upward and may reach above the lower margin of the fifth rib. 8. Aspiration may recover pus containing liver-cells, pus-cells, bacteria, or amebae. The distinctive features between hepatic carcinoma and sarcoma will be found under consideration of the latter condition (below), as will also that of hydatids (p. 980) and amyloid disease (p. 593). Duration. — All cases tend to terminate fatally in from a few months to one year. Cotttplications. — Most serious of these are perforation of the colon or of the stomach. There is also likely to be carcinomatous peritonitis and carcinoma of certain of the other abdominal viscera. HEPATIC SARCOMA. Pathologic Definition. — A disease characterized by infiltration of the hepatic tissue by a sarcomatous growth, together with enlargement of the organ. Sarcoma may be primary, but in the majority of instances it is secondary to a similar lesion elsewhere. Melanotic sarcoma commonly attacks the liver after sarcoma of the choroid has been present. The en- largement is fairly uniform, and the organ may occupy the greater part of the abdomen, extending below the brim of the pelvis, and as far to the left as the left midclavicular Ime. 586 THE LIVER. Predisposing and Bxciting Factors.— The liver is often attacked by sarcoma following the removal or incision of a sarcomatous growth else- where in the body. Following the removal of sarcoma of the choroid, mela- notic sarcoma of the liver may develop in from one to two arid one-half years. Sarcomatous growths removed from the scalp are especially likely to recur in the liver, as are also those situated upon the lower extremities. Generally speaking, the liver is the viscus most likely to be secondarily at- tacked after the removal of a sarcoma. Principal Complaint and Symptoms.— In general, the symptoms of hepatic sarcoma are those of mechanical obstruction, e. g., gastritis, ascites, and, in certain cases, hemorrhoids. There are distinct anemia and pro- gressive emaciation, both of which appear to result from malnutrition. The liver is uniformly enlarged, extending below the costal margin. I/aboratory Diagnosis. — ^There is a somewhat progressive secondary anemia. When there is extensive metastasis to other organs and the sar- coma is of the melanotic type, the urine may be brownish or blackish in color (melanuria). Differential Diagnosis. — Hepatic sarcoma is differentiated from hepatic carcinoma by the following diagnostic features: Sarcoma is more common in the young, and often follows in the wake of a tumor of the eye. Pain is less frequent in sarcoma and cachexia is not so common. The hepatic surface is not nodular. Duration. — AU cases tend rapidly toward a fatal termination. ACUTE HYPEREMIA. Pathologic Definition. — A condition characterized by slight en- largement of the liver, with acute arterial congestion of the hepatic vessels. Predisposing Factors. — Active hepatic congestion is seen to follow dietetic errors, chronic or acute alcoholism, and traumatism to the organ. It is also encountered in unfavorable cases of typhoid fever, typhus fever, pernicious malaria, and other infections. Hyperemia may be vicarious in character, e. g., following sudden cessation of hemorrhage from the bowel and of the menstrual flow; rarely it may complicate hepatic cirrhosis (early stage). Clinical Course. — Those cases due to dietetic error terminate favor- ably within from a few hours to one week. Hyperemia occurring duringthe course of hepatic cirrhosis is of grave prognostic significance, and when acute congestion follows traumatism over the liver, subsequent abscess-formation is to be feared. PASSIVE HYPEREMIA. Pathologic Definition. — A secondary condition excited by cardiac insufficiency (tricuspid regurgitation) and characterized by dilatation of the hepatic veins, with uniform enlargement of the liver. Fxciting Factors. — This is clearly tricuspid regurgitation, since the blood regurgitating from the right ventricle to the right auricle continues its backward current through the inferior vena cava until it reaches the liver — the first organ capable of being expanded. Predisposing Factors. — Among the predisposing factors are: All diseases of the heart and lungs, or even those of the blood itself, in which there is a tendency toward the formation of blood-clots. Any condition that favors or excites tricuspid insufficiency predisposes to venous hepatic ACUTE HEPATIC ABSCESS. 587 congestion — e. g., disease of the left heart, myocarditis, increased blood ten- sion in the lung, anemias, and thoracic tumors of whatever nature pressing upon the ascending vena cava. Such local conditions as pressure over the portal area by new-growths, cysts, etc., and abnormalities of the walls of the veins, as is seen in syph- ihtics and in thrombosis of the hepatic vessels, are among the predisposing factors. Principal Complaint and Symptoms. — The patient complains of an undue sense of fullness in the upper portion of the abdomen that often increases to a distinct distress. Such gastric symptoms as nausea, vomit- ing, anorexia, and constipation are likely to be present. Dyspnea is a common symptom, and the patient frequently complaias of an annoying cough, which may be accompanied by expectoration. Physical Signs. — Inspection. — ^The upper right abdominal quadrant is unduly prominent, and in advanced cases edema of the feet and of the hands is seen. Jaundice, while not common, is occasionally observed, and when present ia a marked degree, the patient also displays the clinicat fea- tures usually associated with jaundice. (See p. 605.) Palpation confirms inspection, and in addition enables one to outline the liver, the anterior inferior margin of which will usually be found some distance below the costal cartilages, and may even extend below the umbUicus. When the veins of the liver are greatly distended and tricuspid regurgi- tation is pronounced, the entire organ is found to pulsate. Percussion and Auscultatory Percussion. — Percussion confirms pal- pation as to the size of the liver, and is of further service in determining the outline of the heart (cardiac dullness usually blending with liver dullness). Auscultation. — In pronounced cases a distinct murmur is heard over the liver. The heart-sounds are weakened, as a rule, and murmurs are pre- sent in those cases that have reached the stage of cardiac dilatation. I,aboratory Diagnosis. — The blood-findings are those of secondary anemia. In cases showing jaundice the stools are clay colored, and the urine is of high color, of high specific gravity, and often contains a trace of albumin, which may be the result of passive renal congestion. Duration. — ^This is governed entirely by the cause. In those cases re- sulting from valvular heart disease the liver may return to its normal size after the institution of judicious treatment. The rule is for the hyperemia condition of the liver to return as soon as treatment of the cardiac condition is stopped or the patient exercises beyond a limited degree. ACUTE HEPATIC ABSCESS (Suppurative Hepatitis). Pathologic Definition. — A circumscribed accumulation of pus in the Hver substance, with destruction of the hepatic tissue. The organ is, as a rule, enlarged, and such enlargement is often symmetric, whereas to the feel one or more areas of softening are detected. A single abscess is usually located in the right lobe near the superior surface, yet multiple abscesses are by no means uncommon, and may involve the left lobe. The tissues im- mediately surrounding the abscess are deeply congested, and in decidedly acute cases no well-marked abscess-wall is present, but in the subacute variety of abscess a distinct wall of demarcation is produced. Upon cutting through the abscess it is found to be filled with a liquid which contains pus-cells, necrotic tissue (liver-cells), and a variable amount of serous exudate. (See 588 THE LIVEK. also Amebic Abscess.) The amount of fluid contained in a hepatic abscess may vary from a few ounces to two or three quarts. Microscopically, many of the hepatic cells are distorted in shape and devoid of nuclei. Round-cell infiltration is seen in the vicinity of the blood- vessels, and certain of the smaller vessels are plugged by emboli. Strepto- cocci and staphylococci are usually present. Varieties. — Clinically speaking, abscess may be acute, subacute, or chronic in character. A special heading is usually employed to designate amebic abscess, which is not in reality a true abscess, since it does not of necessity contain pus-producing bacteria. Exciting and Predisposing Factors. — The introduction of patho- genic bacteria (cocci and bacilli) into the liver substance excites acute abscess. Climate is the most potent predisposing influence, the majority of cases developing in tropical or subtropical districts or in those persons who have recently lived in the tropics. Occlusion of the bUe-ducts, including that re- sulting from gall-stones, antedates nearly 50 per cent, of cases. Disease of the ggll-bladder and other hepatic conditions were found by Kobler to be present in nearly 25 per cent, of cases; he also found that 13 per cent, of his cases followed pyemia. Gastric ulcer is frequently followed by hepatic ab- scess, as is also ulceration of the colon and appendix. Kelsch, in his analysis of 500 cases, found that 85 per cent, of them followed dysentery. Manson refers to 3680 fatal cases of dysentery on which autopsies were made (col- lected by Woodward), in 21 per cent, of which abscess of the liver existed. Suppurating wounds of the scalp are not infrequently followed by hepatic abscess, as are also operations upon the rectum. Intestinal parasites may find their way into the gall-bladder and excite acute cholecystitis, which may terminate in abscess, as is shown by Leik's report of 19 cases following migration of the Ascaris lumbricoides to the gall-bladder. Liver-flukes and hydatids may excite the initial inflammation whioh terminates in hepatic suppuration. Foreign bodies taken into the stomach occasionally reach the liver, and there produce abscess; among such mechanic irritants are pins, fish-bones, needles, and buttons. Principal Complaint and Symptoms. — Pain, a constant feature, is in the hepatic region, and radiates to the shoulder. The more superficially the abscess is located, the more severe is the pain, which is due to involve- ment of the peritoneum. The patient describes his pain as dull and boring in character. Pleuritic pain is experienced when the abscess is situated near the superior surface of the liver, and has excited an inflammation that in- volves the diaphragm and the pleura. Relief is afforded when the patient is in certain positions, and his agony is intensified by pressure over the right costal margin and by lying on the left side. Chills, and even distinct rigors, are frequently experienced, and these are followed by profuse sweating. In chronic hepatic abscess there are progressive weakness, emaciation, and the general symptoms of chronic sepsis. Gastro-intestinal sjrmptoms are constant, but are of such nature as to be of but limited service in formulating a diagnosis; they consist of flatu- lence, epigastric uneasiness, nausea, and vomiting, all of which symptoms become intensified as the disease progresses. Nervous Symptoms. — The rule is for the patient to remain rational during the first thirty-six hours, after which period the nei-vous manifesta- tions depend upon the degree of hepatic destruction and the grade of intoxication. Cephalalgia, muttering delirium, tremor of the tongue and ACUTE HEPATIC ABSCESS. 589 hands, mental hebetude, and finally coma are seen in cases that terminate fatally. Thermic Features. — In those acute cases in which there is rapid, ex- tensive destruction of liver tissue the temperature rises somewhat abruptly, reaching 103° or 104° F. during the first thirty-six hours. The character of the fever is distinctly irregular, and, as a rule, intermittent, resembling that of malaria. (See p. 948.) In those cases in which hepatic abscess is about to terminate fatally the temperature becomes subnormal, and the general condition is that of collapse. Physical Signs. — Inspection. — ^The face is flushed at first, but later becomes pale, and jaundice may develop, depending upon the degree of hepatic destruction and the location of the abscess, as well as upon an as- sociated involvement of the gall-bladder and the bUe-ducts. Bulging over the region of the liver is present only when there is extensive abscess forma- tion. Chest expansion is often limited upon the right side, due to an abscess resting near the surface of the diaphragm, and consequently exciting dia- phragmatic and possibly pleural irritation. The tongue is coated, the lips are dry and fissured, and the teeth are often covered with sordes. Palpation. — By deep palpation it is usually possible to elicit distinct tenderness along the costal margin. The liver is often felt below the margin of the ribs, and when the patient is directed to inspire deeply, the lower hepatic outline presents a smooth surface. In unusually large abscesses fluctuation may be elicited. Abscess of the left lobe of the liver is decidedly uncommon, yet when present, is quite easy of recognition. In those cases in which the adjacent peritoneum is involved, a friction fremitus may be felt. The abdominal muscles overlying the liver are at times unusually tense, which materially interferes with palpation. The pulse becomes rapid and bounding during the first twenty-four hours, but as the disease advances, its frequency is increased, whereas its volume and force, are diminished. In subacute and chronic cases the pulse is that of general sepsis, e. g., weak, rapid, dicrotic, compressible, and irregular. Percussion. — An increased area of liver dullness may or may not be present, although in tj^pical cases the liver note will be found above the lower border of the fourth rib, and rises high (fifth rib) in the axillary line. Pos- teriorly, hepatic dullness usually extends to the angle of the scapula. In outlining the area of hepatic dullness by auscultatory percussion it will be found that the liver extends for a slight distance below the normal level. Pulmonary Symptoms and Signs. — ^There is cough, which may be severe and non-productive, although in characteristic cases there is moderate ex- pectoration of a reddish-brown, mucosanguineous material. Auscultation reveals numerous fine and coarse rales over the base of the right lung, and rarely a friction murmur is detected. I^aboratory Diagnosis. — The blood changes are those of sepsis — e. g., leukocytosis with a proportionate increase in the number of polymorpho- nuclear cells. As the disease progresses the hemoglobin and red cells are gradually decreased. During the height of the fever albuminuria is present, and casts and leukocytes may be found. In those cases developing jaundice the urinary sediment is colored, and in other respects the urine is that of jaundice. (See p. 606.) Indicanuria is to be expected. Summary of Diagnosis. — A history of dysentery, gastric ulcer, or operation upon the intestinal tract (rectum) is of great help in formulating a diagnosis. The character of the pain, the presence of tenderness over the liver, an increased area of hepatic dullness when associated with leukocytosis, 590 THE LIVER. and an increase in the polymorphonuclear elements of the blood strongly favor hepatic abscess. Fever, while not characteristic, is highly suggestive of this condition, its main features being that it is decidedly irregular at first, but assurnes the intermittent type as the disease advances. Chills and profuse sweating are likewise of clinical importance. Differential Diagnosis. — Malaria. — Abscess, when developing in those residing in malarial districts, is likely to be mistaken for malaria on account of the periodicity with which the chill, fever, and sweating recur. Again, hepatic tenderness and splenic enlargement are characteristic of both conditions. Although there are many slight differences between acute hepatic abscess and malaria, in the light of our present knowledge there ap- pear to be but three actually distinctive features: (a) Finding of the Plas- modium of malaria in the blood; (6) the recovery of pus by aspiration of the abscess; and (c) leukocytosis is a feature of hepatic abscess and leukopenia is a characteristic feature of malaria. Hepatic Colic. — ^There is usually a history of previous attacks that were followed by jaundice. The paroxysms (chills, fever, and sweat) of hepatic colic do not occur with such regularity as do those of hepatic abscess. Ex- treme pain with each seizure is characteristic of gall-stone colic, whereas in abscess a deep burning pain may be almost constant. In those cases in which a gall-bladder is impacted with stones there may be persistent jaundice, with practically all the symptoms known to accompany this condition, whereas in uncomplicated abscess of the liver jaundice is by no means constant. Hepatic carcinoma can scarcely be confounded with hepatic abscess. (See Carcinoma, p. 581.) Echinococcus cyst, while it may present enlarge- ment of the liver resembling that of abscess, is characterized by a normal or subnormal temperature, imless the cyst becomes infected with pathogenic bacteria, in which case it becomes a true hepatic abscess. The prolonged existence of hepatic enlargement, the absence of tenderness, the possible intimate association with dogs, and a residence in a country in which echinococcus disease is indigenous, all taken together, go far to support the diagnosis of hydatid cysts. DISTENTION OF THE LIVER AND OF THE GALL-BLADDER. Pathologic Definition. — A condition produced by obstruction to some one or more of the hepatic ducts, and characterized further by an ab- normal distention of the ducts of the liver, with enlargement of the organ. In certain cases, as the result of undue pressure, there may be destructive changes in the parenchyma of the organ. Bxciting Factors. — Any condition that obstructs anyone or more of the bile-ducts must of necessity be followed by a variable degree of hepatic enlargement. Intrahepatic Conditions. — (1) Gall-stones, by blocking the common duct or the cystic duct; (2) carcinoma of the common duct; (3) nodular car- cinomata of the liver pressing upon one of the ducts ; (4) catarrhal inflamma- tion of the common duct with obstruction by edema of the mucous lining (excited by cholecystitis, liver flukes, and extension of catarrh from the duodenum); (5) perihepatitis (syphilitic), by constriction and eventual interference with the flow of bile through the common duct. Extrahepatic Causes. — (1) Carcinoma of the head of the pancreas, by pressure and obstruction of the common duct; (2) epithelioma of the duo- FATTY INFILTRATION AND FATTY DEGENEKATION. 591 denum, by extension to the duodenal orifice of the common duct; (3) gastric ulcer with extensive peritoneal adhesions, resulting in obstruction to the common duct; (4) abdomiaal tumors pressing upon the common duct or upon the inferior surface of the liver; (5) displacement of the liver (floating liver), with a variable amoimt of torsion; (6) blocking of the common duct by migrating intestinal parasites. Principal Complaint. — ^There is a sense of fullness or discomfort in the superior right abdominal quadrant. There may or may not be pain, this symptom dependiag upon the cause of the enlargement. Physical Signs. — Inspection. — The patient is, as a rule, jaundiced, although jaundice is not an essential feature of cystic distention. There is prominence of the right superior abdominal quadrant. Palpation. — ^The pulse is unusually slow in those cases displajong jaim- dice. When enlargement follows carcinoma, the pulse becomes weak, thready, and almost imperceptible as the disease advances. One is able to outline the peculiar sausage-shaped mass projecting from the lower hepatic margin in those persons ia whom the abdominal wall is not unusually thick. The enlarged gall-bladder may attain an enormous size, extending to a point on a level with or below the umbilicus. The tumor is usually dough- like in feel and may display fluctuation, and firm pressure does not excite pain. Percussion. — Both percussion and auscultatory percussion confirm pal- pation with reference to the size of the gall-bladder and the hver. Auscultation. — ^In those cases in which there have been quite extensive peritoneal adhesions, a friction murmur may be heard by placing the stetho- scope over the lower margin of the liver, and then directing the patient to inspire deeply. If this sound is dependent upon obstruction of the common duct and impaction of the gall-bladder with calculi, then auscultation com- bined with firm palpation over the liver may result in producing a grating soimd caused by friction of the calculi. I^ey Transverse lines on level with spine of second lumbar vertebra. Bromidrosis is commonly a functional disorder of the sweat-glands characterized by a production of sweat which emits a disagreeable odor. Ordinarily the quantity of sweat is increased. Offensive odor of the sweat may result from the ingestion of certain drugs and foods, and also from the development of the bacillus foetidus in the perspiration. It is also a clinical feature in coimection \vith neurotic and psychic individuals. This condi- tion usually affects the feet, axillary, inguinal, mammary, and perineal regions. Hyperidrosis. — Collectively speaking, this term includes any condition wherein there is an increased amount of sweat. Over-production of sweat EXAMINATION OF THE URINE. 639 may be more or less continuous, remittent, intermittent, or periodical. This condition may also be either acute or chronic. Again it may be general or local, and at times we find it of clinical importance where sweating is unilateral. (See Aneurysm, p. 311.) Profuse sweating is a clinical mani- festation in practically all infectious conditions that are accompanied by a chill at the onset, e. g., malaria, scarlet fever, acute sepsis, tonsiUitis, small- pox, and puerperal sepsis. Profuse sweating and also sweating of the head and neck are common features among the continued fevers, e. g., typhoid fever, pneumonia, and ulcerative endocarditis. Profuse drenching sweats may occur during sleep as a result of profound exhaustion; pulmonary tuberculosis with cavity being a typical example of disease in which this type of hyperidrosis is seen. Lastly the skin may be beaded by drops of perspiration, and yet the cutaneous temperature be normal or subnormal , a clinical feature character- istic of all conditions accompanied by shock. Anidrosis (decreased or complete cessation of sweat) is a clinical feature in connection with certain cutaneous maladies involving the sweat-glands; and it is also a conspicuous feature in diabetics, nephritis, scurvy, and such constitutional conditions as cretinism, exophthalmic goiter, and myxedema. In all patients displaying anidrosis the skin is dry and harsh to the feel, and if the condition persists for weeks or months, decided roughening develops. EXAMINATION OF THE URINE. _ We shall not attempt to discuss at great length the examination of the urine, but shall endeavor to explain certain practical methods that will enable the physician to collect specimens for examination, and, at the same time, we will describe certain approved methods by which albumin, glucose, acetone, and other pathologic urinary constituents are to be distinguished. Collection of the TJrine. — Whenever possible, the specimen for examination should be taken from the urine collected during the twenty- four hours, the quantity being measured. We have found it possible to obtain satisfactory results by collecting, in separate bottles, from two to four ounces of the urine voided three hours after a full meal and after the day's toil (evening urine), and the same quantity of urine voided in the morn- ing after a night's sleep. The bottles should be thoroughly cleansed before using, and after placing the urine in them, they should be corked tightly and kept in a cool place. Under normal conditions the quantity of urine excreted should measure about 1500 c.c. (50 fluidounces), but owing to various conditions that cause decided fluctuation in the quantity of the twenty-four hours' product, this standard is not essential. Conditions that Cause Excessive Excretion of Urine. — Baro- metric and thermometric conditions (humidity, temperature) are responsible for marked fluctuation in the quantity excreted daily. An increase in the quantity of urine excreted occurs during the early part of the night and early morning hours. Exposure to cold, certain conditions of the skin in which free perspiration is impossible, and the too free imbibition of liquors are also responsible for an increase. In such pathologic conditions as diabetes in- sipiduSj diabetes mellitus, chronic interstitial nephritis, and amyloid disease 640 DISEASES OF THE UKINAKY SYSTEM. an increase in the urine voided during the twenty-four hours occurs. Hy- dronephrosis, floating kidney, and hysteria may cause a temporary increase, but such increase is intermittent, lasting for but a few hours. True poly- uria is seen in diabetes and during the absorption of serous exudates. It is to be remembered, further, that between the paroxysms of intermittent fever the flow of urine is usually increased — a feature well exemplified by relapsing fever. A moderate increase in the urine will be seen after the ad- ministration of certain drugs. Conditions tliat Cause a Decrease in the Bxcretion of Urine. — Diminution in the quantity of urine excreted occurs during deep sleep, when persons are taking a dry diet. Pathologically, we find the urine dim- inished in acute nephritis, acute exacerbations of chronic nephritis, chronic parenchymatous nephritis, during the fastigia of acute fevers, and in robust and gouty individuals in whom the quantity of liquid taken during the day is extremely small. Oliguria may also develop as a result of interference with the renal circulation, as occurs, e. g.,'m chronic heart disease, cirrhosis of the liver, ascites, cardiac embarrassment, anemias, abdominal tumors, pleural effusion, and other conditions. Suppression of the urine is a common feature of uremia and of conditions in which a large quantity of fluid has been excreted from the body-tissues, as, e. g., in hemorrhage, Asiatic cholera, and dysentery. Suppression, toxic in origin, may follow the administration of such drugs as oxalic acid, arsenic, turpentine, and others, although some of these drugs are capable of causing a moderate increase in the renal secretion when administered in medicinal doses. CHYLURIA. Chyluria, or milky urine, as a rule results from the rupture of lacteals into the urinary tract. Clinical Significance. — Chylous urine is seen in those cases in which infection with the Filaria bancrofti has occurred. (See p. 960.) It is also seen in disease of the bladder and following surgical operations along the genito-urinary tract (traumatic chyluria), and a few. cases are reported that followed severe injury to the kidney. In one instance chyluria followed septic infection of the pelvic organs, and in two cases it occurred after opera- tions upon the pelvic viscera. The detection of embryo filarise in the urine will serve to separate parasitic from traumatic chyluria. HEMATURIA AND HEMOGLOBINURIA. Definition. — The former term is applied to a symptom the result of blood entering the genito-urinary tract, whereas the latter term designates a state in which merely the coloring-matter of the blood escapes with the urine. Remarks. — Hematuria occurs in acute nephritis, and may follow the administration of drugs (renal irritants) or traumatism of the kidney. The condition may develop during the course of severe anemia, malarial cachexia, purpura, etc._ Hematuria is a symptom of pyelitis, renal calculi, cystic calculi, cystitis, enlarged prostate, vesical polypi, tuberculosis of the bladder, tuberculosis of the kidney, carcinoma of the bladder or of the kidney, and urethral stricture. _ It is also a characteristic feature of Bilharz's disease (see p. 961) and of infection of the bladder with other animal parasites. HEMATURIA AND HEMOGLOBINURIA. 641 Causes. — The following is a list of the chief causes for blood in the urine: Renal Causes. Pronounced hematuria. Hydronephrosis. Sarcoma. Polycystic disease. Carcinoma. Nephritis (acute). Papilloma of pelvis. Drug-poisoning, turpentine, carbolic acid, Calculus. cantharides, quinin. Tuberculosis of pelvis. Calculus (renal). Injury to the loins. Traimiatism. Eustrongylus gigas. Oxaluria. Hematuria may be slight. Tuberculosis. Floating kidney. Vesical Causes. Papilloma. Acute cystitis. Villus-covered carcinoma. EpitheHoma. Prostatic enlargement (adenoma or car- Tuberculosis. cinoma). Calculus. Traimiatism, usually instrumental. Traumatism. Bilharzia hematobia. Filariasis. Strongyloidis stercorals. Disease op the Adjacent Tissues Involving the Urinary Tract. Carcinoma of the vagina. Acute salpingitis. Carcinoma of the rectum. Pelvic abscess. Carcinoma of the uterus. Tuberculosis of intestine (rare). General Maladies and Infections. Small-pox. Purpura. Malaria. Scurvy. YeUow fever. Leukemia. HemophiUa. Endocarditis. Acute fevers. Detection of Hematuria. — The recognition, microscopically, of red blood-cells in the urinary sediment is positive evidence of the existence of hematuria, and unless the examiner is skilled in laboratory methods, will prove his most reUable test. (See also tests for blood-pigment in feces, p. 515.) Recognition of Hemoglobinuria. — Whenever the urine is of a bloody color and it is impossible to detect by microscopic examination red blood-cells in the urinary sediment, the condition in question is probably one of hemoglobinuria. Method. — In order to demonstrate the presence of hemoglobin in the urine powdered tannic acid is added to the filtered urine until a heavy pre- cipitate is produced. This precipitate is collected on a filter-paper, thor- oughly washed with distilled water, and allowed to dry in the air. A small granule of this precipitate is then put on a microscopic slide with a granule of sodium chlorid of the' same size, and a few drops of glacial acetic acid are added. A cover-glass is then put on the mixture and the slide is warmed over a flame until the acid steams. If the acid evaporates completely, more is added, until there is a brown color in the fluid. After cooling, the specimen is examined with a J-inch objective, and if hemoglobin was present in the urine, the characteristic crystals of hematin will be discovered. Caution. — In performing this test the slide must not be heated too hot and the cooling must take place slowly. Good crystals are obtained by al- 41 642 DISEASES OF THE URINAHY SYSTEM. lowing the mixture of precipitate, sodium chlorid, and glacial acetic acid to stand overnight at room temperature. LEUKOCYTURIA. Remarks. — Normal urine, when studied microscopically, wiU be found to contain an occasional leukocyte, but white cells are seldom demonstrable unless the urine be centrifugalized and a large amount of sediment be em- ployed for microscopic study. Whenever leukocytes are found in a urinary sediment in large number, pus is said to be present. Pathologic leukocyturia is found whenever there is congestion of the kidneys or any irritation of the pelves of the kidneys, ureters, bladder, prostate, or urethra, at which times the number of leukocytes present de- pends entirely upon the degree of irritation and the size of the area of mucous membrane affected. Leukocytes often enter the urine as the result of an inflammatory process of the prostate or of the seminal vesicles. Leukocyt- uria is also a feature of endometritis, vulvitis, vaginitis, and sexual excesses. Again, leukocytes may appear in the urine whenever an inflammatory process is present in any of the structures adjacent to the urinary tract. PYURIA. Definition. — ^The presence of pus in the freshly voided urine. Naked-eye Appearance. — ^There is a white or milky white sedi- ment that collects if the urine is allowed to stand for a few hours, and upon shak- ing the bottle this sediment is found to be extremely heavy, and to float up through the clear liquid, assuming a more or less fringed-rope appearance. Pus may be found in either acid or alkaline urines, although it is more com- mon in the latter. Microscopic Appearance. — ^Microscopically, this sediment is found to contain many pus-cells (Fig. 256), and at times red blood-cells. Pus-cells are round objects of fairly uniform size, each of which contains a polymorphous nucleus. In some specimens the nucleus is so obscured by the granules in the cell cjrtoplasm as not to be easily distinguishable. In such a case a crop of 50 per cent, acetic acid, if allowed to flow imder the cover-glass will dissolve the granules and bring the polymorphous nucleus into view. The pus-cells, or leukocytes, are the smallest round granular cells seen in urinary sediments. Renal epithelium, the cells of which have a single nucleus, in contradistinction to the polymorphous nucleus of the pus-cell, is about one and one-half times as large as the pus-cell; while round, pelvic, ureteral, vesical, and prostatic epithelial cells are from two to seven times as large as the pus-cell. Clinical Significance. — Pus-cells appear in the urine as the result of inflammatory processes along the genito-urinary tract. In pyonephrosis, pyelitis, and the more severe forms of cystitis and urethritis erythrocytes are also present. Pyuria not infrequently results from the escape of pus from other tissues into the urinary tract, and it may depend upon the admixture of leukorrheal discharge. It is of great importance to determine the origin of the pus in a given specimen of urine, and by examining the genito-urinary tract, it is usually possible to determine this point. It has been stated that pus-cells coming from the kidney and from the pelvis of the kidney are equally disseminated throughout the urine^ but in our experience we have found many exceptions ALBUMINURIA. 643 to this rule. The deposit of pus as a thick, ropy sediment depends, in great measure, upon the amount of mucus present in the specimen. ALBUMINURIA. Remarks. — Albumin may appear in the urine as the result of a number of varied pathologic conditions, and some writers believe that the urine may contain albumin under normal conditions — the so-called physiologic albumin- uria. The question that concerns the clinician most is, whether or not, in a given case, the albumin is renal in origin; and this point it is frequently difS- cult to determine. We have found many cases of albuminuria in which it Fig. 256. — Urinary Sediment from Case of Pyelitis (Boston). 1, Epithelial cells, probably from pelvis of kidney; 2, large pus-cells; 3, small-pus cells (obj. Spencer one-sixth). was quite impossible to determine whether or not we were dealing with a true renal albuminuria. For convenience of study we have considered albuminuria under the following subheadings: Renal Albuminuria. — A symptom resulting from temporary irrita- tion of the renal tissue, or inflammatory or degenerative disease of the kidney, and depending upon the escape of albumin into the uriniferous tubules, if there should be disease of the pelvis of the kidney, albumin might enter the urinary tract at this point, and the condition should be considered as one of renal albuminuria. The changes capable of exciting the escape of albumin into the uriniferous tubules are of two types — (a) Inflammatory, in which there is congestion or inflammation of the kidney substance; and (6) de- generative changes, in which case evidences of acute inflammation are want- ing. The former variety of albuminuria is to be seen occasionally in acute nephritis; the latter tj^e is best exemplified in the chronic nephritides. Without doubt we have, at times, to deal with albuminuria resulting from the combined action of these two pathologic processes. During the early stages of acute nephritis the amount of albumin that 644 DISEASES OF THE URINABT SYSTEM. escapes with the urine is extremely high, and may equal one or one and one^ half per cent, by the Esbach method. Caution. — The urine of a patient with nephritis which is voided after eating and exercise will contain more albumin than that collected after rest and sleep. Toxic Albuminuria. — Renal albuminuria may be toxic in origin, and is to be seen after the administration of certain renal irritants, as, e. g., copaiba, turpentine, phenol, following ether anesthesia, etc. ; acting probably in a similar manner we find the toxins of certain acute diseases (diphtheria, scarlet fever, typhoid fever, pneumonia) capable of exciting the escape of a large amount of albumin with the urine. It is quite impossible to sepa- rate febrile from toxic albuminuria, since they frequently occur together. Intermittent and Remittent Albuminuria. — Renal albuminuria may be intermittent, remittent, or continuous in character, and, in fact, it is not unusual to find all three of these types of albuminuria in chronic dis- eases of the kidney, as, e. g., in interstitial nephritis, mild parenchymatous nephritis, and early during amyloid disease. In these chronic conditions the quantity of albumin passed may be comparatively small, and, in fact, it is necessary to concentrate the urine before one is able to detect this body. Clinically speaking, we do not consider albuminuria a pathologic condition unless the albumin is capable of detection by the methods ordinarily employed for this purpose. Orthostatic, postural, alimentary, and cyclic albuminuria are special varieties of the intermittent type. ^ During the course of an acute exacerbation of a chronic type of nephritis the amount of albumin passed during the twenty-four hours is high, and may even exceed that excreted in primary acute nephritis. In general, however, the larger the amount of urine excreted, the lower the percentage of albumin present. (o) Traumatic albuminuria may follow injury to the kidney, abdominal massage, traumatism to the head, and severe injury to the extremities. (b) Alimentary Albuminuria. — Following the ingestion of foods rich in albumin, the urine not infrequently contains albumin in pathologic amounts. We have repeatedly seen this form of albuminuria in patients taking from six to twelve eggs a day. It seems that when uncooked eggs are taken, albuminuria is most likely to follow, yet our series of experiments is not sufficiently large to enable us to state positively that this is the rule, al- though it was found by us in nearly 60 cases. (c) During the course of certain chronic and malignant maladies there may be a decided impoverishment of the blood, -in consequence of which albumin escapes from the kidney into the uriniferous tubules. Thus we find albuminuria in both primary anemias (leukemia) and secondary anemias. The albuminuria that accompanies chronic lead-poisoning does not belong strictly to this second class, and there is room for question as to whether or not the albuminuria of anemia is not toxic in origin. Extrarenal Causes of Albuminuria. — General Consideration.— Inflammatory processes involving the pelvis of the kidney, ureter, bladder, prostate, or urethra are capable of exciting albuminuria, and in this connec- tion it may be well to mention especially such maladies as stone and tuber- culosis of the pelvis of the kidney, stone in the ureter, and torsion of the ureter due to movable kidney; vesical polypi, ulcerative cystitis, vesical calculus, and tuberculosis and carcinoma of the urinary tract may in turn produce albuminuria. Pus generated along the genito-urinary tract or escaping from other tissues with the urine may be responsible for albuminuria, and blood and ALBUMINURIA. 645 blood-serum (filariasis; Bilharzia disease), when added to the urine, cause this condition. Prostatic Albuminuria. — Experiment has shown that in massage of the prostate the seminal fluid passes into the bladder without any escape of semen from the meatus ; again, the urine may be free from albumin prior to prostatic massage, whereas following this operation the urine may contain albumin. In view of the foregoing facts this variety of albuminuria has been termed prostatic, and we regard the albuminiu'ia or prostatic, o\'arian, and uterine congestion as extrarenal in origin. Albuminuria of prostatic origin is most likely to develop after exercise, hot and cold l)aths, etc. ; this renders it difficult to distinguish between it and the so-called intermittent, cyclic, or- thostatic, and transitory albuminuria, which is common after inflammatory processes of the urethra, prostate, or in conditions known to irritate these tis- sues. In prostatic allDuminuria the urine is likely to contain spermatozoa. Parasitic Albuminuria. — Infection with the Schistosomum liaematobium causes hemorrhage into the bladder, and consequently alljuminuria. There may be infection of the l:)ladder with round worms — ascaris, oxyuris, anguillula — or with rhabiditiform embryos, all of which excite all^uminuria. The animal para- sites known to infect the kidney in man are : Eustrongylus gigas, which usually inhabits the pelvis of the kidney, and is quite common in the lower animals, and the Tjenia echinococcus, which most often invades the substance of the kid- ney. Infection of the kidney with these parasites may be accompanied by both hematuria and albuminuria, and we have .studied ca.sas representing each of these types of infection. Recognition of Albumin. — Boston's Pipet Method. — Reagents. — (1) Concentrated nitric acid; or (2) nitric acid, 1 part, and saturated solu- tion of magnesiiun sulphate, 9 parts. " Albiunin causes a white cloud to appear in the form of a ring at the zone of contact of the two liquids (reagents and urine) (Figs. 257, 258), and this test, when carefully applied, must be regarded as one of great value." 1. A pipet is filled for a distance of from one inch to one and one-half inches with the urine to be tested. The mine is then removed from the sur- face of the pipet by washing or by wiping. 2. The pipet, with its contained urine, is then placed near the liottom of a bottle containing nitric acid, when the pressure of the index-finger is lessened and the acid allowed to flow gradually up into the pipet. 3. When the pipet is seen to contain about equal amounts of acid and urine, the finger is again pressed firmly upon the top of the pipet, which is then removed from the bottle and held toward the light on a level with the eye. If albumin is present, a distinct white ring of coagulated albumin ap- pears at the junction of the ui'ine and the reagent. "The ring is often in- FiG. 2.57. — Boston's Method of Filling Lower Portion of Pipf.t, that Con- tains Urin'e to be Tested, with Nitric Acid. 646 DISEASES OF THE URINARY SYSTEM. tensified by placing the pipet in different lights or against a dark background. The hand, when placed l)ack of the pipet and carried slowly aljove and then below the level of the ring, serves this purpose." The Heat and Nitric Acid Method.— Fill a test-tube three-quarters full of filtered urine, and boil the top layer. In the presence of phosphates or albumin a precipitate will be produced. The addition of one drop of nitric acid will dissolve this precipitate if it be due to phosphates. If it be due to albumin, the precipitate will not be dissolved, and the drop of acid, as it falls through the unboiled portion of the urine, will produce a second precipitate Ijy its coagulating action on the albumin. Heller's Test. — About three cubic centime- ters of nitric acid are placed in a test-tube, and filtered urine is allowed to flow down the side of the tube so that it lies in a layer above the acid. In the presence of albumin a white line of coag- ulated albumin will be seen at the junction of the two layers of fluid. A brownish ring due to acid urates is formed a short distance above the line of junction of the two fluids, and is to be tlifferentiated from the ring of albumin. After the administration of copaiba and other balsamic drugs the urine contains substances that produce a brownish ring below the junction of the two fluids. The Acetic Acid and Potassium Ferrocy- anid Test. — A small quantitj' of filtered urine is acidulated with five drops of acetic acid, and a 10 per cent, solution of potassiimi ferrocyanid is added to the mixtvu'e one drop at a time. In the presence of albumin a white precipitate wiU he produced. Significance. — The heat and nitric acid test is the most reliable method for the de- tection of serum-albumin in the urine. The other tests will give positive reactions for other albuminuous substances than serum-albumin. It occasionally happens that the amount of serum-albumin in the urine is so small, or that fermentative changes have taken place in the specimen to such an extent, that the heat and nitric acid test is difficult of interpretation. Under such circumstances the other reactions suggested may be used as confirmatory tests. The acetic-acid-potassium-ferrocyanid test will give a precipitate with mucin and other albuminoid bodies, and is not to l^e used in the routine examination of urine for albumin. Frequency. — Certain foreign authors claim to find albumin in about 7 per cent., and others in 20 per cent., of cases studied; in patients under our obser\^ation we have not found allmminuria so common. In fact, we incline to the belief that those who found so high a percentage of urines to contain albumin must have been considering all the coagulable substances, and that they have included reactions caused by the presence of the albu- moses (peptones), mucin, phosphates, and the like. Esbach's Method. — The Esloach method for the quantitative determina- tion of albumin is the best method available for clinical work. The instru- FiG. 258. — Boston's jMethod. Pipet Containing an Upper Stratum of Urixe, a Lower Stratt^m of Nitro-magne- sium soli'tion, and show- ING A White Line (Albttmin Ring) at Zone of Contact. SPECIFIC GRAVITY. 647 ment has been tested against estimations made by precipitating out and weighing the albumin and has been found to be quite accurate. The follow- ing solution (Esbach's solution) is used: Picric acid, 10 gm. ; citric acid, 20 gm. ; distilled water, 1000 c.c. Process. — Fill an Esbach tube with filtered acid urine to the mark U, and add the reagent until it reaches the mark R. Then place a cork in the mouth of the tube, and mvert it several times to insure perfect mingling of the urine with the reagent. The tube should now be placed in a special receptacle (Fig. 259) and allowed to stand for twenty-four hours, when the sediment that collects at the bottom of the tube will consist of serum-albumin, serum- globulin, albumoses, uric acid, and kreatinin. The amount of sediment is read directly from the scale, and indi- cates the amount of albumin in grams in 1000 cubic centimeters of urine. Caution. — When the specific gravity is above l.OOS, the specimen should be diluted with water to reach this den- sity. The temperature of the room should be 15° C. (59° F.). The urine must be acid in reaction. SPECmC GRAVITY. Consideration . — The s p e c i fi c gravity of the urine for healthy Ameri- can is given at 1.020 and for Chinese 1.004 to 1.012. It usually varies in in- verse ratio to the quantity excreted daily. If a large quantity of urine is excreted daily, and such urine is of high specific gravity, — 1.030 to 1.040, — gly-. cosuria is to be suspected. Urines rich in solids display a high specific gravity, and when the quantity of urine voided during the twenty-four hours is far below the normal, a high specific gravity is usual. A diet rich in albumins also tends to increase the specific gravity of the urine. As a rule, the specific gravity is high in acute nephritis, dur- ing the fastigium of acute fevers, in chronic parenchymatous nephritis, and also in specimens recovered from persons who live luxurious lives and take insufficient exercise. A low specific gravity occurs after ether anesthesia, after hysteric seizures, in cHabetes insipidus, chronic interstitial nephritis, amyloid disease of the kidneys, and after imbibing too freely of liquids. During convalescence from acute nephritis and from acute fevers the specific gravity is compara- tively low. REACTION OF THE URINE. Fig. 259.' — Receptacle for Esbach's Albu- MINOMETER, DeVISED BY DR. W, G. MUDIE. In the bottom of aa ordinary tumbler place a piece of heavy cardboard and cut central openings in two other cardboards which are glued in position. Normal urine is acid in reaction, such acidity depending upon the pres- ence of acid sodium phosphate, (NaH2P04) • The total acidity of the twenty- 648 DISEASES OF THE URINARY SYSTEM. four-hours' product is estimated to be equivalent to 14 grains of sodium carbonate. The acidity of the urine is increased by violent muscular exercise, a diet rich in meats, mineral acids, during certain fevers, in scurvy, diabetes melli- tus, diabetes insipidus, leukemia, gout, rheumatism (chronic and acute), and in the acute infections. Increased acidity is also present in persons who eat too heartily, and who take insufficient exercise. It is characteristic of the uric-acid diathesis and of oxaluria, and is commonly observed when the quantity of urine passed during the twenty-four hours is below the normal. When an oxalic or a uric-acid stone of either the bladder or the kidney exists, the urine is often highly acid. Decreased acidity may follow the ingestion of a light meal, a vegetable diet, and the ingestion of alkaline carbonates. Decreased alkalinity is also seen following profuse sweating, paroxysmal vomiting, and more rarely under other circumstances. The acidity may be lowered during certain hours of the day. Standing lessens the acidity of the urine. Neutral and Amphoteric Urines. — Rarely, one encounters a urine which causes no change in either red or blue litmus; such a specimen is neutral. Occasionally, the urine wUl give both an acid and alkaline reaction with litmus-paper, when it is styled amphoteric. This phenomenal reaction is dependent on the presence of both acid and neutral sodium phosphates, which substances are held in equal suspension. This reaction is of no clinical significance. CHLORIDS. Remarks. — Sodium in combination with chlorin forms the chief alkaline constituent in normal urine, from 10 to 15 grams being excreted during the twenty-four hours. It should be stated that chlorin, in combination with calcium, potassium, ammonium, and magnesium, is also present in normal urines. Decrease. — During health the amount of sodium chlorid excreted is in direct proportion to the quantity and quality of the food taken. The chlo- rids are decreased in such febrile conditions as scarlet fever, smallpox, typhoid fever, typhus fever, acute hepatic atrophy, and in disease in which starvation occurs. It is asserted that the chlorids are diminished or absent in croupous pneumonia. The chlorids are diminished slightly in certain diseases of the insane in proportion to the degree of involvement of the kidney. In maladies attended with an excessive drain upon the system, such as diarrhea, and in disease in which the body tissues are imperfectly nourished (e. g., carcinoma), the chlorids are much below the normal limit. Increase, — A marked increase is seen to follow the administration of potassium salts, whereas a less pronounced increase results from the absorp- tion of the serous exudates, during diabetes insipidus, convalescence from fever, the afebrile stage of intermittent fever, and after epileptic seizures. Recognition of Chlorids. — Reagents required: (1) Nitric acid; (2) solution of silver nitrate (1 dram of the crystalline salt to the ounce). The foregoing solution of silver, when added to albumin-free urine, is capable of precipitating the chlorids when the urine is first acidulated by adding a few drops of nitric acid. This precipitate appears as an opaque, milk-white silver chlorid. Normal urine contains from i^ to 1 per cent, of chlorids. Application. — 1. From 10 to 15 c.c. of albumin-free urine are placed in a PHOSPHATES. 649 test-tube — and to it are added a few drops of nitric acid, and the mixture shaken gently. 2. The silver solution is added drop hj drop, careful note being made of any changes that may occur. Each drop of the solution causes a curdy white clump to fall to the bottom of the tube; in normal urine this mass does not become disseminated upon shaking the tube, nor does the entire liquid tend to become milky. Should the chlorids be reduced to 0.1 per cent., the drop of solution merely causes an opalescence, whereas in the absence of chlorids, no change is ob- served, a feature seen in lobar pneumonia. A copious precipitate is indica- tive of an increase in the amount of chlorids present. The precipitate due to chlorids is soluble in ammonia, but insoluble in nitric acid. Although the quantitative estimation of chlorids is desir- able in certain instances, it is not within the scope of this volume to give the details of such a test. PHOSPHATES. Consideration. — The twenty-four hours' urine should contain from 2.05 to 3.05 grams of phosphoric acid. Most of the phosphoric acid enters into combination with sodium, whereas the remain- der of it is found to be united with calcium and magnesium. The earthy phosphates (cal- cium and magnesium) are found in a proportion of .3.3 to 67, and constitute one and one-half grams of the twenty-four-hours' product. Alkaline phosphates (sodium and potassium) constitute the greater portion of the daily excretion, sodium phosphate being by far the more abun- dant. Approximately, four grams of alkaline phosphates are excreted daily. Increase. — The urinaiy phosphates are found to be decidedly increased during convalescence from the acute fevers, in diabetes insipidus, leukemia, diabetes mellitus, and phosphatic diabetes. Drugs. — An increase in the excretion of phosphates may be due to the administration of drugs, as, e. g., alcohol, chloral, chloroform, vegetable acids, and the broniids. Violent exercise, mental strain, anxiety, and hot baths are likewise followed liy a moderate increase. Phosphatic Diabetes. — This term is descriptive of a condition in which the symptoms of diabetes accompany phosphaturia. Here the most decided increase in the urinary phosphates is seen, and the twenty-four-hours' prod- uct may exceed four grams. Decrease. — The urinary phosphates are diminished in conditions in which the vitality is greatly lowered, in most forms of anemia, rheumatism, chronic plumbism, and atrophic hepatic cirrhosis. The phosphates have been found below the normal in melancholia, but observations upon the in- sane are highl}' unsatisfactory. Fig. 260. — Crystals of Phosphates (Boston), 650 DISEASES OF THE UBINARY SYSTEM. In estimating the amount of phosphates, it is important to ascertain that the patient has not been taking cocain, strychnin, alcohol, valerian, quinin, and phosphoric acid, since these drugs cause a temporary diminution in the excretion of phosphates. Estimation of Phosphates. — For a description of the methods of estimating the amount of phosphates in the urine the reader is referred to special works upon clinical diagnosis. SULPHATES. Remarks. — During health, from two to three grams of sulphates are secreted during the twenty-four hours, the amount being influenced largely by the quantity of proteid food ingested, and by the tissue destruction that is taking place. Increase. — The daily excretion of sulphates will exceed three grams when the patient is fed upon a diet rich in animal proteids. During acute fevers and in inflammation of the meninges and of the serous sacs there is a rise in the output of urinary phosphates. A decided increase is occasion- ally seen in diabetes mellitus, eczema, pseudohypertrophic paralysis, muscu- lar atrophy, and myeloid leukemia. Drugs. — It must be remembered that sodium salicylate, antifebrin, morphin, and the bromids cause a somewhat marked increase in the urinary sulphates. A feature of great clinical importance is that whenever the percentage of hydrochloric acid is lessened, the ethereal sulphates are increased; con- sequently an increase is present in intestinal fermentation. Decrease. — The total sulphates are diminished following a diet rich in vegetables. After diarrhea, depleting conditions, and when the gastric juice is found to contain lactic and butyric acids in excess, the ethereal sxil- phates are also diminished. Recognition of Sulphates. — Reagents. — 1. Solution of barium chlorid (1 : 8). _ 2. Acetic acid (specific gravity, 1.04). Application. — 1. Place 10 c.c. of urine in a test-tube. 2. Acidify with acetic acid. 3. Add about 3 c.c. (one-third volume) of barium chlorid solution, 1 c.c. at a time, shaking gently after each addition. Reaction. — A white, milky precipitate indicates the presence of sul- phates in normal amounts; but should the liquid assume the consistence of cream, sulphates are present in excess. If the liquid becomes opalescent, sulphates are diminished. For the quantitative estimation of sulphates see special works upon Laboratory Methods, since the clinical employment of such knowledge scarcely warrants further description in this volume. SULPHUR. Loosely combined sulphur, when present in the urine, is a characteristic feature of disease of the bones (myelomata), and this unusual condition is, as a rule, associated with albumosuria. See Myelomata and Bence-Jones' Albumosuria (p. 1004). Urine containing sulphur when heated with a solution of lead acetate causes a brown or blackish precipitate. UREA. 651 UREA. Physiologic Quantity. — From 20 to 40 grams (300 to 600 grains) of urea constitute the normal quantity for twenty-four hours. Increase. — The amount of urea excreted is influenced by the rate of tissue destruction ; consequently after prolonged exertion the urea-content is in excess of 40 grams a day. An increase is also a feature of scurvy, leukemia, pernicious anemia, paralysis, diabetes mellitus, cyanosis, epilepsy, intestinal fermentation, chorea, and pregnancy. Drugs. — The prolonged use of such drugs as caffein, the chlorids, mor- phin and its derivatives is followed by an increase in the urea output, as is also the drinking of lithia waters. Owing to direct effect upon the tissues, the proportion of urea increases after the application of electricitj^ and in. poisoning by phosphorus. Decrease. — The quantity of urea is said to be decreased in acute yellow atrophy of the liver, and following such decrease leucin and tj^rosin, the re- sult of destructive changes in the liver, appear in the urine. A lessened excretion of urea is ex- pected in such chronic conditions as hepatic cirrho- sis, jaundice, lead-poisoning, melancholia, paresis, nephritis, and hysteria; this is also commonly seen in Addison's disease and in certain nervous affec- tions. It is generally believed that gastro-intes- tinal derangements materially influence the ex- cretion of urea, but when the amount of urea is studied in conjunction with the various conditions that may influence the output of this secretion, it becomes difficult for the clinician to draw any definite deductions from the amount of urea ex- creted during the twenty-four hours. Recognition of Urea. — Hypobromite Method. — The procedures of physiologic chemis- try give the only accurate methods for the esti- mation of urea, the chief nitrogenous excrementi- tious product in the urine. The total nitrogen content should be determined hj the Kjeldahl method, and this may be expressed as urea. Such a procedure, however, is too complicated for clinical work, and we are obliged to use a less accurate method for such a determination. It must be remembered, however, that the determination of urea by any method is of no value unless a portion of a twenty-four-hour specimen of urine is used. The Hypobromite Method. — The hypobromite method is the most convenient for clinical work; but it has been shown by Ryan and Marshall that an average of 92..56 per cent, of the nitrogen of urea is liberated as free nitrogen gas in the tube. The Doremus-Hinds ureometer is the instrument most used in this method. The vertical tube and bulb are filled with a solution of sodium h3T5obromite made by dissolving 100 grams of sodium hydroxid in 250 cubic centimeters of water and adding 25 cubic centimeters of bromid. The side arm of the tube is then filled with urine to the one cubic centimeter mark, after opening the stopcock sufficiently to allow the reagent to fill itslunien. The stopcock is now opened wide and the one cubic centimeter of urine is allowed to mix with the reagent. The reaction liberates nitrogen gas, which collects Fig. 261. — Hinds' Modifica- tion OF THE DOREMUS Ureometer. 652 DISEASES OF THE URINARY SYSTEM. in the vertical tube, and after the bubbles have subsided the volurne is read off. The graduations represent grams of urea per cubic centimeter of urine. This figure multiplied by the number of cubic centimeters in the twenty-four-hour specimen will give the amount of urea eliminated during the day. URIC ACID. Consideration. — The daily elimination of uric acid for normal man is given as 0.2 to 0.5 grams. After a time, uric acid usually collects at the bottom of the specimen in the form of a brick-red, crystalline sediment. Microscopically, these crystals are seen to take the form shown in the ac- companying illustration (Plate XIII). Crystals of uric acid precipitate from urines of high and low specific gravity, but, as a rule, this sediment is most copious in urines in which the specific gravity is above 1.025. Increase. — ^The amount of uric acid excreted is influenced largely by the foods ingested, e. g., such animal foods as liver, thymus gland, brain, and kidney cause an increase in the amount excreted daily. Violent exercise results in cell destruction, affecting particularly the leukocytes, which is followed by a similar increase. In from four to six hours after a meal rich in meats, during the paroxysmal stage of gout, during high temperature, and in acute articular rheumatism an increased elimination of uric acid occurs. The urine of leukemia contains a high percentage of uric acid. Decrease. — A vegetable diet, lead-poisoning, nephritis, muscular atrophy, and chlorosis shov/ a decrease in the amount of uric acid excreted. A decrease is also usually associated with the primary and the secondary anemias. The great difficulty encountered in estimating the uric acid of the urine renders a knowledge of this excretion of comparatively little clinical value; Personally, we have been unable to draw any deductions from our own observations, and even a review of the literature has not provided us with suflacient facts from which to draw valuable conclusions. CARBOHYDRATES. Clinical Consideration, — Clinically, we are concerned with but two sugars that occur in the urine: glucose and lactose. Occasionally, levulose is to be detected in urines in which glucose is also present, and less commonly maltose, saccharose, and pentose are found in the urine. Glucose. — We shall first discuss the clinical significance of glucose (dex- trose or grape-sugar) when it appears in the urine. The presence of glucose in the urine is usually considered under the heading of glycosuria. It may be stated here that the mere presence of glucose in the urine does not denote that diabetes mellitus exists, unless the other essential symptoms of the dis- ease — progressive weakness with emaciation, intense thirst, excessive appe- tite, and polyuria — are also present. If any of these symptoms are ab- sent, we are possibly dealing with alimentary glycosuria. Clinical Significance. — ^Under normal conditions slight traces of glucose are found in the blood (glycemia), but it is doubtful whether it is present in sufficient amounts in the urine to be detectable by the clinical methods ordinarily employed for its recognition, " except after the ingestion of an excess of food rich in saccharin or starchy substances" (Anders). Conse- quently whenever this substance is present in the urine in sufficient amounts to induce a reaction with Fehling's solution, glycosuria exists. (See Dia- betes Mellitus. p. 992, for clinical varieties of glycosuria.) PLATE XIII Crystals of Uric Acid from Permanentlv Mounted Sjieciraen Slides (obj. B. and L. one sixth; eye-piece 2j. i Boston.) CARBOHYDRATES. 653 Alimentary glycosuria follows the free ingestion of carbohydrates, and is not infrequently seen in those who eat heavily and take but little exercise. Again, alimentary glycosuria may be seen in certain diseases in which mal- nutrition is prominent. Toxic glycosuria follows the administration of lethal doses of hydro- chloric acid, sulphuric acid, mercury, strychnin, glycerin, alcohol, nitro- benzol, lead, arsenic, phosphorus, potassium iodid, caffein, thyroid extract, and tuberculin. Caution. — After the administration of any of the aforementioned drugs, and when any of the coal-tar products have been taken, the fermentation test should always be employed before deciding that glucose is present, since these drugs may cause a reduction of the copper in Fehling's solution. Pathologic toxic glycosuria is the term applied to a condition in which glycosuria is found to develop during the course of acute and chronic infec- tions as, e. g., cerebrospinal meningitis, cholera, relapsing fever, typhoid fever, diphtheria, phthisis, some of the exanthemata (scarlet fever), hepatic cirrhosis, rachitis, gastritis, malarial paroxysms, scarlatinal nephritis; chronic interstitial nephritis, cholelithiasis, syphilis, asthma, and whooping- cough. Glycosuria may occur during the course of cerebral hemorrhage, brain tumor, brain abscess, epilepsy, neuralgia, sclerosis of the spinal cord, and the various forms of insanity. Maladies in which there is general loss of circu- latory equilibrium, as, e. g., exophthalmic goiter, myxedema, etc., are not infrequently accompanied by glycosuria. Nervous glycosuria is that form of the disease in which the nervous manifestations are most prominent, e. g., neuroses, psychoses, traumatic neuritis, brain'injury, and permanent lesions of the nervous system. Certain emotions, anxiety, mental strain, financial embarrassment, etc., are also capa- ble of causing a temporary glycosuria, and if such contributing causes persist for an indefinite period, a permanent glycosuria may follow. Traumatic Glycosuria. — Traumatism to the head, trunk, and extremi- ties is occasionally followed by glycosuria. Puerperal glycosuria is somewhat unusual, whereas lactosuria is of com- mon occurrence during the latter months of gestation and during the puer- peral period. Intermittent Glycosuria of Arthritis.— Glycosuria may develop during the course of certain chronic affections of the joints, and is most likely to make its appearance while one or more joints are acutely involved. This form has been called the "glycosuria of gout and obesity." Test for Glycosuria. — Experience with the various tests for the recogni- tion of sugar in the urine has caused us to employ Fehling's test for routine work. Although we have found other recognized tests — e. g., Nylander's (bismuth) test and the phenylhydrazin tests of value, though less practical than the Fehling's test as now employed. Fehling's Test. — Reagents — Solution A. — Powder, 34.64 gm. of pure crystallized sulphate of copper, and dissolve in 200 c.c. of warm distilled water; cool, and add distilled water to make 500 c.c. Solution B. — Crys- tallize Eochelle salts, 180 gm., and dissolve in 300 c.c. of distilled hot water; filter, and add 70 gm. of pure costic soda; cool, and add distilled water sufiicient to make 500 c.c. This solution should be kept in a colored-glass stoppered bottle. Collection of Urine for Examination. — It is our practice to secure 2 to 4 oz. of the first urine that is passed upon rising in the morning, and an 654 DISEASES OF THE URINARY SYSTEM. equal quantity passed during the evening, preferably three hours after the heaviest meal of the day. In specimens thus collected the morning urine usually shows the smallest, while that voided after exercise and a full meal is liable to contain the largest amount of sugar that is present durmg the twenty-four hours. All specimens thus collected should be filtered before tested, and it is further to be remembered that ammoniacal urine may not give a satisfac- tory reaction with Fehling's solution. (1) Place in a test-tube an equal quantity of Solutions A and B, which, when mixed thoroughly, results in an "alkaline solution of potassic cupric tartrate" (1 c.c. of this solution is reduced by 5 mgm. of glucose). When employing the test for qualitative analysis, add to the above mixture ap- proximately three times its volume of water, which will result in a deep amethyst blue solution. (2) Fill a test-tube two-thirds with the diluted Fehling's reagent and heat the upper portion of the reagent to the boiling-point. Then should it remain clear add drop by drop from a pipet the urine to be tested, boiling after each additional drop. (3) In the presence of glucose in pathologic amoimt the upper and heated portion of the solution becomes first slightly turbid, and changes to a reddish or yellowish color. (See Plate.) The color produced by glucose varies, greatly depending upon the quantity of this substance present. The addition of from five (5) to twenty (20) drops of filtered urine free from albumin is usually sufficient to give a characteristic reaction should glucose be present. Whenever the reaction is imcertain, allow the tube containing it to stand for a time, then if the substance in question be sugar it will fall to the bottom of the hquid as a granular precipitate. Caution. — Never employ a urine for analysis that has not first been fil- tered and proved to be free from albumin. The upper portion of the hquid in the test-tube should not be boiled briskly, and the lower part should not receive any heat from the Bunsen burner. Where the amount of glucose present is but slight, a characteristic precipitate may not appear until the mixture (diluted reagent and urine) is allowed to cool. Substances Reducing Copper. — ^While many of these are given in our own experience, but two of such substances have actually confused the reac- tion for glucose, these being glycuronic acid and lactose. Among the several precipitates seen when adding urine to diluted Fehling's solution as previously outlined none of these substances are seen to fall through the clear unheated reagent as is characteristic of glucose. Quantitative Estimation of Sugar. — This may be readily accomplished when it is remembered that 1 c.c. of a solution containing equal parts of reagent A and reagent B is reduced by five (5) mgm. of pure glucose. Fermentation Test. — This method is probably quite as reliable as are certain of the more complicated laboratory methods, and is much more readily employed by the general practitioner. Method. — After it has been shown by Fehling's or some other reUable test that sugar is present in a given urine render a portion of such urine acid by the addition of tartaric acid, after which boil for several minutes. Add to the urine a portion of a cake of yeast (i to i inch square), shaking until the mixture is free from lumps, and then place this prepared urine in an Einhom Saccharimeter, nearly filling the expanded portion, then place the thumb over the mouth of the apparatus and incline the tube so as to CHOLURIA. 655 compel the yeast mixture to occupy the graduated portion. Place the filled saccharimeter at a temperature of from 77° to 95° F. ; when at the expiration of twelve hours should sugar be present, the carbon dioxid formed will have collected at the top of the tube and have displaced the urme, as shown by the graduation on the perpendicular limb of the saccha- rimeter. The reading obtained from the saccharimeter should be multi- plied by the degrees of dilution (2 to 10) of the urine employed. Caution. — Since yeast may give rise to the formation of a small volume of gas, in the absence of sugar it is advisable to conduct at the same time a control test with normal urine. Maltose, lactose, and levulose, when present in the urine, may give a similar reaction to that obtained with glu- cose, although these substances are usually excluded through the cautious employment of Fehling's solution. I/actosiiria.— Whenever there is a reduction of Fehling's solution or a reaction by the bismuth test and negative results are obtained with the phenyl-hydrazin and fermentation test, the presence of lactosuria should be suspected. Clinical Significance. — Lactosuria frequently occurs during the period of lactation, and is seen to develop when there is some interference with the flow of milk. The amoimt of lactose in the urine is no direct guide to the degree of interference with the mammary function. Lactosuria is likely to develop on the second or third day after delivery, and disappears in from five to seven days (physiologic lactosuria). It should be remembered that milk-sugar may be placed in the urine by hysteric individuals. Pentosttria. — Clinical^ Features.— Traces of pentose are present in normal urine, and pathologic pentosuria may develop during the course of glycosuria. Cases have been reported which show that pentosuria, like glycosuria, may develop in several members of the same family. A fact to be borne in mind is that pentose is capable of reducing Fehling's solution, and that it gives the phenyl-hydrazin test for glucose. The clinical significance of pentosuria remains doubtful. Test for Pentose. — ^To five cubic centimeters of filtered urine add an equal quantity of hydrochloric acid (sp. gr. 1.19) and 30 milligrams of phloro- glucLn. Mix the ingredients and warm. In the presence of pentose a red color appears in the solution, and, on examining it with the spectroscope, an ab- sorption band wiU be seen in the green. Lactose and galactose give the same color reaction as do the pentoses; but, of course, a different spectro- scope absorption band. CHOLUKEA. General Consideration. — Both bile-pigments and the bile acids may enter the urine as the result of disease, the rule being to find these two sub- stances in the same specimen, the pigment occurring in profusion while the acids are but scanty. The yellow color of the urine, the presence of a heavy yellow froth, and the detection, microscopically, of bile-stained epithelial cells serves as positive evidences of choluria. There are many clinical tests by which bile in the urine may be detected, but they are also reactions for other organic substances, a fact that further emphasizes the importance of the color of the froth and of the staining of microscopic organic cells as valuable diagnostic points. Clinical Significance. — Choluria results when there is any inter- ference with the hepatic circulation or with the flow of the bile through the 656 DISEASES OF THE URINARY SYSTEM. hepatic ducts or through the common bile-duct, or when the hepatic cells are diseased. Choluria develops during the course of cholelithiasis, chole- cystitis, parasitic disease of the liver (echinococcus cyst, ascaris infection, liver flukes), hepatic abscess, carcinoma of the common bile-duct, gall- bladder, or head of the pancreas, and duodenal catarrh. Pressure of new- growths upon the liver or upon its ducts may cause choluria. Test. — In the presence of bile the urine froth is yellow. (See tests for bile in gastric fluid, p. 473, also 464.) ACETONE. In the progress of diabetes mellitus acetone, diacetic acid, and ^-oxy- butyria acid are found in the urine. Acetone is the first of these bodies to appear; when from 0.4 to 0.5 gram is present in the twenty-four-hours' urine, diacetic acid may also be found ; but /3-oxybutyric acid does not usu- ally occur until the amount of acetone exceeds one gram. After the /3-oxy- butyric acid appears it is the substance to which the increase in these acid substances is chiefly due. Sometimes the /3-oxybutyric acid excretion reaches as high as 180 grams in twenty-four hours, while acetone and diacetic acid together rarely exceed 7 or 8 grams. Acetone. — 250 c.c. of urine and 5 c.c. of strong sulphuric acid are placed in a distilling flask and 5 c.c. or 10 c.c. of distillate are collected in a test- tube (a condenser is not necessary). The distillate is rendered alkaline with 10 per cent, sodium hydroxid solution and a few drops of Lugol's solution are added (iodin, 1.0; potassium iodid, 2.0; water, 300). In the presence of acetone yellow crystals of iodoform are produced which have a characteristic odor. Another but less satisfactory test is the sodium nitroprussid test. A quarter of a test-tube of filterea urine is mixed with an equal quantity of freshly prepared dilute solution of sodium nitroprussid and five drops of acetic acid are added. A 10 per cent, solution of sodium hydroxid is then added, one drop at a time, and, in the presence of acetone, a strong purple color is produced. Significance. — Acetone may appear in the urine when the patient is •suffering from any disease accompanied by high temperature, such as ty- phoid fever, scarlet fever, pneumonia, measles, and smallpox. The condition is known under such circumstances as febrile acetonuria. Diabetic acetonuria is the most common and most grave form. Acetonuria occurs sometimes in cases of carcinoma independent of inanition. It occurs in persons who are not sufficiently nourished, consequently in cases of gastric ulcer in which sufficient nutriment is not being absorbed. It is seen in certain of the psychoses, in digestive derangements, as an expression of autointoxication, and in chloroform narcosis. Diacetic Acid. — A small quantity of filtered urine is treated with a 10 per cent, solution of ferric chlorid. If a white precipitate of phosphates forms, it should be filtered out and more ferric chlorid solution added. In the presence of diacetic acid a Bordeaux red color is produced. Sali- cyluric acid gives the same color reaction with solution of ferric chlorid; but saHcyluric acid is not volatile, while diacetic acid is volatile. Conse- quently, when this test is positive upon first application, a fresh portion of the urine should be boiled briskly, and, after cooling, the ferric chlorid solution should be added. If in this specimen the Bordeaux red color fails to appear, the original reaction was due to diacetic acid. If the OXALURIA. 657 Bordeaux red color develops in this boiled specimen, salicyluric acid is present. ,3-Oxybutyric Acid. — The tests for /^-oxybutyric acid are too complex and require too expensive instruments for use in the laborator^' of the general practitioner, and consequently are not described in this work. In a case of diabetes mellitus, however, the presence of acetone and diacetic acid in the urine in increasing amounts, as shown by the intensity of the reactions, may be taken as an indication of the existence of j-oxybutyric acid and of the imminence of coma. OXALURIA. Consideration. — The oxalic acid in normal urine is probably derived from two sources : as the result of a vegetal^le diet and from tissue destruc- tion. Oxahc acid is also produced by oxidation of m-ic acid and from the imperfect oxidation of carbohydrates. Under normal conditions from 10 to 20 mgm. (0.31 grain) of oxalic acid are excreted daily. Oxalic acid, when present in pathologic amounts, may be detected by the microscope, the envelop crystals being found. Should no crystals collect in the sedi- ment, cautiously neutralize the urine by adding a few drops of ammonia, and stand the specimen aside for a few hours, when a copious sediment, rich in crystalline calcium oxalate (Fig. 262), results if oxalates are present in the urine in excess. Increase. — A pathologic in- crease in the oxalic acid excreted with the urine is observed after the ingestion of large amounts of certain vegetables, among which should be mentioned .spinach, carrots, toma- toes, string-beans, celery, onions, rhubarb, and asparagus. Apples and grapes cause a similar increase. Oxaluria often accompanies gastro- intestinal derangements, and this in all probabihty depends upon the imperfect oxidation of carbohydrates. Calcium oxalate is often pre.sent in the urine during the course of chronic diseases of the skin. Localized er\i:hematous areas affecting the backs of the fingers, the no.se, the eyes, the lips, and, rarely, portions of the chest and abdomen, disappear when oxaluria subsides as the result of treatment. Decided itching of the skin, particularly at the junction of the skia with the mucous membranes, appears to be occasioned by the excretion of oxalic acid. At times these cutaneous manifestations of oxalic acid intoxication are most pronounced when the amount of oxalic acid excreted daUy is comparatively low. Calcium oxalate is a common constituent of the urine during the course of gastro-intestinal derangements, and particularly during the course of chronic gastritis. Oxaluria is also influenced by obstinate constipation. It must be remembered that oxaluria is most common in early adult and middle life, although we have repeatedl}^ foimd it present in children imder ten years of age and in those over sixty. In our experience oxaluria is unusualh' 42 Fic. 262.— C.\LciuM Oxalate Crystils (Jakob). 658 DISEASES OF THE URINARY SYSTEM. common in those cases in which there is oxalate calculus in the bladder or in the pelvis of the kidney; a few such instances have come under our observa- tion. The urine of hemophiliacs is often heavily charged with calcium oxalate, and when these patients are unable to take sufficient exercise, the oxaluria can be relieved only with difficulty. In fact, the oxaluria increases with the development of a ravenous appetite. Course. — In practically all cases the condition is relieved by treatment. The real cause of oxaluria is commonly found in the gastro-intestinal tract or in the faulty hygiene of the patient, particularly as regards his exercise and diet. Oxaluria, when permitted to exist over a long period, is likely to irritate the kidney sufficiently to cause mucous cylindroids to appear in the urine. In fact, we have found cylindruria to accompany oxaluria more often than any other pathologic condition of the urine in which there is no true nephritis. LEUCmURIA AND TYROSINURIA. Consideration. — Leucin and tyrosin appear in the urine as a result of the decomposition of albumins. These substances are to be found in the urine of persons suffering from acute yellow atrophy of the liver, acute phosphorus-poisoning, and during the course of the severer forms of small- pox, yellow fever, typhoid fever, and other maladies in which the decomposi- tion of proteids is rapid. The detection of leucin and tyrosin crystals in the urine of pernicious anemia, leukemia, and septicemia is an occasional finding. Leucin and tyrosin are, as a rule, found in the same urine, and may be precipitated out as characteristic crystals (Fig. 263). Characteristics of Crystals. — Crystals of tyrosin are soluble in both acids and alkalis. Fig. 263. — Leucin Discs and Tyrosin- Crtst.vls (Boston). Differentiation. — Crv'stals of tyrosin must be distinguished from the crystals of acid and neutral phosphates. Crystalline tyrosin resembles fat crystals to some extent, from which it is distinguished by the fact that tyro- sin is not dissolved in ether, whereas fat is. CHOLESTERINUEIA. 659 CYSTINLTRIA. Consideration and Significance. — The presence of large numbers of cystin crj^stals in the urine is an extremely rare finding, but these cr}'stals, when present, cause a milky-white sediment to appear. Cystinuria has been known to occur in several members of the same family. Recognition. — Place a drop of the sediment on a slide, and examine under a J-inch objective, when, if c}'stin is present, the characteristic crj'stals (Fig. 264) will appear. These cr\'stals are soluble in ammonia and are reprecipitated by acetic acid, but remain unchanged upon treatment with ether, water, and alcohol. Fig. 264. — Crystals of Cystin (Boston). CHOLESTERINURIA. Cholesterin is seldom found in the urine unless a mixture of chyle or of fluid from hydatid, ovarian, or other cysts has been added. Rarely, cholesterin is found during the course of chronic cystitis and in acute ne- phritis. Cholesterin is commonly found in the fluid from cysts, abscesses of the liver, and fluid from the serous sacs. Recognition. — Cholesterin is recognized by the appearance of the Fig. 265. — Cholesterin Crystalb (Ogden). urine; e. g., upon shaking the bottle containing such urine small, snowflake- like bits are .seen floating through the fluid. Microscopically, we find the specimen rich in characteristic crystals (Fig. 265). 660 DISEASES OF THE UKINAKY SYSTEM. INDICANURIA. General Consideration. — Indican appears in the urine in pathologic amounts in the form of indoxyl-potassium sulphate. It is said to be formed during the decomposition of an excess of albuminous material. Although the amount of indican eliminated with the urine daily is to a certain degree controlled by the character of the diet taken, Gaffe hasfixed the normal excretion at 6.6 mgm. for each 1000 c.c. of urine. It will be found that Gaffe's figures are entirely too low for healthy individuals who live upon a diet rich in animal foods. Significance. — Indoxyl-potassium sulphate and indoxyl-sodium sul- phate are the particular forms of indican present in pathologic urines. (a) Indicanuria is a feature of chronic intestinal obstruction, and while in this instance it is probably due to stagnation of the contents of the in- testines, some observers believe it to result from the action oi the colon bacillus and other bacteria. Indicanuria is a feature of chronic constipa- tion, acute peritonitis, wasting diseases, such as, e. ^.,_ dysentery, cholera, Addison's disease, carcinoma, and other affections. It is absent in diseases of the pancreas. Indican is found in pathologic amounts in practically all diseases in which a high degree of intestinal putrefaction exists. Clinical observation points strongly to the fact that the amount of indican bears a more or less close relation to the acidity of the gastric juice, and an increase in the amount of urinary indican is often associated with hypochlorhydria. We would suggest that in gastro-intestinal conditions the indican and the hydrochloric acid be studied correlatively. The special diseases in which this variety of indicanuria is seen are gastric carcinoma and ileus. Exceptions to the foregoing rule are occasionally encountered, e. g., an excessive amount of indican is found in acute and subacute gastritis, and is not infrequently seen in gastric ulcer, a condition in which hyper- chlorhydria is presenti The maladies in which intestinal putrefaction takes, place are so numerous that it appears vmwise to mention each condition in which indicanuria may occur. We repeat that the degree of indicanuria is, with few exceptions, an index to the digestive power of the stomach. (6) Diminished peristalsis contributes toward the elimination of an increased amount of urinary indican, in consequence of which indicanuria is the rule in acute and chronic peritonitis and in ileus. It should be borne in mind that the increased production of indican often depends upon some abnormality of the small intestine, and that pathologic indicanuria is not a feature of uncomplicated constipation. Gastroptosis and enteroptosis may be present when indicanuria is a prominent symptom, but either of these conditions may influence both the secretion of hydrochloric acid and the peristalsis of the small intestine, which makes it difficult to determine the exciting cause of indicanuria- in these peculiar misplacements of the viscera. (c) In accord with the view formerly held, that albuminous putrefaction results in indicanuria, we find it a feature of pulmonary gangrene, gangrene of the extremities, emphysema, puerperal sepsis, and in certain of the acute infectious diseases. For reasons which are not readily explained indican is often present when the leading primary feature is oxaluria. Test. — ^To 10 c.c. of filtered urine add one drop of a 1 per cent, potassium chlorate solution, then 5 c.c. of chloroform, and, lastly, 10 c.c. of pure fuming ACUTE NEPHRITIS. 661 hydrochloric acid (specific gravity, 1.19). It is necessary that the reagents should be added in the order given. Mix thoroughly by pouring repeatedly from one test-tube to another. By this method the indican (indoxyl-potassium sulphate) is oxidized to indigo, which dissolves in the chloroform and imparts a blue color to it. In about ten minutes the maximum coloration has been reached, and the whole should again be thoroughly mixed. The chloroform wUl be colored more or less blue according to the amount of indigo set free. If the urine contains iodids, the chloroform wUl be colored violet. This color may be removed by adding three drops of a 5 per cent, aqueous solu- tion of sodium thiosulphate, whereupon the blue coloration will appear. Indigo appears in the urine in the form of amorphous debris, in which there are fine, needle-like crystals that possess a variable degree of blueness. The reaction of the fresh urine has little, if any, effect upon the formation of these crystals, although they are commonly present in decomposing urines. Dia^o-reaction. — ^A reaction commonly present during the course of high fever and dependent upon the presence of a chromogen in the urine. Reagents. — (1) A solution of sulphanilic acid (1 gm. to every 100 c.c.) in 5 per cent, hydrochloric acid. (2) Solution of sodium nitrate, J per cent. It is necessary that both solutions be fresh. Method. — Place 10 to 20 c.c. of urine in a test-tube and to it add an equal volume of solution No. 1, shakii^ gently to effect a perfect mixture; then add from 3 to 6 drops of solution No. 2, and shake until a heavy froth collects. Render alkaline with ammonia. The diazo-reaction consists in the liquid becoming a port-wine color; the froth is also red. Clinical Significance. — The diazo-reaction is a fairly constant sjnnptom of typhoid fever after the end of the first week of the disease. We have found it present in cases of measles, tuberculosis (with cavity), meningitis, croupous pneumonia, in a number of obscure conditions with high fever; and less often in scarlet fever, acute miliary tuberculosis, erysipelas, pyemia, diphtheria, puerperal sepsis, and tonsillitis. The value of this reaction in diagnosis is limited. DISEASES OF THE KIDNEY. ACUTE NEPHRITIS (Acute Parenchymatous Nephritis^ Acute Glomerulonephritis). Pathologic Definition. — An acute, diffuse inflammation of the kidney, which may vary greatly as to severity, duration, and extent of destruction of renal tissue. Special varieties of acute nephritis, as, for example, acute degenerative, exudative, and productive, have been described. For clinical purposes we shall consider them all as acute nephritis. Refer- ence may be made to the types of acute inflammation attacking the kidney substance, such as acute tubular, acute glomerular, and acute diffuse nephri- tis,_ although it is impossible to distinguish clinically between these patho- logic subvarieties. The microscopic appearance of the kidney will be found to vary greatly, depending upon the severity and extent of the in- fection, but in the average case, however, the organ is slightly enlarged, swollen, and appreciably softened. Before the kidney is sectioned it dis- 662 DISEASES OF THE UEINABY SYSTEM. plays a somewhat reddened or bluish appearance, and there is a distinct mottling of its surface. Occasionally there are minute hemorrhages be- neath the capsule (acute hemorrhagic nephritis). The kidney cuts with ease, and the cut surface of the parenchyma shows decided mottling, while the pyramids are intensely reddened. The capsule strips with ease. Microscopically, there is infiltration with intrusion upon the tubules, and the Malpighian tufts also show inflammatory changes. Later, cellular necrosis, and also fatty degeneration, may be present. Predisposing and Bxciting Factors.— Age.— This disease occurs at all ages, but is more common in children and during early adult and middle life. Owing to the fact that exposure and contagious diseases are most frequent during the first forty years of Hfe, acute nephritis is likewise more common then. Sex. — Acute Bright's disease is encountered oftener in males than in females, owing to the fact that males are more exposed to cold and wet. Heredity is often an important predisposing factor in nephritis ; we have in mind a family in which the father died of acute nephritis at the age of thirty-seven; two sons and a daughter developed acute Bright's disease between the ages of twenty-five and thirty, and died before reaching the age of thirty-three; a third son suffered his first attack of acute nephritis at the age of twenty-nine. Among the exciting causes are: (o) Both acute and chronic cutaneous diseases, as, e. g., conditions in which the skin is inactive either from disease or from exposure to cold and following extensive burns. (b) Chemic Causes. — Either excessive doses or the prolonged use of any one or more of the following drugs may result in the production of acute nephritis: Ether, as in prolonged ether anesthesia, phenol, salicylic acid, iodin, the iodids, turpentine, phosphorus, lead, arsenic, mercury, and potas- sium chlorid. The kidneys may also be irritated as the result of the inges- tion of certain adulterated foods. (c) Biologic Causes. — ^Under this head we must consider the poisons resulting from the development of bacteria within the human economy, as is well exemplified in nephritis complicating scarlet fever (second or third week of convalescence), t}^hoid fever, relapsing fever, cholera, dysentery, pneumonia, diphtheria, rheumatism, and allied conditions. Septicemia, septicopyemia, and severe pyogenic infection, such as is seen during the course of pulmonary tuberculosis with cavity formation, are also capable of exciting an acute inflammation of the kidneys. Rarely, indeed, nephritis follows measles, chicken-pox, syphilis, and a single attack of malaria, but it must be remembered that repeated infection with the malarial parasite is productive of true nephritis and of hematuria and hemoglobinuria. (d) Traumatism to the kidney, and at times traumatism to the trunk and the extremities, is followed by acute nephritis. (e) Pregnancy. — Nephritis may develop at any time during gestation, but it is far more common in primiparse after the seventh month. (/) Latent. and insidious chronic nephritis may be the cause of the onset of acute nephritis (Anders). Principal Complaint. — ^The patient's description of his illness will vary greatly, depending upon the grade of nephritis present, but, as a rule, he will be found to complain of chilliness or of a series of chilly sensations, slight pains in the loins, with nausea, decreased appetite, and at times vomit- ing. Within the next twenty-four hours there will be a variable degree of headache, edema, and mental apathy. In children, the onset not infre- ACUTE NEPHRITIS. 663 quently begins with a convulsion, the child having been apparently well up to this time. The patient early observes the characteristic swelling of the ankles and puifiness beneath the eyes, and in severe cases the edema of the skin becomes quite general. Epistaxis and conjunctival hemorrhage are among the less common symptoms. Thermic Features. — ^The temperature begins to rise after the pro- dromal symptoms, gradually reaching about 100° to 101° F. ; it is of an irregular type, declining to the normal whenever the acuteness of the renal inflammation subsides. Fever, while usually present, is by no means a constant feature of acute nephritis, although in severe cases the temperature may occasionally reach 102° to 104° F. In mild cases the nephritis is not detected until an examination of the urine is made; we have seen many cases in which malaise was the only other symptom present. Physical Signs. — Inspection. — ^In mild cases of acute nephritis inspection is negative, but later slight edema beneath the eyes and at the ankles may be detected. In moderate and in more severe types of the disease the skin is pale, and there is swelling of the feet, ankles, and fingers, with edema of the eyelids and face, all of which vary greatly with the severity of the type of disease present. General anasarca may follow, at which time there is edema of the scrotum, prepuce, and labia. The face may be so distorted as to make recognition impossible. Palpation. — There is pitting about the ankles, and over all edematous tissues the skin is dry, and at times rough to the touch. The cardiac im- pulse is forcible, and the apex-beat is usually diffuse. The pulse is acceler- ated, except when uremic toxemia has developed, when it will be found to be slow and of high tension. When repeated attacks of acute nephritis have occurred, the heart is hypertrophied, and the apex-beat is found below the fifth interspace and to the left. Percussion. — ^There may be evidence of the presence of fluid in the pleural sacs; this is manifested by bilateral flatness, which extends only to the top of the fluid, and above about this point there is compensatory hyper- resonance. It is ofttimes possible to detect fluid in the peritoneum, and hydropericardium may be present, which gives an increased area of cardiac dullness. This area is conoid in outline, the apex being directed downward. Not infrequently the area of cardiac dullness is increased, owing to hyper- trophy of the left ventricle, but this area differs from that caused by peri- cardial effusion in that the apex of this triangle is directed downward and to the left. In extreme cases the triangular area of dullness is directed down- ward. Auscultation. — ^Early during the course of acute nephritis the heart- sounds are clear and forcible, and their frequency is slightly increased, but after uremia has developed they are slow, clear, and the second aortic sound is decidedly accentuated. During the course of unfavorable and fatal cases the heart-sounds become very rapid, feeble, and intermittent, but it must be remembered that slow cardiac action is characteristic of uremia before cardiac dilatation has developed. The respiratory murmurs are at first apparently normal ; later the respira- tions may become slightly accelerated, but until circulatory embarrassment and edema of the lungs develop, the breath-sounds are clear. The respira- tions become slow and shallow at first, but as the disease advances, or after cardiac dilatation supervenes, they become feeble, rapid, and are accom- 664 DISEASES OF THE URINARY SYSTEM. panied by numerous bubbling rales. Cheyne-Stokes breathing occurs fate. Nervous Manifestations. — Headache, mental dullness, and twitch- ing of the muscles are commonly seen. Paroxysmal vomiting, difficulty in speaking, marked by thickness of the voice, the floating of specks before the eyes, vertigo, and even convulsions may develop during the course of acute nephritis. When the condition is that of an acute exacerbation of a chronic nephritis, localized paralyses, involving most often the muscles of the arms, face, or eyes, are to be seen. These paralyses are shifting in char- acter, and may disappear promptly upon the administration of the proper remedies, only to reappear and involve some other portion of the body-— the so-called shifting paralyses of Bright's disease. Maniacal delirium is oc- casionally present, and is at times the initial symptom of an acute exacerba- tion of chronic nephritis. Intense headache and backache may precede the onset of uremia. Uremic coma is quite characteristic, and is to be dis- tinguished from coma due to other causes. (See Differential Table.) Special Symptoms. — The productive type of acute nephritis most often develops during the course of some other infectious malady, in which case the symptoms of acute nephritis are added to the symptoms of the initial disease ; e. g., in typhoid fever the development of a high temperature, maniacal delirium, and the urinary phenomena of acute nephritis are sug- gestive of this complication, and there may be added dyspnea, diarrhea, vomiting, and coma. I/aboratory Diagnosis. — ^The amount of perspiration excreted is de- cidedly lessened during the course of acute nephritis, and the more active the inflammatory process in the kidneys the more reduced is the activity of the sweat-glands. Tlie Urine. — In mild cases the quantity of urine excreted is moderately diminished, but with the advance of the disease it gradually lessens until, in severe types of nephritis, but a few oimces of fluid may be voided during the twenty-four hours, and, in fact, there may be anuria. Naked-eye Study. — The urine is of high color, cloudy, acid in reaction, of high specific gravity, and deposits a heavy precipitate upon standing. In hemorrhagic nephritis it is bloody, and a dark-red sediment collects upon standing. Should the hemoglobin escape with the blood-serum into the urine, the urine is of a bloody hue. Microscopic Study. — In mild cases of nephritis the urinary sediment will be found to contain granular and hyaline casts, a few red blood-cells, and many leukocytes. (Plate XIV.) In severe cases, in addition to the findings just mentioned, there are present renal epithelium, blood-casts, many red blood-cells, and blood-pigment. Chemistry. — ^The urine will be found to contain large amounts of albu- min, the quantity of which fluctuates with the degree of irritation present in the kidney and with the amount of urine voided during the twenty-four hours. Such urines may give a reaction for hemoglobin. The inorganic constituents of the urine are lessened in acute nephritis, but during convalescence from such attacks these substances reappear in the urine in abnormally large amounts, the increase, however, being of but short duration. In mild cases of acute nephritis the blood-findings are of little if any clin- ical value, whereas in nephritis complicating other diseases the blood-findings of the primary disease are present. In severe nephritis in which uremia is well established the blood flows sluggishly from the site of puncture in the PLATE XIV Various Forms of Urinary Casts (Boston) : 1, Hyaline casts from case of puerperal eclampsia (original) (oljj. B. and L. one-sixth). 2. B. J., age twenty-two, female, suffering from puerperal eclampsia. Urine showing large, finely granular casts (original) (obj. Queen one-sixth ; eye-piece '2). 3. S. A., age fifty-eight, male. Urine showing granular and fatty casts ; post-mortem showed chronic parenchymatous nephritis (original) (obj. Queen one-sixth ; eye-piece 4). 1. .J. I)., age fifty-four, male, suliering from cancer of the connnnn duct and head of the pancreas. Urine showed bile-stained exists (original) (olij. Queen one-sixth ; eye-])iecc 4). 5. A. (4 , age tifteeu, male, suffering from acute ncphiitis. Urine showed granular casts (original) (obj. Queen one-sixth; eye-piece 2). 6. C. A., age nine, male. Scarlatinal nephritis, third week of convalescence. Urine showed granular casts (original; (obj. Queen one-sixth ; eye-piece 2). ACUTE NEPHRITIS. 665 skin and is dark in color. The percentage of hemoglobin is often above the normal, as is also the number of red cells in a cubic millimeter, but this in- crease is dependent upon the presence of general cyanosis. When nephritis accompanies certain acute infectious maladies, such as typhoid fever, micro- organisms may be found in the blood in great numbers, and are likewise present in_ the urine. Judging from the cases reported, no standard as to the degree of importance to be attached to the demonstration of bacteremia and bacteriuria can be established. Duration of the Disease. — ^When acute nephritis does not occur during the course of some other disease, it is of but short duration, running its course in from a few days to a few weeks; but if the patient's resistance is undermined by some infection, the nephritis may last longer and may tend toward chronicity. In repeated attacks of acute nephritis each successive attack lasts longer than did the preceding one. Illustrative Case of Acute Nephritis Followed by Chronic Parenchymatous Nephritis. — B. A., male, aged twenty-seven years; height, 5 feet 8J inches; weight, 140 pounds, for the past five years. Family History. — Parents bom in Ireland. Father Uving at fifty-six; mother in apparent health at fifty. No definite record could be obtained with reference to nephritis in either paternal or maternal ancestors. An older brother, however, de- veloped nephritis at the age of twenty-nine and died at thirty-three; another brother, two years older, developed nephritis at twenty-seven and died at the age of thirty years. One sister living and is apparently in good health at the age of twenty-two years. Previous History. — The patient had the diseases of childhood. He suffered from diphtheria at the age of twelve, from which he made a complete recovery. He had malaria at the age of twenty-two, but at this time there were no evidences of renal disease. On account of the pecuhar tendency his brothers have shown to develop nephritis he has had his urine examined at periods of a month for the past five years, and it has never contained either albiimin or casts, although it has always been of low specific gravity — 1.010 to 1.015. Social History. — Single, student of medicine, senior class. Habits good; has never been addicted to the excessive use of alcohol or tobacco, and for the past five years has avoided undue expostire to cold and wet. He has been somewhat nervous, and has shown considerable mental anxiety since his second brother contracted renal disease. Present Illness. — ^About one month ago he contracted a cold resembling grip, and was confined to the house for a period of one week, but at no time was he compelled to remain in bed diniig the entire day. As he was thoroughly familiar with the subject of urinalysis, he examined his urine the third day of the cold, and found that it gave a feeble reaction for albumin. Extreme prostration, unusual thirst, and constipation were also present. Headache was annoying during the onset of the attack, and disappeared by the end of the first week, since which time it has occasionally occurred after a night's sleep. Cough was at no time severe, although it continued for one week from the beginning of the attack. As the disease advanced it became more annoying, and within the course of one year he suffered from headache a portion of each day. At times he complained of vague pains over the loins and muscles of the Umbs. With the onset of the disease the temperature rose during the first twenty-four hours to 101° F., and ran an irregular course, fiuctuating between the normal and 100° F., imtil the fifth day of the disease, when there was a moderate decline, and by the middle of the second week the temperature was normal, and remained near this point at the morning hours throughout the iUness. An ophthalmoscopic examination made eight months following the initial attack revealed the existence of albmninuric retinitis and retinal hemorrhage, distinct impair- ment of vision developing about six months later . Physical Examination. — General. — When first seen, the general appearance of the patient was quite identical with that usually displayed by those stifiering from an attack of influenza. (See Illustrative Case of Bronchopneumonia, p. 110.) Following convalescence from the cold the patient did not gain flesh nor strength, but, on the contrary, there appeared to be progressive weakness, with slight loss in weight. The patient was readily exhausted after slight exercise, and there were restlessness, inability 666 DISEASES OF THE URINARY SYSTEM. to sleep during the night, and mental hebetude during the day. The skin and mucous membranes were pale, the cheeks presented a pecuUar baggy appearance, and there was puflSness beneath the eyes. Palpation. — The skin was dry, somewhat roughened, and there was distinct pitting (edema) in the malleolar regions. The pulse was full, strong, and of high tension, the beats numbering 80 a minute. Repeated estimations of the blood-pressure showed it to be decidedly above the normal. The heart impulse (apex) was forcible, and best felt about two inches below and just outside the left nipple. Systolic blood-pressure was 1.54. Percussion. — The area of cardiac dullness was somewhat increased downward and to the left. Auscultation. — The first sound of the heart was loud and booming in quality. Laboratory Findings. — During the first three days of the acute, grip-like cold the urine contained only a trace of albumin. By the sixth day there was a decided reaction for albumin, and the microscope revealed the presence of numerous pale, hyaline casts following the cold, and for a period of six weeks casts became more numer- ous; at this time some of them were slightly granular in appearance. Many leukocytes and a few erythrocytes were also present. The specific gravity of the urine fluctuated between 1.010 and 1.016 for a period of about six months, when the specific gravity was found to be increased, ranging between 1.020 and 1.025. At first the total quantity of urine excreted approximated fifty to sixty ounces for the twenty-four hours, but as the disease advanced there was a progressive lessening in the quantity of urine, until the renal condition had merged into the chronic parenchymatous type, when the urine excreted did not exceed twenty ounces a day. With the course of the disease the urinary findings underwent a change, and at length were typical of those described for chronic parenchymatous nephritis. (See p. 671.) The amount of urea excreted during the twenty-four hours was slightly below that of normal at the first examination, and there was a noticeable progressive decrease in the amount of urea excreted throughout the course. The hemic changes were those of a chloranemia, and a blood examination made at the sixth week of the illness showed: hemoglobin, 72 per cent.; red cells, 3,600,000; white cells, 7200. After the disease had advanced to the stage of chronic parenchyma- tous nephritis, the degree of anemia became more pronounced. Diagnosis by Induction from Clinical Data. — Here the clinical history was of unusual importance, and after obtaining this, we immediately proceeded to make an analysis of the urine, which gave findings characteristic of nephritis. Course of Illustrative Case. — During the first three weeks of the illness the clinical course resembled somewhat that of obscure influenza, but convalescence was protracted and albuminuria persisted. The patient did not regain strength, as is ordinarily the ca^e following an acute cold or an attack of influenza, and he continued to lose weight for from three to six months, when the characteristic sjonptoms of chronic parenchymatous nephritis developed. Treatment materially modified the quantity and character of the urine after parenchymatous nephritis had developed, but during the first six weeks of the disease it had but limited effect upon this secretion. Including the stage of chronic parenchymatous nephritis, the patient's condition fluctuated be- tween periods of improvement and exacerbations, ending in uremic coma two and one- quarter years after albuminuria was detected. Summary of Diagnosis.— The recognition of acute nephritis depends almost entirely upon the detection of albumin and of casts in the urine, since these two findiugs afford positive evidence of the existence of the disease. Dryness of the skin, thirst, parched lips and tongue, and constipation are early manifestations of the disease. Later, the quantity of urine is decreased, and headache, mental dullness, and even stupor may supervene. In chil- dren nausea, vomiting, chilly sensations, and headache appear to be among the cardinal complaints, whereas in the adult there are usually stiffness and soreness of the muscles, slight pain in the back, and general malaise. Course and Gravity of Disease.— The prognosis is dependent, to a great extent, upon the primary disease or causal factor of the nephritis, as well as upon the degree and character of the renal inflammation. When nephritis is the result of exposure to cold and wet, a permanent recovery is likely to ensue. Postscarlatinal nephritis is far less likely to be followed by ACUTE INTERSTITIAL NON-SUPPURATIVE NEPHRITIS. 667 permanent restoration of the function of the kidney than is the previously described variety. In the acute infections (typhoid fever, diphtheria, etc.) and in pregnancy the acute parenchymatous degenerative type of renal infection is present, and recovery is the rule. Occasionally one encounters a virulent type of renal infection during the course of some other infectious disease, and this grade of nephritis is not unusual in acute yellow atrophy of the liver, cholera, and following poisonous doses of mercury, phosphorus, etc. In this last class of cases the manifestations of renal insufhciency are grave, and the patient grows rapidly worse until uremic symptoms appear. The factors that warrant a favorable prognosis are an increase in the quantity of urine excreted, the amount of urea and other solids being also increased, the sldn, at the same time, recovering its normal color and mois- ture. The edematous areas disappear rapidly after the increased flow of urine, as does also the fluid that has accumulated in the serous sacs (pleura, pericardium, peritoneum). Among the most serious symptoms of acute nephritis are edema, effusion in both pleural sacs, and such nervous manifestations as stupor, partial paralysis, convulsions, and coma. The development of complications such as pneumonia, meningitis, and pericarditis renders the prognosis unfavor- able. Throughout the course of acute nephritis the prognosis is either favorable or unfavorable, depending directly upon the quantity of urine excreted during the twenty-four hours (the smaller this quantity, the less favorable the prognosis), upon the presence or absence of complications, and upon the ability of the physician to institute proper hygienic and thera- peutic measures. After the renal process has assumed a productive charac- ter, the life of the patient is, as a rule, prolonged over months and at times years, but complete recovery seldom foUows. ACUTE INTERSTITIAL NON-SUPPURATIVE NEPHRITIS. Pathologic Definition. — An acute inflammation of the kidneys, either localized or diffuse, resulting in the production of a non-suppurative exudate in the interstitial tissue, without essential accompanying degen- eration of the parenchyma. The kidney is enlarged and its surface mottled. There is a distinct proliferation of the cells in the interlobular tissue, and these changes are in excess of those found in the parenchyma. The pro- liferative changes are especially conspicuous about the venous and capillary epithelium. Plasma cells, lymphocytes, and polymorphonuclear leukocytes are present in the exudate. General Consideration.— Thus far the majority of recorded cases of this type of nephritis have developed after such acute infections as scarlet fever and diphtheria, although they have been known to follow typhoid fever, pneumonia, meningitis, and measles. A pathologic study of the kidneys reveals the presence of streptococci in the interstitial tissue. Some authors believe that this type of nephritis is the result of the action of powerful toxins, and that bacteria enter the kidneys secondarily. Clinical Picture.— The characteristic clinical features of this type of nephritis are: (1) That it develops during the course of some other m- fection; (2) the patient rapidly enters a moribund state; and (3) edema is slight and often absent. 668 DISEASES OF THE URINARY SYSTEM. CHRONIC NEPHRITIS (EXUDATIVE) (Chronic Bright's Disease; Chronic Parenchymatous Nephritis > Chronic Diffuse Nephritis with Exudation , Chronic Tubal and Chronic Desquamative Nephritis; Chronic Glomerulonephritis; Large White Kidney; Secondary or Fatty AND Contracted Kidney). Pathologic Definition. — A diffuse, chronic, inflammatory^ process, involving both kidneys, and characterized by epithelial degeneration, with the formation of permanent connective tissue, and the escape of certain portions of the blood (serum and pigments) into the renal tubules. Several types of pathologic kidney are present in this disease, but the distinctive differences as to size, etc., are dependent upon the varying causal factors and the stage and duration of the case in question. (1) The large white kidney (without amyloid degeneration) is either enlarged or of normal size, and of a pale or yellowish color. The surface of the organ is smooth, and its capsule strips with ease. The cut surface dis- plays a yellowish-white color throughout, with certain opaque areas and here and there some mottling with red. Microscopically, the destructive changes are pronounced; the renal epithelium is swollen; and hyaline, granular, and fatty degeneration is conspicuous. The glomeruli are appre- ciably enlarged, owing to overgrowth of the capsular epithelial cells. The interstitial tissue is seen to be increased. The small white kidney is generally believed to be but the result of a later stage of the preceding variety, in which, owing to advanced degeneration and overgrowth of connective tissue, contraction has taken place. The organ, in addition to being small, is firm and resistant to the knife, and its capsule is adherent. The cut surface is grayish or yellowish in color, and at times mottled. Distinct foci of fatty degeneration are usually disseminated throughout the cortical portion of the organ. The large red Iddney, in addition to being swollen and congested, or mottled, frequently shows distinct irregularities or humping on its surface. Here the capsule is somewhat adherent, especially at the points of indenta- tion. The cut surface of the organ also shows many irregularities, and at times slight hemorrhages, and its mottling is shown microscopically to depend upon various stages of degeneration. In certain respects the microscopic changes simulate those described for the large white kidney. Varieties. — This type of nephritis has been divided into several varieties, according to the peculiar grade of pathologic change present in the kidney; in our experience it has been found generally difficult, and sometimes impossible, to ascertain, either by an examination of the urine or by other clinical methods, the exact type of kidney present. Predisposing and iExciting Factors. — Age. — Chronic parenchy- matous nephritis may be found at practically all ages, but it is especially common in children who have suffered from scarlatina, as well as in young adults, and the disease is by no means uncommon during the fourth, fifth, and sixth decades. The age at which both men and women are subjected to hard work and exposed to cold and wet appears to be the most susceptible period. Persons who eat heavily of rich foods and who take but a moderate amount of exercise are especially prone to this malady, as are also those who imbibe too freely of alcohol, beer, malt, and • other intoxicating liquors. Exposure to cold and wet, and employment in which the temperature is extremely high, as in the case of firemen, workers about furnaces^ etc., are CHRONIC NEPHRITIS (eXUDATIVe). 669 predisposing factors — dependent either upon the intense heat or upon the sudden change of temperature in passing from a hot into a cold atmosphere. The toxins of acute infectious diseases excite in themselves an acute nephritis that becomes subacute, and eventually chronic, in nature. Prac- tically all conditions that favor the development of acute nephritis figure prominently in the etiology of chronic parenchymatous nephritis. CUmate is believed to contribute slightly toward the development of this disease, and it is said that the disease prevails in humid and marshy locali- ties. We have observed it in certain persons living in regions known to be highly malarial. Persons suffering from any malady in which chronic suppuration is a feature are especially likely to develop this type of nephritis ; this variety has been considered under the head of amyloid disease of the kidney. Principal Complaint. — The symptoms present in acute nephritis are nearly all present during the course of chronic parenchymatous nephritis, V ^V ■Mf\f\f\r\r "W -^y/vvv Fro. 266. — Bilateral Pnbumogeam Showinq Respikatoht Ahetthemia, from a Case of 'Dbeuta Studied at the Philadelphia General Hospital. Note especially the great variations in amplitude of the curve, also variations in time of the respiratory movements (distance between summits). (See Movements of Chest, p. 131.) although they are less conspicuous, since each individual symptom is not so acute, but more persistent. Heaelache is a conspicuous symptom in this type of nephritis, and is present every day, in various degrees of severity, affecting either the frontal or the occipital region. There are also dull, wandering pains in the muscles and progressive weakness, which eventually becomes extreme. Nausea is commonly experienced, apd the appetite is lessened at the onset of the disease and lost entirely in extreme cases. Par- oxysmal attacks of indigestion, accompanied by headache, mental dullness, sleeplessness, and vertigo, occur. Coma may follow a gastric attack. In many cases we have observed an inordinate appetite for eggs and other albuminous foods. With the progress of the disease the patient observes that he cannot open his eyelids widely when he awakens in the morning, and that there are also present bagginess of the skin of the cheeks and swelling of the ankles, which latter symptom increases rapidly until anasarca appears. The swelling of the face present on rising in the morning lessens during the day, whereas the swelling of the feet is less evident in the early morning hours and becomes more apparent after the day's exertions. 670 DISEASES OF THE URINABY SYSTEM. Dyspnea is a common complaint, and becomes more marked as the disease advances. It may be toxic and nervous in character, or it may depend upon mech anic interference with the pulmonary circulation. Cardiac dyspnea, which is dependent upon faulty action of the heart, is always present in the course of chronic parenchymatous nephritis, and is aggra- vated on assuming the recumbent posture. Dyspnea not due to cardiac insufficiency may be dependent upon vasomotor constriction, and should be regarded as of serious prognostic moment; indeed, we have studied cases of chronic nephritis in which renal asthma was the chief complaint; for this reason an analysis of the urine should be made in all cases of asthma. Catarrhal bronchitis is frequently associated with this form of Bright's disease. Without doubt it contributes toward the dyspnea and cough, as well as to the free expectoration. The patient's discomfort is materially increased by the presence of com- plications, among which should be mentioned retinitis with failing vision, diseases of the skin, pericarditis, endocarditis, pneumonia, and colitis. Cer- tain of these conditions may give rise to fever, which is not present in un- complicated chronic nephritis. The symptoms common to these complicat- ing maladies are added to those of the primary nephritis. Physical Siirns. — Inspection. — During the first few months in- spection is practically negative, but as the disease advances there are decided pallor of the sldn, edema of the face, eyelids, and extremities, particularly of the ankles, and prominence of the superficial veins- of the face, calves of the legs, abdomen, and chest; small red blotches may also appear on the skin. The hair and that portion of the skin covered by clothing are lusterless, slightly roughened, and covered with fine scales, which are seen to surround the roots of the hair. After the accumulation of fluid in the pleural, pericardial, and peritoneal sacs has taken place, there is prominence of the abdomen. The respirations are hurried, and the attitude of the patient is altered in accordance with the degree of serous exudation, in order to enable him to breathe more easily. Before pericardial effusion occurs the cardiac apex-beat is displaced down- ward and to the left, whereas after the accumulation of fluid in the peri- cardium it is seen at the third or fourth interspace and in the midclavicular line. In ascites the breathing is thoracic, and the superficial veins of the abdomen and chest are seen to be greatly enlarged. There is generally decided edema of the lower extremities and of the genitalia, as well as edema of the hemorrhoidal veins and hemorrhoids. Palpation. — The skin is often dry and harsh, but when it is edematous, it pits upon pressure. Palpation serves to confirm inspection as to the position of the apex-beat of the heart; it is further found to be forcible early during the course of this malady, but late in the disease it is weak and irregular, and in both pericardial effusion and acute cardiac dilatation it may be scarcely perceptible. The expansion of the chest is greatly lessened when either pleural or pericardial fluid has accumulated. In order to demonstrate the presence of free fluid in the peritoneal cavity an assistant makes pressure with the ulnar border of one of his hands in the median line of the abdomen, while the examiner, with the palm of one hand pressed against the skin of one flank, taps gently against the skin of the opposite flank with the tip of one of the fingers of his other hand. If fluid is present, a transmitted wave will be apparent to the palm of the palpating hand. Polyhydramnios, large ovarian cyst, hydronephrosis, chylous cyst, and a distended bladder may give such a wave. CHRONIC NEPHRITIS (eXUDATIVE). 671 Percussion. — The area of cardiac dullness is increased downward and to the left early, and it is decidedly increased in the transverse diameter, owing to hypertrophy of the left ventricle. In pericardial effusion the area of cardiac dullness is likewise enlarged, but forms a triangular area, the base of the triangle being directed downward, whereas its apex rises to the second left interspace. The three conditions that cause the area of cardiac dullness to be increased are: (1) Hypertrophy of the left heart; (2) pericardial effu- sion; (3) acute cardiac dilatation. These are readily differentiated by the aid of physical signs other than percussion, and it is important to remember that they may all be present at different stages during the course of chronic parenchymatous nephritis. (See Differential Table.) Hydrothorax is readily detected by the fact that it gives bilateral dull- ness at the base of the chest, which dullness changes with the position of the patient. The presence of free fluid in the abdominal cavity in cases of nephritis with associated cardiac failure is indicated by dullness on percussion in the flanks and above the pubes, with tympany above the dullness. If both ascites and pleural effusion are present, a continuous area of dullness may be detected throughout the lateral region of the trunk from the axilla to the brim of the pelvis. Auscultation. — ^The breath-sounds are unaltered at first, but later, and especially after the accumulation of fluid in the serous sacs, numerous small crackling and large bubbling rtlles are audible over both lungs. The respira- tory murmurs become more and more rapid, depending upon the amount of fluid in the serous sacs and the degree of cardiac embarrassment. The heart- sounds are first accentuated, most marked over the aortic cartilage, and this bounding element in the sounds persists whUe the hypertrophy continues, but when the hypertrophy has reached its limit and cardiac dilatation be- gins, the sounds become weak, rapid, and fetal in character. If there is pericardial effusion, the cardiac tones are extremely weak, distant, and muffled. I^aboratory Diagfnosis. — ^The quantity of urine voided during the twenty-four hours may be normal or moderately increased, at times falling to between ten and thirty ounces. The color is high, and the specific gravity ranges between 1.016 and 1.030. (The larger the quantity of urine, the lower the specific gravity.) Chemically, this urine contains quite a large amount of albumin. It is generally conceded that the greatest amount of urinary albumin is lost in this type of Bright's disease. The amount of solids voided during the twenty-four hours is, as a rule, decreased, and this decrease becomes more and more pronounced with the advance of the disease. Microscopically, the urinary sediment is found to contain many long and short granular casts and a few epithelial and leukocytic casts. Leukocytes, which are present in normal urines, appear in pathologic num- bers during the entire course of parenchymatous nephritis. Red blood-cells are seldom seen except during an acute exacerbation of this condition, but when found, they are of grave clinical significance. Hematologic Study. — ^Throughout the entire course of parenchyma- tous nephritis the percentage of hemoglobin will be found to be below the normal limit; with the progress of the malady it shows a decided decline — to even below 50 per cent, in the latter stages of the disease. The erythro- cytes likewise show a proportionate decrease in number, falling to below 2,000,000 during the height of the disease. The leukocytes are normal in number early, but may be found moderately increased in advanced cases. The skin is less moist than normal, and the moisture of the breath is above 672 DISEASES OF THE URINARY SYSTEM. 85 per cent. Widal, Weil, and Laudat* have discovered that Upemia is rather common in those cases which show retinal hemorrhage. . Chauffard found that cholesterinemia is also present and that it runs parallel with the degree of lipemia. Likewise cholesterinemia may be present in other conditions where there is a so-called simple albuminuria, and where there is retention of chlorids or nitrogen. The naked-eye appearance of the blood-serum simulates that of milk. Summary of Diagnosis. — Progressive loss of strength and of weight, anemia, dyspnea upon exertion, diminished excretion of urine, which is rich in albumin, and numerous granular casts serve as the cardinal symptoms of chronic parenchymatous nephritis. When, associated with these findings, there are cardiac hypertrophy, dropsy, headache, and gastro-intestinal dis- turbances, the diagnosis becomes quite clear, irrespective of the urinary findings, which are in themselves characteristic of the disease. Differential Diagnosis. — Chronic parenchymatous nephritis is dif- ferentiated from chronic interstitial nephritis with difficulty, since both processes may be progressing in the same patient. In pure types, however, the urine in the case of chronic parenchymatous nephritis is usually less than normal in quantity; of rather high specific gravity; and contains a moderate amount of albumiQ — 0.1 to 0.5 per cent, by the Esbach method, and pale and dark granular and hyaline casts. The urine in the tjrpical case of chronic interstitial nephritis, on the other hand, is increased in quantity; is of low specific gravity; and contains little or no albumin and a few hyaline casts. The associated arteriosclerosis and the more marked nervous manifestations are important characteristics of chronic interstitial nephritis. A history of prolonged suppuration or of syphilis is highly suggestive of amyloid kidney. The table below shows the chief characteristics of chronic interstitial nephritis. TABLE SHOWING THE DIFFERENTIAL FEATURES BETWEEN CHRONIC PARENCHYMATOUS NEPHRITIS, AMYLOID KIDNEY (WAXY), AND CHRONIC INTERSTITIAL NEPHRITIS. Chronic Parenchyma- tous Nephritis. 1. History of one or more attacks of acute Bright's disease. 2. Commonest during early adult and mid- dle life, but may occur at any age. 3. Duration, two to seven years. Dropsy of the face and ankles, with general anasarca, common. Clinical Features. Amyloid Kidney (Waxy). 1. History of prolonged suppuration or of syphilis involving the bones. 2. May appear during childhood or early adolescence. 3. May persist over a long period, and ap- parent recovery or improvement fol- lows removal of the cause or the institu- tion of proper treat- ment. 4. Not pronounced, al- though moderate edema of the face and ankles may be seen. Chronic Interstitial Nephritis. 1. Commonly follows high living and exces- sive indulgence in al- coholic liquors. 2. Usually noticeable after the age of forty. Duration, ten to thirty years. Death usually results from some in- tercurrent infection, as, e. g., pneumonia, influenza, etc. 4. Dropsy absent, unless it be the result of cardiac insufficiency or during an acute exacerbation of the renal process. * Semaine Medicale, Nov. 6, 1912. CHRONIC NEPHRITIS (EXUDATIVE). 673 Chronic Parenchyma- tous Nephritis. 5. Anemia with extreme pallor develops early and increases steadily with the progress of the disease. The hemoglobin and red cells are relatively re- duced. 6. Leukocytes uncom- 7. Nervous symptoms do not appear until the other clinical evi- dences of the disease are prominent. 8. Pallor of the conjunc- tiva and of the retina. Retinal hemorrhages rather common until disease is well ad- vanced. 9. Liver and spleen of normal size. 10. Quantity of urine voided during the twenty-four hours normal or subnormal. 11. Specific gravity, as a rule, above 1.018. 12. A high percentage of albumin is present. Clinical Features. — (Continued.) Amyloid Kidney (Waxy). 5. Hemoglobin and red cells show decided reduction. 13. Numerous short, thick, granular casts, with few hyaline casts pres- ent. 6. Leukocytes com- mon, but not con- stant. 7. Not a characteristic feature. 8. Extreme pallor of conjunctiva and retina. Amyloid deposits in retina 9. Enlargement of spleen and liver common. Laboratory Findings. 10. Normal or in- creased. 11. Specific gravity nor- mal or often ex- tremely low — 1.015 to 1.005. 12. A low percentage of albumin. 13. Most of the casts are of the hyaline vari- ety, and at times there are to be seen the so-called amy- loid casts (Fig. 268) . Wide hyaline casts with hyaline-like epithelial cells upon their free surface common. Chronic Interstitial Nephritis. 5. Less marked anemia in proportion to the dura- tion of the disease. 6. Leukocytes may be present during the lat- ter stages and during complications. 7. Nervous manifesta- tions appear early, as, e. (/., shifting paralyses, headache, neuralgia, asthma, and coma. 8. Retinal hemorrhages' common, and choking of the disc is occasion- ally seen. 9. Liver usually small. 10. Decidedly increased — ■ 70 to 150 ounces a day. 11. Specific gravity low — 1.015 to 1.005. 12. Merely a trace of al- bumin, but when this is studied in compari- son with the large quantity of urine voided, the amount of albumin lost during the twenty-four hours is quite large. 13. Hyaline casts predomi- nate, and they are, as a rule, long and nar- row, at times appear- ing as mere shadows. Wider crests arc seen during the early course of the disease. Renal epithelial cells are of- ten present. Course and Duration. — During the first six months there are slight edema of the face and ankles, some pallor, and pronounced dyspnea, after which the disease advances, as a rule, rapidly from bad to worse. 43 674 DISEASES OF THE URINARY SYSTEM. Judicious treatment may prolong life for a period of several years. We have seen cases showing slight pallor, somewhat scanty urine of high specific gravity, with albumin, but with no other complaint for years, develop severe attacks, with dropsy and dyspnea, lasting for several months, thus showing that the disease may run an intermittent course. We have also seen severe cases that terminated fatally within a few months, during which time the patients manifested uremia, dropsy, acute cardiac dilatation, and inter- current complications, such as bronchopneumonia. When parenchymatous nephritis has existed for more than a year, recovery is not likely to occur. Rarely, indeed, an apparently permanent recovery follows this type of nephritis in the young, and we have had under our care several such cases in which there was no recurrence for a period of several years. CHRONIC INTERSTITIAL NEPHRITIS (Chronic Nephritis (Non-exudative)> Chronic Bright's Disease) Primary OR Genuine Contracted Kidneyj Cirrhotic Kidney» Red Granular Kidney, Chronic Productive (Diffuse) Nephritis WITHOUT Exudation (Delafield), Gouty Kidney). Pathologic Definition. — A chronic disease of the kidneys, character- ized by the presence of inflammatory changes, with the extensive production of fibrous tissue and a consequent lessening in the size of the organ, obstruc- tion to some of the uriniferous tubules, and a tendency toward the formation of cysts in the parenchyma of the kidney. The size of the kidneys is greatly diminished, being reduced to about one-third or one-half that of the normal. The capsule is appreciably thickened, often opaque, and decidedly adherent. The surface of the organ is usually reddened, somewhat granular, and may display distinct nodules and cysts. The kidney cuts with difficulty, and the cut surface shows the cortical portion to be greatly thinned (the result of atrophic changes), and mottling is effected by dark-red bands that course through paler ateas of the organ. Cysts, varying in size from that of a millet-seed to that of a walnut, may be seen in any part of the cortical portion. The essential microscopic change is an increase in connective tissue, and such increase is most conspicuous in the cortical portion of the organ, and is always accompanied by a variable degree of atrophy and degeneration of the renal parenchyma. (b) Heredity stands as a prominent predisposing factor in interstitial nephritis. (c) Adult and advanced middle life are the periods at which this type of nephritis is most likely to develop. (rf) Sex figures prominently, males being far more commonly affected than females. (e) The prolonged use of such toxic substances and chemic irritants as alcohol, chronic lead-poisoning, the so-called uric-acid diathesis, gout, chronic gastritis, etc., are believed to favor sclerotic change in the kidney substance. Again, such biologic irritants as the toxins of malaria and syphilis serve as potent factors in the production of chronic interstitial nephritis. (/) Persons who indulge too freely in rich foods and in alcoholic drinks are especially likely to suffer from this form of Bright's disease, and it may here be stated that the prolonged daily use of small quantities of alcoholic stimulants is also followed by sclerotic change in the kidney. CHRONIC INTERSTITIAL NEPHRITIS. 675 (g) Those who are inactive or whose occupations necessitate confinement indoors during the day are frequently attacked by this affection. Qi) Nervous strain, the result of bereavements, financial embarrassment, and anxiety, is believed to exercise a decided influence upon the production of this tj^e of renal affection. (i) Sclerotic changes in the kidney may follow irritation of these organs from hydronephrosis, pyelitis, retention of stone, either in the bladder or in the renal pelvis, and any interference with the flow of the urine through the ureters. Principal Complaint. — ^The disease comes on insidiously, and may exist for years without causing the patient much discomfort, although his friends may see that his health is gradually failing. Ofttimes the first symptoms observed by the patient do not appear until late in life, at a time when the kidneys may be in an advanced stage of degeneration. Indeed, the physician often detects nephritis while making a routine examination of the urine or of the cardiovascular system. Attacks of uremia are occasionally one of the early symptoms, and among the phenomena that accompany these should be mentioned headache, stupor, nausea, vomiting, dyspnea, especially upon exertion, and later convulsions. At times the patient hears a constant roaring, and states that he hears his heart beat when lying at rest. He further describes attacks of palpitation, and may be annoyed by the forcible beats of his heart. Epistaxis may be an early and distressing symptom. Curiously enough, many of the most distressing of these symptoms may disappear for an indefinite period, to return with increased violence. Even during the intervals of comparatively good health the patient complains of drowsiness or insomnia, headache, dyspnea, and indigestion, but all these symptoms are of a mild form. Early during the course of chronic interstitial nephritis there is frequent micturition, and following an interval of subsi- dence of the symptoms a severe uremic attack may occur which may ter- minate fatally. If, however, the patient recovers, there will be progressive loss of weight and strength and failing vision, which is due to retinal hem- orrhages. At times the patient is annoyed by specks floating before his eyes, and these may be described even before retinal hemorrhage has taken place. Uremic Asthma. — Spasmodic dyspnea may be £in early symptom of chronic interstitial nephritis, and a correct diagnosis is reached only by making a chemic analysis of the urine, and the additional fact that the dyspnea is promptly relieved after free diaphoresis has been effected. Paralyses. — Attacks of monoplegia and of paraplegia may be ex- perienced at any time during the course of chronic interstitial nephritis, but these paralyses, like the spasmodic dyspnea, may disappear promptly upon the institution of treatment. Indeed, the paralyses may disappear from one side or from one portion of the body, to reappear in a few days or weeks on the opposite side. Physical Signs. — Inspection. — Early during the course of this disease there is a variable degree of pallor, which becomes more marked as the disease advances. The skin of the face and ears is also roughened, of a slight lemon tint, and there is an absence of luster. The nails are clubbed and brittle. The temporal arteries stand out prominently, and in advanced cases they are often tortuous and may show slight pulsation. The superficial fat appears to be fairly well preserved, although the skin hangs in folds and wrinkles. The apex-beat is usually displaced down and to the left, and if there is an organic lesion of the heart, pulsation of the vessels of the neck and 676 DISEASES OF THE URINARY SYSTEM. over the main arteries occurs. During the later stages of chronic inter- stitial nephritis there may be cardiac dUatation, at which time there will be noticed pulsation in the epigastrium, at the third interspace on the right, and pronounced throbbing of the vessels of the neck. The tongue_ is likely to be dry and coated, and the patient describes a sticlcy condition of the mouth. Palpation. — ^The skin is dry and rough, and gives a somewhat graty feel to the palpating hand. The hair is also dry. Throughout the entire course of chronic interstitial nephritis the arterial tension is increased, the pulse is small and wiry, and the arteries display an unusual hardness; in advanced cases the radials are wiry, and the temporal arteries are readily outlined by the finger. A fact to be borne in mind is that persons suffering from chronic interstitial nephritis are especially prone to have, in conjunction with the general arteriosclerosis, which is so characteristic of this disease, disease of the valves of the heart, and consequently they display the symptoms of organic heart disease. As a rule, therefore, a patient who has suffered from chronic interstitial nephritis for a long time will show the pulse more or less imperfectly characteristic of either mitral or aortic disease, and it is for this reason that we seldom find a pulse that can be said to be characteristic of chronic interstitial nephritis that has advanced for several years. With loss of compensation the pulse becomes weak, rapid, dicrotic, and irregular. The apex-beat is felt to be displaced downward and to the left, and is de- cidedly forcible during the early stage of the disease, but after dilatation has resulted, there is diffuse feeble pulsation over the precordium, and, depending upon the variety of organic lesion of the heart, impressions may be conveyed to the hand. Edema of the skin is seldom present except in the later stages of the disease or after cardiac dilatation has taken place. During an acute exacerbation of a chronic nephritis there may be edema of the skin of the extremities and of the face, and, in fact, ascites may result from the same cause, in which case a wave is transmitted over the abdominal fluid. Percussion reveals nothing of special importance, and simply confirms previous findings — cardiac hypertrophy or dilatation and, rarely, the pres- ence of fluid in the peritoneum, pericardium, or pleural sacs. The area of cardiac dullness is shown to extend downward and to the left, ofttimes reach- ing the midaxillary line at the lower border of the seventh rib transversely. This degree of cardiac hypertrophy will be seen to increase gradually from year to year, so long as compensation remains complete. Cardiac dilatation is likely to follow after the rupture of compensation, and it is in these cases that we find the greatest area of cardiac dullness. We have seen cases in both hospital and private practice in which the transverse diameter of the area of cardiac dullness during acute dilatation extended for ten inches, and we have in mind a recent case in which the transverse diameter of the heart extended from the angle of the vertical diameter during the stage of dilata- tion. Auscultation. — ^There is decided accentuation of both the aortic and pulmonic second sounds, and the first sound of the heart is also forcible early during chronic interstitial nephritis. After myocarditis and consequent cardiac dilatation have developed the heart-sounds are weak, feeble, and even f'^tal in charact'=;r. Ivaboratory Diagnosis.— Urinary Findings. — ^The quantity of urine voided during the twenty-four hours is always above that of the normal, and, in fact, often exceeds 100 ounces. This urine is pale, clear, of a specific CHRONIC INTERSTITIAL NEPHRITIS. 677 gravity of 1.005 to 1.016, acid in reaction, and does not show an abundant sediment upon standing. Chemically, the urine is found to contain a small percentage of albumin, except in those cases in which there is an acute exacer- bation of the renal condition, and also after cardiac compensation has been ruptured, when the urine contains a comparatively large amount of albumin. It may be absent altogether, especially from the urine voided in the morning. The apparent trace of albumin present in the urine of chronic interstitial nephritis, when studied ia relation to the large quantity of urine voided during the day, discloses the fact that the pati3nt is constantly losing a large amount of this substance — a feature of vital clinical importance, and one that deserves most careful consideration. The solids (urates, phosphates, sulphates) and the percentage of urea are lessened in the urine of chronic interstitial nephritis, and the clinical evidence that solids are not eliminated from the body is strongly suggestive that other substances (toxic in character) that should be eliminated with the urine are likewise retained in the body tissue. It is supposed to be the retention of excrementitious products of metabolism that explains the frequent occurrence of profoxmd nervous symptoms in chronic interstitial nephritis. Microscopically, the urine is found to be deficient in crystalline substances, and to contain a few small, narrow hyaline casts, with an occasional granular cast. Leukocytes and epithelial cells are present, and the latter may be seen clingiag to the surface of the hyaline casts. Blood Findings. — A study of the blood reveals the presence of secondary anemia. Rarely, the blood is decidedly concentrated in chronic interstitial nephritis, consequently the number of red cells in a cubic millimeter may be but moderately reduced, or, rarely, it may be above that of the normal, whereas the total number of cells in the body is far below the normal. After cardiac insufficiency and cardiac dilatation have developed, the number of red cells in a cubic millimeter may be far above the normal average (5,000,- 000 in a cubic millimeter), this peculiarity depending upon the presence of cyanosis, and it may be well to mention that, late in the course of kidney disease, cyanosis is the commonest cause of error in maldng an estimation of the number of red blood-cells. The hemoglobin usually falls to between 75 and 50 per cent., except late in the disease, and shortly prior to a fatal termination, when the hemoglobin in the circulating blood may register near the normal (80 to 95 per cent.) ; this apparent increase in the percentage of hemoglobin, like the pseudo- increase in the number of red cells, is dependent upon the existence of cyan- osis, and is of somewhat unfavorable prognostic significance. The moisture of the skin is below that of the normal, and may fall to 40 or even to 25 per cent. The moisture of the breath is increased, registering above 80. Illustrative Case of Chronic Interstitial Nephritis. — Henry M.,male, aged fifty- four years; apparent age, sixty-five years; height, 5 feet lOJ inches; weight, 140 pounds; at the age of thirty-five the weight was 160 pounds. Family History. — Father died of heart disease at the age of fifty-four; mother died at the age of fifty-six, the cause being unknown. A paternal uncle now Uving has been a victim of gout since the age of fifty, and another uncle died of hepatic cirrhosis at the age of forty-seven. No record of malignancy in ancestors. Previous History. — Does not recall having had any of the diseases of childhood except measles and scarlet fever at the age of ten years. Was subject to frequent attacks of sore throat between the ages of ten and twenty-five, but since then has suffered but sUght inconvenience. Had typhoid fever at thirty, and influenza at thirty-three. Social History. — ^Engaged in mercantile business, and bears the responsibilities 678 DISEASES OP THE URINARY SYSTEM. of a concern that employs at least fifty clerks. Married at the age of twenty-five, and has three children living, all in apparent health. He has used alcohol since the age of twenty, taking from two to six drinks of what he regards as the best of gin or whisky each day. Uses tobacco freely, smoking from six to ten cigars daily. His work does not necessitate exposure to cold and wet, and, indeed, he has been unusually careful in this respect since his attack of influenza. Present Illness. — At the age of thirty-eight he observed that he tired easily, and that he felt a throbbing in the head following violent exertion (climbing stairs, etc.J. The latter condition increased in severity for a period of about one year, when he con- sulted his physician for an attack of vertigo that yielded promptly to treatment. Since that time he has occasionally been annoyed by a similar throbbing sensation in the head, and he states that he cannot rest upon the left side when in bed on account of hearing the sounds of his heart. Weakness has been progressive, although he is stiU able to follow his usual occupations, but he complains greatly of exhaustion during the after- noon hours of each day. The appetite is disturbed, and he is unable to eat at the morn- ing meal because of nausea, although he seldom vomits. He does not appear to be able to endure cold, and is uncomfortable unless dressed in heavy clothing. States that his hands and feet are continually cold, even during the summer months. Constipation is obstinate, sleep is not restful, and he is continually tossing from side to side while in bed and awakens repeatedly during the night. Pain. — At present there is more or less aching of the muscles of the lower limbs and of the back, and this is most pronounced after a day's work. Headache has been more or less persistent for the past three years, and the patient states that at present it is unusual for him to be free from headache upon arising in the morning. His temperament has altered materially during this illness, and he is extremely irritable. He has observed that at certain times he is more nervous than at others, and he has found that a hot bath at night before retiring usually insures him a restful sleep, and that following such bath and sleep he is less likely to be annoyed by headache. Physical Examination. — General. — The face is somewhat drawn, the skin and mucous membranes are pale, and the surface of the skin is unusually dry. Upon rising in the morning there is slight pufEness beneath the eyes, and by firm pressure it is possible to detect slight pitting in the malleolar regions. While sitting, the patient is more or less nervous, shifting about in his chair. Local Examination. — Inspection. — The hair appears to be poorly nourished, dry, and sparingly distributed over the scalp. The finger-nails are somewhat brittle, and the patient has difiiculty in keeping the surface of the nails smooth. The tongue is slightly coated, and the mucous surface of the lips and mouth is pale. The apex impulse of the heart is forcible, and is seen l\ inches below and an inch outside the left nipple- line. There is sUght pulsation of the vessels of the neck, and epigastric pulsation is also visible. Palpation confirms what has already been stated under general examination and inspection, the apex-beat being strong. The pulse is slow, the beats numbering 65 to 77 a minute, of high tension, and there is distinct hardening of the arteries. The tem- poral arteries stand out prominently and are readily palpable, and even the brachial artery can be distinctly felt for a short distance of its course. Percussion. — ^The area of cardiac dullness is increased downward and to the left. The area of liver dullness is distinctly decreased, its superior border beginning at the sixth rib ; it does not extend to the costal margin; indeed, in the midclavicular line it is found to be from one to one and one-quarter inches above the costal border. The area of liver dullness is also confirmed by auscultatory percussion, there being an appre- ciable decrease in the size of the organ. Auscultation. — The heart-sounds are strong, booming in quality, and a distinct diastolic murmur is heard at the aortic cartilage, which is transmitted downward along the left border of the sternum. A murmur of moderate intensity is also heard at the apex of the heart, and is well transmitted for 2i inches toward the left axilla. No murmur is audible at the ensiform cartilage, although the venous pulsation in the right carotid region strongly suggests the existence of tricuspid regurgitation. Laboratory Findings. — The first urinalysis was made about six and one-half years ago, and at that time the attending physician detected a feeble reaction for albumin. Three years ago a more complete analysis was made, and at this time the quantity of urine voided during the twenty-four hours varied between 50 and 70 ounces. The specific gravity was 1.010; the urine was pale in color, and a precipitate did not collect when it was permitted to stand for several hours. Microscopically, many hyaline casts, a niunber of leukocytes, and a few epithelial cells were detected. At present the urinary findings are practically the same as those obtained four years ago, except that casts are more numerous, and that occasionally a granular cast is present. Some CHRONIC INTERSTITIAL NEPHRITIS. 679 of the hyaline casts are unusually long and narrow, and occasionally they assume a spiral outline. The hemic changes are those characteristic of secondary anemia, the hemoglobin ranging between 68 and 75 per cent., and the red cells fluctuating between 3,500,000 and 4,000,000 in a cubic millimeter. Diagnosis by Induction from Clinical Data. — The history of the vitality having been below that of normal for several years and the additional evidence that he had lost twenty pounds during this period give some clue to the diagnosis. Progressive weakness, mental irritability, and gastro-intestinal disturbances are also to be considered important symptoms. The diagnosis was confirmed only by making an analysis of the urine. Course of Illustrative Case. — It is clearly evident that the patient's general condition, including the loss of weight and progressive weakness, has for several years steadily become worse, and although he is still able to attend to his duties, their per- formance has become a hardship, and he has observed that he is unable to cope with business propositions with the same astuteness that he did in former years. Summary of Diagnosis. — Progressive anemia, pallor, and polyuria in persons in whom the skin is dry and the breath emits an odor of urine seive as points on which to base a diagnosis of chronic interstitial Blight's disease. The presence of relatively small amounts of urinary albumin, together with the finding of small, narrow hyaline casts and a few leukocytes and renal epithelial cells, are almost conclusive evidence of the existence of this form of nephritis. The marked tendency toward nervous symptoms, the progressive weakness, the frequency of headache, and the duration of the malady are all common to chronic contracted kidney. DiflFerential Diagnosis. — Contracted kidney is seen after middle life, and there is often a histoiy of overeating, alcoholism, gout, chronic rheumatism, and sedentary habits. The symptoms of uremia, when ^'''\fJ^r^J,CsT\^"^^So^ATTVo manifested, are practically the same in all Kidney. forms of nephritis. Shifting paraly,ses and ^^^^^t B^'a/d^ii^'ot^ixth?."'"''"' retinal hemorrhages are far more common in chronic interstitial than in other forms of nephritis. The low specific gravity of the urine and the large quantity voided during the twenty-four hours serve to differentiate this disease from chronic parenchymatous nephritis. (See Differential Table, p. 672.) The absence of edema, anasarca, and ascites in chronic interstitial nephri- tis is valuable. The foregoing symptoms aid when this malady is to be differentiated from chronic parenchymatous nephritis, in which these symp- toms are common. During the course of an acute exacerbation of chronic interstitial nephritis it is impossible to differentiate chronic interstitial from chronic parenchymatous nephritis, either by the urinarj' findings or by the general clinical picture. Clinical Course of Disease. — Chronic interstitial nephritis ex- tends over a period of from ten to thirty years, although the duration depends largely upon the presence or absence of certain other acute infectious con- ditions (e. g., pneumonia). In the aljsence of these intercurrent infections and of accidents, such as cerebral apoplexy, the course of the disease may be lengthy. The prognosis as to life is good, but as to permanent recoverj^, it is un- favorable. Persons with chronic interstitial nephritis seldom, if ever, enjoy 680 DISEASES OF THE URINARY SYSTEM. perfect health, although, by the institution of judicious treatment, many of them are enabled to attend to their duties and derive a hmited amount of pleasure out of life, going on from year to year, and showing no decided change in their physical condition. AMYLOID DISEASE. Pathologic Definition.— Amyloid degeneration of the kidney, while at the present time generally conceded to be a rare disease, is encountered during the course of certain chronic conditions (suppuration, syphilis). It differs widely from other forms of nephritic degeneration. The kidney is usually enlarged, pale in color, displays some mottling, and does not offer decided resistance to the knife. The cut surface of the organ shows the cortical portion to be thickened and waxy in appearance. Microscopically, there is amyloid degeneration of the epithelium. Predisposing- and :Bxciting Factors. — Amyloid kidney niay occur at any age, although it is more common during early adult and middle life. The conditions that predispose to amyloid kidney are: (1) General amyloid cUsease, which is usually marked by amyloid de- generation and enlargement of the liver and spleen; (2) prolonged suppuration, e. g., pulmonary tuberculosis with cavity, and syphilis with lesions of the bones. Principal Complaint. — In a few instances the patient appears to enjoy fairly good health, and when symptoms arise, they are dependent on the marked secondary anemia; consequently the pa- tient complains of general weakness, dysp- nea, palpitation, tinnitus aurium, anor- exia, chronic dyspepsia, and attacks of apparent acute gastritis. The abdominal protrusion may be distressing, and is due to enlargement of the liver and of the spleen, although in some cases ascites has been seen. E,arely, a moderate amount of edema of the ankles is present. Headache is the rule, but severe nervous symptoms are unusual. The pa- tient complains early of specks floating before the eyes, 1nit albuminuric retinitis is uncommon until late in the disease. Chronic dysentery may l^e distressing. The general complaint differs slightlj' from that of chronic parench5aTiatous nephritis, with which it may be confounded, and the dif- ferentiation will depend chiefly upon the clinical historj', the evidences of gene'-al amyloid disease, and the late appearance of edema. lyaboratory Diagnosis. — The quantity of urine voided during the twenty-four hours is, as a rule, increased, although it has been seen to be normal, and in two instances the quantity was slightly subnormal. A feature of great importance in connection with amyloid disease of the kidnejf is that the quantity of urine excreted varies at different stages of the disease (the more advanced the condition, the larger the quantity of urine) until late, when it may display a great diminution. The quantity of urine voided is also influenced by the presence of complications, being lessened when such conditions as dysentery, diarrhea, and paroxysmal vomiting coexist. The specific gravity of the urine fluctuates with the quantity Fig. 206. — Epithf.lial and Amyloid Casts (Boston). Patient a female, aged forty-two years, suffering from septicopyemia with amyloid Icidney. HYDRONEPHROSIS. 681 voided during the twenty-four hours, but is seldom above 1.015; as a rule, it is between 1.005 and 1.010. A well-marked trace of albumin is always present in the urine of amyloid kidney, and a high percentage is not unusual, the amount of albumin lost during the twenty-four hours being quite large. The urinary solids are diminished. Microscopically, the urine contains many hyaline casts (Fig. 267) some of which are wide, plump, and tapeworm-like in outline — ^the so-caUed amyloid casts (Fig. 268). Summary of Diag^nosis. — ^The diagnosis of amyloid disease is de- pendent largely upon a clinical history of suppuration or of syphilis and upon the urinary findings, neither of which, however, is characteristic of this affection. We have sometimes found cases of amyloid disease of the kidney at autopsy in which there were no positive evidences of this condition during life. Course. — Usually, when the disease complicates pulmonary tubercu- losis with cavity formation, the course of the disease is protracted; but should it develop during chronic bone suppuration, surgical iaterference may effect an apparently permanent cure. In syphilis, specific treatment often gives relief, and life may be prolonged for a number of years. HYDRONEPHROSIS. Pathologic Definition. — An accumulation of urine within the pelvis and calices of one of the kidneys. The fluid, by exerting pressure, may pro- duce pyelitis, dilatation of the renal pelvis, atrophy, and cystic degenera- tion 01 the parenchymatous tissue; an abdominal tumor may also be present, which may suddenly disappear after the passage of a large quantity of urine. Predisposing and Bxciting Causes. — Hydronephrosis is generally a secondary condition, although it may be classified as either congenital or acquired. It is always dependent on occlusion of the lumen of the ureter. Among the causes of hydronephrosis are : 1. Congenital malformation in the urinary passages, and in this class of cases it may be bilateral. Instances are recorded in which congenital hydronephrosis in the fetus was known to complicate labor. 2. Hydronephrosis among adults is far more common in the female than in the male, and this is especially true of women who have borne many chil- dren. Rarely, indeed, the disease is bilateral in the adult, and when such is the case, the obstruction is in either the bladder or the urethra. 3. Impaction of renal calculi in the pelvis of the kidney. 4. Inflammatory disease of the ureter, which results in narrowing of the lumen of this membranomuscular tube. 5. Floating or movable kidney, with torsion of the ureter. 6. Adhesions following pelvic and abdominal operations. 7. Pressure upon the ureter from abdominal tumors, among which should be considered new-growths, ovarian cysts, fibroid uterus, prolapsed spleen, ectopic gestation, and normal pregnancy. 8. Impaction of a calculus at the junction of the ureter with the bladder. There are but few recorded instances of this condition being the predisposing cause. 9. Tumors and sclerotic changes of the bladder, with the production of new tissue and the consequent closure of the orifice of the ureter. 682 DISEASES OF THE URINARY SYSTEM. 10. Urethral obstruction, dependent on either an enlarged prostate or upon urethral stricture. 11. Vesical paralysis. Principal Complaint. — In the presence of an abdominal tumor m the infant, hydronephrosis should be suspected. The mother often describes increasing prominence of the child's abdomen, and this abdominal dis- tention is less likely to disappear in children than it is in the adult. It is possible for a congenital hydronephrosis to exist without evincing any marked symptoms, and the patient may continue in comparatively good health, the condition being discovered later in life, and possibly not until uremic symptoms develop. In bilateral hydronephrosis the patient shows symptoms of uremia early. In adults the intermittent form of hydronephrosis may be marked by the presence of a periodic or a constant tumor in the abdomen. The tumor mass decreases in size or disappears with the passing of an increased quantity of urine, and, on the other hand, while the mass gradually increases in size, there is a diminished flow of urine. The patient may complain of a tumor- mass in the abdomen, which is decidedly prominent, and which does not show any apparent change in size — a variety of hydronephrosis usually seen after the pelvis of the kidney has been dilated for months or even years. There is some loss in flesh, but secondary anemia is not common, unless uremic intoxication is also present. Pain occurs in practically all cases, and in intermittent hydronephrosis it disappears with the subsidence of the tumor, but returns with the re- appearance of the abdominal distention. In the majority of instances the patient believes that straining or violent exercise induces the accumulation of fluid in the pelvis of the kidney, and not infrequently there is a history of pains having followed some violence of this kind. The pain, which is often excruciating, may last for from one to twelve hours, after which the patient observes a gradual swelling of the abdomen. Sufferers from hydronephrosis may continue in fairly good health for weeks, months, and even years during the intervals, or while the pelvis of the kidney is not distended with urine. Acute symptoms are by no means uncommon in hydronephrosis, and following the initial pain there may be a chill, succeeded by an elevation of temperature to 102° to 104° F., after which there is a drenching sweat. These three stages simulate somewhat closely the malarial paroxysm. Nausea, obstinate vomiting, and increased respiration and pulse-rate are often present. Constipation is frequently an annoying symptom, yet it is by no means constant in hydronephrosis. Nervous Symptoms. — ^The majority of women suffering from hydrone- phrosis are of the neurasthenic type, and suffer from headache, neuralgia, and the like. Paraplegia has been known to complicate hydronephrosis, and there may be extremely acute pains, which are described as shooting in character, and radiating down the thighs to the calf muscles and the ankles; cramp of the lower limbs is often distressing. Thermic Features. — ^When, as previously stated, the obstruction is due either to torsion of the ureter or to plugging of the ureter with a calculus, the temperature may rise suddenly. If the severe pain continues over a period of several hours, the temperature will first rise suddenly to say 100° to 103° F., and may then fall to the normal, or in severe cases to a subnormal, level, and remain at this point for an indefinite period — ^the so-called renal HYDEONEPHBOSIS. 683 intermittent fever. During the stage of hypopyrexia the skin is blanched, cold, and clammy, and the general condition is that of shock. Physical Signs. — Inspection reveals the presence of asymmetric abdominal distention. Palpation. —It may be possible to palpate the kidney and to find it freely movable in the abdominal cavity when the pelvis is not filled with urine. When, however, the pelvis of the kidney is distended, a distinct mass is readily palpable, and a wave may be transmitted through the fluid. This mass is usually soft and doughy, and commonly occupies the brim of the pelvis, although a hydronephritic tumor may be found on either side of the abdomen, quite irrespective of the particular kidney involved. Percussion is of but little value in making a diagnosis of hydronephrosis unless the intestines are comparatively free from gas ; in our experience we have found this condition to be generally associated with a variable degree of tympanites. , Peritoneal adhesions are also likely to anchor portions of the bowel over the tumor-mass, which interferes materially with the value of the percussion- note. I/aboratoiy Diagnosis. — The quantity of urine passed during the twenty-four hours is usually diminished prior to and during the development of the tumor, and in intermittent hydronephrosis an increased flow of the urine is observed during the disappearance of the tumor. The urine is usually pale, of low specific gravity, and at times contains a trace of albumin. We have seen two cases in which bloody urine followed hydronephritic tumor. Microscopically, the urine contains many leukocytes and few solids, and red blood-cells are occasionally seen. Summary of Diagnosis. — The diagnosis is based largely upon the somewhat rapid development of a tumor in the abdomen, accompanied by colicky pains, and the passing, from time to time, of a large quantity of urine, irrespective of whether or not there has been a subsequent decrease in the flow of urine. The disappearance of the tumor coincident with the discharge of an abnormally large quantity of urine is almost positive evidence of the presence of hydronephrosis. In abdominal tumors of the new-born and during infancy hydronephrosis should be considered a prominent cause. Differential Diagnosis. — This is reached by excluding such ab- dominal masses as ovarian cysts, a distended urinary bladder, and chylous cysts. The table on p. 684 shows the distinctive features of five of these abdominal conditions . Rarely, if ever, does the tumor of hydronephrosis attain sufficient size to warrant its being mistaken for ascites. Percussion is of little value in diagnosticating hydronephrosis, since in most abdominal growths the colon is anterior to the tumor-mass. Tapping of these cystic or fluid tumors by abdominal puncture cannot be recom- mended as a safe diagnostic measure, although a study of the aspirated fluid aids materially in distinguishing between such tumors of the abdomen. Urea is found in small amounts in both the fluid from the pelvis of the kidney and in that from an ovarian cyst, whereas red and white blood-cells may be present in practically any fluid tumor of the abdomen. Catheterization of the ureters serves as a means of diagnosis when unilateral hydronephrosis is present. Clinical Course. — It is common for hydronephrosis to run a some- what chronic course, although this is in a measure modified by the etiologic factors in each case. Surgical intervention is necessary to correct the condition. 684 DISEASES OF THE URINARY SYSTEM. W s O O H n -■i a o H . Hoi "I CQCQ So fMQ gn Wp a HO «^ O K H I— I s-si? •2 ;--5 I £ S £ a § a S'C £3 o ft O li'Sal S 1, => a Ah tj Ul!>, gscS ^ S.S a Q P.T3 .a li — Jo ^ 2 ^Si 3- ihral atri tic disea ale subjeo ent. ^1 -P 1=^ g5S.S M P S'3 2'3 a---C H t, s .3 bo > rt (0-z t. .>i5 §•- .a-^M "- a »-a fe &: o ft d 5 o 5-S22 . O O o s cd < o dja-g in ■ 4^ m ii°s ft-5 SO' Ph CO m I ftft o a 6^>. a-S'a aag ■2° g: d Sg»E « d Ot(H d QJ -^ o wio « S C3 ^. o » 03 d "a2 .^T3 d Q) o » . d n a> ^uh cq 03 d m3 dona H ft 10 «3 ^ 05 rt o il PYELITIS (pyelonephritis, PYONEPHROSIS). 685 PYELITIS (PYELONEPHRITIS; PYONEPHROSIS). Pathologic Definition, — A punilent inflammation involving the pelvis of one or of both kidneys. The suppurative process may also extend from the renal pelvis to the kidney substance, and, rarely, both the pelvis and the parenchyma of the organ become distended by pus (pyonephrosis). The condition may be found to depend upon infection with pus-producing bacteria, and in many instances tuberculosis of the pelvic mucosa has pre- ceded the condition. Stone in the pelvis of the kidney is at times the ex- citing factor. An important feature in this connection is that infection of the pelvis is commonly secondary to a similar suppurative process involving the bladder. Varieties and Pathology. — (1) Catarrhal pyelitis is a condition ia which the pathologic changes in the pelvis of the kidney are mild, and con- sist of reddening and swelling, with loss of luster of the mucous membrane. The greater part of the mucous membrane is covered with a mucopurulent exudate in which many desquamated epithelial cells are present. (2) The moderately severe forms, in which, in addition to what is found in catarrhal pyelitis, there are numerous ecchymoses into the mucous mem- brane. This type is often the result of renal calculi or of virulent infection with pyogenic bacteria. All urine contained in the pelvis of the kidney is purulent from the admixture of pus. (3) Calculous Pyelitis. — Calculi not infrequently set up a catarrhal in- flammation of the pelvis of the kidney, which in turn becomes infected with pyogenic bacteria. (4) Extraneous Pyelitis. — Abscess of the kidney occasionally empties into the renal pelvis and excites a purulent inflammation of the lining of this mucous surface. (5) Pseudomembranous Pyelitis. — ^The formation of a false membrane in the renal pelvis has been known to develop during the course of certain infectious fevers. (6) Tuberculous Pyelitis. — In tuberculosis of the pelvis of the kidney it is customary to find small irregular ulcers in the mucous membrane. The surface of these ulcers is covered with mucopurulent exudate. Their edges are thin and slightly irregular. Tuberciilosis of this structure may be chronic in its course, in which case caseous masses may be formed within the walls of the pelvis of the kidney. (7) Suppurative Pyelitis. — ^When the pelvis of the kidney becomes in- fected from the bladder (e. g., following a severe cystitis), it is usually re- ferred to as ascending pyelitis, and when the suppurative process extends to the renal parenchyma, it is called surgical kidney. (8) Obstructive pyelitis, which is dependent on obstruction to the flow of urine from the kidney, is described under Predisposing and Exciting Fac- tors. Predisposing and Bxciting Factors. — Pyelitis is usually secon- dary to some preexisting pathologic condition, and among the numerous maladies and conditions it complicates or in which it appears as a sequel should be mentioned.: (a) Renal calculus, (b) Torsion of the ureter and hydronephrosis. (c) Direct extension of an inflammatory process from the ureter (ureteritis), bladder (cystitis), urethra (urethritis), or enlarged prostate (prostatitis). (d) Dilated pelvis of the kidney, in which the urine may become decom- posed, (e) Acute nephritis. (/) Renal tuberculosis, (g) Renal carcinoma. 686 DISEASES OF THE URINARY SYSTEM. (h) Foreign bodies in the bladder, such as vesical calculus. (i) Such chemic irritants as turpentine, cantharides, cubebs, and copaiba contribute toward the development of pyehtis. (j) It has been known to follow infectious fevers, as, e. g., typhoid fever, scarlet fever, smallpox, diphtheria, typhus fever, etc. (k) Obstructive pyelitis may follow plugging of the ureters with a small calculus, and the constant irritation produced by the passing of large amounts of uric acid is also capable of exciting true pyelitis. Portions of large calculi occupying the pelvis of the kidney would in turn irritate its mucous membrane, (l) Severe traumatism to the kidney is also followed by the development of obstructive pyelitis, (m) Pyehtis occurs during the course of such nervous conditions as hemiplegia and paraplegia, but here it is probably secondary to cystitis. Parasitic pyelitis may result from infection of either the kidney or its pelvis with the Taenia echinococcus, Eustrongylus gigas, and filaria. Age. — Pyelitis may develop at practically any age, but it is somewhat more cormnon after the thirtieth year. Principal Complaint. — This varies greatly with different stages of the disease, and also with the virulence of the type of infection. When pyelitis occurs during the course of the infectious fevers, it does not cause any inconvenience to the patient unless the suppurative process is a severe one. Generally speaking, however, even in mild types of infection of the renal pelvis there are backache, tenderness upon deep pressure in the loins and over the kidneys. As the disease progresses all these symptoms become exaggerated until the distress in the loins is painful, and the patient may describe pains that are boring or tearing in character. At the onset of the disease there is usually a chill or a series of chilly sensations, which may last for from a few minutes to several hours, and, as a rule, is followed by moderate fever. The effect of the suppurative process upon the general health becomes apparent early, and the patient complains of weakness, emaciation, anorexia, palpitation, headache, dyspnea, and lassitude. Night-sweats are occasionally a troublesome symptom late in the disease. We have seen cases in which, after several weeks, general infection of the kidney developed, which was followed by septic foci in different parts of the body. One of our cases terminated in abscess of the brain, and another in ulcerative endocarditis. Septicemia has been known to follow pyelitis, and in such instances the symptoms are those of septicemia plus the symptoms resulting from infection of the special organ showing most marked involve- ment (brain, lung, heart, etc.). At times pyelitis becomes chronic, and this is especially true when the infection is tuberculous in nature. Thermic Features.-;-Pyelitis, when it develops during the course of any other infectious condition, causes an exaggeration of the symptoms of the initial disease present, causing a moderately increased elevation in the temperature. If the fever has been regular, it may be converted into either the remittent or the hectic type. In iruld pyelitis the temperature is usually elevated from one-half to two degrees, but in the severer type it is common to see an elevation of from two to four degrees in the afternoon. When pyelitis alone exists, the temperature is that of general sepsis displaying evening exacerbations with morning remissions, and at times intermissions — the so-called septic temperature. A fact ever to be borne in mind is that suppura- tion of a mucous surface may exist without any coincident marked febrile changes. PYELITIS (PYELONEPHBITIS, PYONEPHKOSIS) . 687 Septicemia not infrequently follows, when the temperature assumes a continuous type, and the patient suffers from the so-called typhoid state. Should meningitis, endocarditis, multiple abscesses of the kidney, or abscesses of the perinephritic tissue develop during the course of pyelitis, a high tem- perature of the continuous type is usually observed. Physical Signs. — Inspection is negative except in cases in which the pelvis of the kidney is greatly distended with pus, or in which perinephritic suppuration is associated, when the physical signs are practically those of perinephritic abscess. (See p. 697.) Early during the course of pyelitis there may be but slight, if any, evidence of anemia, but as the disease ad- vances extreme pallor and a hectic flush appear, and at times a muddy or dusky complexion is presented. Palpation discloses 9light rigidity of the muscles of the affected side of the abdomen and of the loin. Upon deep pressure with the finger-tip it is possible to outline a tumor-mass when the nephritic or perinephritic tissue is involved. Catheterization of the Ureters. — ^This means of diagnosis is of great aid, and is especially applicable in pyelitis in the female, but even ia male sub- jects it is possible to catheterize the ureter of the affected side and thereby determine whether or not the urine from that kidney contains pus. Cystoscopic examination is often invaluable, revealing, as it does, the presence of suppuration of the bladder; it may also disclose the vesical condition to which pyelitis is secondary. (See Contributing and Exciting Causes, p. 685.) I Tubercu- lous Dysentery, Consumption of the Bo\!7EL). Pathologic Definition. — ^Either a primary or a secondary infection of the mucosa, and of the deeper coats of the bowel, by tubercle bacilli, with the formation of ulcers that are arranged transversely to the long axis of the colon, and characterized clinically by frequent watery stools, tubercle bacilli in the feces, progressive emaciation, profound weakness, and the blood changes and other symptoms of secondary anemia. General Remarks and Varieties. — ^The lesions present in the colon may be — (a) primary, but, as a rule, they are (&) secondary to tuber- culosis of the lung, throat, or other structures. Primary tuberculosis of the intestine is oftenest seen before the tenth year, a fact that is explained ia part by the large amount of milk that is ingested by children. It is difficult to separate tuberculosis of the intestine from tubercidosis of the peritoneum, since the two conditions often develop conjointly. While the patient complains of the general symptoms produced by the tuberculous enteritis, he is likely to suffer from local or general tuber- culosis of the peritoneum. In many autopsies performed on the bodies of children dead of tuberculosis of the intestine it has been difficult to ascertain whether the tuberculous infection originated in the bowel or in the peri- toneum; and, indeed, in many instances the pathologic changes suggested that the two conditions developed hand in hand. In certain cases the in- fection was probably first manifested in the retroperitoneal lymph-nodes. " The secondary variety occurs in more than one-half of the cases of pul- monary tuberculosis" (Anders). Any portion of the colon may be involved, yet the lower one-third of the ileum serves as the common site for the initial intestinal lesions. The clinical picture is but slightly different, whether tuberculosis of the intestine be primary or secondary. Symptomatology. — In children, the mother usually states that the child has suffered from a somewhat chronic intestinal catarrh for weeks, or possibly for months. Moderate colicky pains and diarrhea are present and the dejecta may be blood-stained. The child has not gained in weight since the intestinal symptoms developed, and, indeed, in most instances there has been a gradual loss in flesh throughout the course of the illness. Tuberculosis of the intestine in the adult gives rise to symptoms quite similar to those described for children. In adults, as previously stated, it is_ extremely common to have the symptoms of gastro-intestinal catarrh, with probably two, three, or even six copious, watery stools daily. Consti- 724 ACUTE INFECTIOUS DISEASES. pation may persist for one or raore weeks, during which time the patient complains of intestinal discomfort. Thermic Features. — In primary tuberculosis of the mucous coat of the intestine there may be slight fever, or the temperature may be sub- normal during the morning hours. When the deeper coats of the intestine become involved, the temperature will range between 99° and 101° F. When tuberculosis of the intestine is secondary to tuberculosis of the lungs with cavity formation, the temperature will be found at or near the normal during the morning hours, with a rise to between 102° and 104° F. during the afternoon and evening hours. The hectic temperature is probably dependent, for the most part, upon the pulmonary condition, and not upon the intestinal lesion. Physical Signs. — Inspection. — There is pallor of the skin and mu- cous membranes, and the tongue is, as a rule, heavily furred, although where there is a great amount of intestinal irritation, it may be red and glazed. The respirations become hurried, and cyanosis and edema of the ankles are present late during the disease. Early during the course of in- testinal tuberculosis the abdomen is scaphoid in shape, and later, as the result of associated peritonitis and tympany, it becomes distended. Should the peritoneum become involved, ascites develops. (See Ascites, p. 567.) Palpation gives negative results until the disease is well advanced, when there is some tenderness over the course of the colon, and particularly in the region of the appendix. As the disease advances tenderness becomes more marked, and finally the features characteristic of general peritonitis are present. In some cases a tumor-like ridge lying transversely just above the level of the umbilicus may be felt. Percussion. — After the disease is well advanced an increased tympanitic note over the entire abdomen is obtained. I/aboratory Diagnosis. — When there are ulcers in the mucous surface of the colon, the feces contains tubercle bacilli, shreds of necrotic tissue, pus, and blood. Large numbers of intestinal epithelial cells are also present, which give the liquid stool a granular appearance. The hematologic changes present are those of secondary anemia. In probably 50 per cent, of all cases of tuberculous enteritis the sputum will be seen. to contain tubercle bacilli, and in several cases we have found tubercle bacilli in the urine of persons suffering from this affection. In nine cases bacteriologic study of the venous blood gave negative results. Illustrative Case. — J. P., male, aged nine months; fed upon modified cow's milk. He was apparently in perfect health until two months ago, when the mother noticed that the child did not gain in flesh, and that he refused to take his usual amount of nourishment at each feeding. Since his illness he has lost four and one-half pounds in weight, and is now very fretful; he frequently awakens and cries during the night, and has paroxysms of crying during the day. Together with the loss of weight pallor and wrinkhng of the skin have developed. There are from six to ten copious, watery bowel movements daily. The features are pinched, the expression old, and the child cries upon the slightest movement. The tongue is covered with a white fur. The ab- domen is tender and somewhat tympanitic. The temperature ranges between 99° and 102° F., the higher temperature being seen during the afternoon and evening hours. A microscopic examination of the feces revealed the presence of tubercle bacilU, streptococci, and other bacteria. Summary of Diagnosis.— The existence of tuberculous enteritis is to be suspected whenever a history of progressive loss in weight, pallor, and weakness, together with diarrhea, is given. The detection of tubercle bacUU in the feces confirms the diagnosis in all cases, and serves to distin- guish tuberculosis of the intestine from other forms of intestinal catarrh. CATARRHAL ENTERITIS. 725 Clinical Course. — The prognosis is unfavorable, the majority of cases terminating in death in from a few weeks to six or more months. We have found tubercle bacilli present in the feces of adults over a period of one year, but it is seldom that the disease is so prolonged in children. In one child, a patient seen in the Philadelphia Hospital, tubercle bacilli were present in the feces during a period of seventeen weeks. PHLEGMONOUS ENTERITIS. Pathologic Definition. — A local or diffuse purulent inflammation of the submucous coat of the large intestine. Predisposing Factors. — Septicemia, pyemia, and abscess of any portion of the body frequently antedate phlegmonous enteritis. Duration. — The majority of cases terminate fatally in from twenty- four to seventy-two hours. CATARRHAL ENTERITIS (Summer Diarrhea? Acute Gastro-intestinal G^TARRHj Diarrhea of Children) Cholera Infantum, Mycotic Diarrhea). General Remarks. — Summer diarrhea is a term applied to a series of gastro-intestinal conditions that are most likely to develop during hot weather. Diarrhea frequently occurs in epidemics, although endemic diarrhea is seen in both tropical and temperate climates. The malady is announced by a sudden onset, with pronounced irritation of the stomach and bowel. High fever, extreme prostration, and nervous symptoms soon follow. Varieties. — (1) Diarrhea Resulting from Dietetic Errors. — This includes those cases caused by the ingestion of improper or indigestible food, which virtually acts as a foreign body. The irritation caused by such foods may, in the milder cases, produce only increased secretion and peristalsis, but in the severer forms inflammation of the gastro-intestinal mucosa may ensue. The stools are first seen to contain the somewhat hardened contents of the intestine; later they are semiliquid, and if the irritation is great, the stools become watery. A bacteriologic study of the feces shows only those bacteria that are present during health. (2) Eliminative Diarrhea. — ^The cases considered under this head are all those in which, clinically, the diarrhea appears to be nature's means of expelling from the body certain toxic substances that are known to circulate in the blood. An example of this tj^e is the diarrhea that develops late during the course of renal disease — the so-called "uremic diarrhea." It is also probable that diarrhea developing during the course of certain other acute or chronic maladies may in reality belong to this subclass. Eliminative or " toxic diarrhea" is to be carefully distinguished from other types of the affection, since to arrest such a diarrhea would be disastrous. (3) Acute Intestinal Indigestion. — The ingestion of food that is not readily digested, and consequently remains unaltered in the intestines, is the exciting cause of this type of diarrhea. The undigested food causesa mechanic irritation, but it is also likely to undergo putrefactive changes in both the stomach and the intestine. Putrefaction may result in the genera- tion of certain toxic substances (gases, ptomains) which, in turn, irritate the gastro-intestinal mucous membrane and aid in exciting diarrhea. The symptoms (e. g., vomiting, diarrhea, convulsions, and pain) may vary greatly with the degree of gastro-intestinal irritation present. This type 726 ACUTE INFECTIOUS DISEASES. of the disease is usually severe in those under two years of age, and propor- tionately lessens in virulence up to the tenth year, after which the condition is uncommon and seldom dangerous to life. If intestinal irritation continues for more than a few hours, acute in- flammation of the mucous coat results. The submucous coat becomes in- volved later. The severity of both the local and the constitutional symptoms serves as an index to the degree of intestinal inflammation present. A baderiologic study of the feces may reveal the presence of pathogenic organisms (streptococci, staphylococci, and bacilli) in severe cases. Blood may be found either by the microscope or by chemic methods. (4) Nervous Diarrhea. — Both mild and prolonged nervous impressions are capable of producing diarrhea in neurasthenic individuals. Among such conditions should be mentioned atmospheric changes, mental excitement, public speaking, rapid chilling of the surface of the body, profound exhaustion, shock from fright, and dentition. Again, the introduction of either liquid or solid substances into the stomach may be followed almost immediately by a bowel movement. Increased peristalsis and malnutrition are cardinal symptoms in this type of diarrhea. A bacteriologic study of the feces is negative as to pathogenic organisms. The feces contain particles of food that have passed through the alimen- tary canal without being digested. (5) Diarrhea Due to Drugs. — A protracted diarrhea may result from the use of cathartics, even though they be administered in moderate doses. The prolonged use of arsenic is, as a rule, followed by diarrhea, and, indeed, this tjrpe of the condition is closely allied to that subclass previously de- scribed as "eliminative diarrhea." Predisposing and iExciting- Factors.— (1) Bacteriology.— In the mild forms of diarrhea (simple diarrhea) only those bacteria present during health are to be found in the dejecta. When diarrhea continues for several days, other microorganisms appear in the feces, e. g., bacilli and cocci. The bacillus of dysentery and streptococci are not infrequently present when diarrhea has lasted for one week. The colon bacillus, while normally present in the feces, may at times assume a pathologic role in this condition. . (2) Age. — Children display an unusual susceptibility to diarrhea, and this susceptibility is amply borne out by the statistics of Crandall, whose analysis of 3000 cases gave the following: Under six months, 14 per cent.; between six and twelve months, 29 per cent. ; between twelve and eighteen months, 24 per cent. ; only 16 per cent, developed after the children were two years of age. The disease is decidedly less common after the tenth year of life, and becomes less and less frequent until the debility of old age asserts itself. (3) Season. — In a temperate climate the majority of cases of diarrhea IS seen during the months of June, July, August, and September, July furnishing the greatest number of cases. Hot weather, together with the unhygienic conditions that are likely to prevail during the summer, pre- disposes to aU varieties of diarrhea. Owing to the intense heat large quan- tities of water are taken, milk is likely to contain a great many bacteria in a cubic centimeter, or become decomposed before use, and these factors, to- gether with the ingestion of unripe fruit, play an important r61e in the pro- duction of summer diarrhea. (4) Environment.— Individual surroundings and circumstances hold prominent places as etiologic factors in diarrhea, as is shown by the fact that this condition is far more common in cities than in rural districts. Poverty DYSENTERY. 727 predisposes materially to diarrhea, but the children of well-to-do parents do not escape. (5) Uncleanliness is considered by many as contributing toward diarrhea. Statistics show that artificially fed children are far more likely to develop diarrhea than are those fed on breast-milk; therefore, the food with which the child is nourished figures prominently as a causative factor. The contamination of food-supplies by flies and street-dust is an important etiologic factor. (6) Dentition. — It is often difficult to show the exact relation between dentition and diarrhea; the fact remains that the two conditions appear simultaneously. The general belief that diarrhea is dependent upon denti- tion when it develops during the summer is an erroneous one in many in- stances. (7) Malnutrition. — Any condition or conditions that tend to lower the general nutrition and vitality of the patient increase the tendency to develop diarrheal disease. Even when such children are placed amid the most hy- gienic conditions possible, the mortality rate is extremely high. Symptomatology. — There is always an increase in the number of stools during the twenty-four hours. The temperature may be normal, or there may be a slight febrile reaction. The- child is somewhat restless, par- ticularly at night. The previously mentioned symptoms continue for two, three, or more days, during which time there is a progressive increase in the number of stools. In some cases the onset is insidious, with anorexia, nausea, vomiting, and acute intestinal pain; in others it is sudden, with fever that rises to 104° or 105° F. In those cases with acute onset convulsions oc- casionally occur, the abdomen is tender, and the child rests upon its back, with the thighs flexed upon the abdomen. I^aboratory Diagnosis. — The stools contain undigested food, and in children fed upon milk they display large " curd-like" masses. By the end of the second or third day the stools emit a decidedly offensive odor. If symptoms develop acutely, the stool is streaked with a yellow or greenish-, yellow substance; in other cases the naked-eye appearance of the stool is identical with that described under the milder type (p. 548) of diarrhea. Microscopically a great many classes of bacteria are found, but practi- cally all are common to the intestinal tract. After acute congestion of the intestinal mucous membrane has developed, pathogenic bacteria (strep- tococci, staphylococci, bacilli) appear in the feces. Clinical Course and Duration. — ^Mild uncomplicated cases go on to recovery in from seven to fourteen days, and the duration of such an attack is materially shortened by the application of Judicious treatment. Relapses are common, and it is after one or more relapses that the child is likely to develop true enterocolitis. When acute indigestion with diarrhea is accompanied by extreme prostration or pronounced nervous symptoms, a fatal issue may follow. DYSENTERY. Pathologic Definition. — A condition in which the mucous mem- brane of the large intestine presents a general redness, with swelling and the exudation of blood-stained mucus, and there may be many ulcers of varying size and depth. The disease may be due to a specific bacterium (bacillus ■dysenteriae), when it is called bacillary dysentery; or to a protozoan parasite (entamoeba histolytica), when it is called amebic dysentery or intestinal amebiasis. 728 ACUTE INFECTIOUS DISEASES. General Remarks. — Generally speaking, acute dysentery should be regarded as an epidemic disease, although it occurs endemically in tropical and subtropical climates. Varieties. — Clinically, acute dysentery is classified a,s — acute bacil- lary dysentery, acute catarrhal dysentery, and acute sporadic dysentery. Bxciting and Predisposing Factors. — The exciting factors of acute dysentery will be discussed under each special type of the disease de- scribed. Season. — Among the predisposing factors of those types of dysentery supposedly of bacterial origin season heads the hst, the disease being more common during the summer and autumn months. Age is a prominent favoring cause in all forms of acute dysentery, and although no age is immune, by far the greatest number of cases are seen dur- ing the first ten years, and also between the tenth and twentieth years. Temperature is not without influence, since many cases develop after sudden climatic changes, as, e. g., the extremes of temperature, humidity, etc. Climate is a prominent factor, and dysentery is more common in sub- tropical and tropical districts, although epidemic outbreaks may be seen in the far north during the summer months. Unhygienic surroundings, as is shown by the epidemic outbreaks seen in prisons, asylums, and armies, doubtless constitute a potent factor in the production of local epidemics. The existence of previous maladies that have lowered the patient's general vitality lends a predisposition to all forms of acute dysentery; con- sequently dysentery is common when malaria prevails, and persons suffering from gastro-intestinal catarrh are likewise especially subject to infection. Diet. — The condition is frequent among those who have committed dietary errors. Acute Bacillary Dysentery. Remarks. — This condition is the epidemic variety of acute dysentery excited by the Bacillus dysenterise (Shiga). Sporadic cases of bacillary dysentery, however, are by no means unusual in certain portions of the United States and Europe, as well as in tropical countries. Pathologic Definition. — The bacillus of Shiga gives rise to an acute inflammation of the large intestine, which is soon followed by the oc- currence of numerous minute ulcers on the intestinal mucosa. The mucous surface is covered with a somewhat tenacious serosanguineous exudate. The exudate and the severity of the ulcerative process vary greatly in different cases. Varieties. — For convenience of study, bacillary dysentery is divided into two subclasses: (a) Catarrhal dysentery; (6) pseudomembranous dysentery. Btiology. — According to the researches of Shiga, Kitasato, Flexner, Vedder and Duval, and many other observers, the weight of opinion is that all types of acute catarrhal dysentery are due to the bacillus of Shiga (Bacil- lus dysenterise). Most of the observers just mentioned, however, are in doubt as to whether or not the bacillus of Shiga is always an essential factor in the production of epidemic dysentery, but this point cannot readily be determined, since many other bacteria that may at times assume a pathologic role are also present in the intestine. dysentery. 729 Acute Catarrhal Dysentery. Pathologic Definition. — The large intestine is attacked, and there is hyperplasia, followed later by necrosis of the solitary follicles, with the ul- timate formation of small ulcers. There may be an extensive purulent in- flammation of the mucous surface of the colon, and the involved area displays numerous superficial ulcers. In exceptional cases the ulcerative process may extend from the large intestine to the ileum. General Complaint. — The patient feels indisposed for one or more days, during which time he suffers from a somewhat indefinite type of gastro- intestinal catarrh, characterized by a lack of desire for food, slight intestinal pain, and mild diarrhea. Following these prodromes more characteristic syraptoms develop, e. g., intestinal colic, which is followed by frequentevac- uations of the bowel. At first the stools number from two to ten daily, but they gradually become more and more frequent, and by the third or fourth day the number has increased to from 20 to 100 a day. The movements are accompanied by tenesmus. With the progress of the disease an almost con- stant desire to empty the bowel develops, and there is a continuous burning sensation in the rectum. The patient complains of extreme weakness and of a feeling of faintness and vertigo upon slight exertion. Sufferers from acute dysentery refrain from unnecessary talking, and the voice is harsh and rasping. Thermic F'eatures. — Early in the disease the temperature may range between 99° and 100° F., and may rarely reach 104° F. by the fifth or the sixth day. Generally speaking, the temperature in dysentery is irregular, but in no way characteristic. Physical Signs. — Inspection. — The expression is anxious, the cheeks are sunken, the lips are pale and fissured, and the tongue is dry and heavily coated. The extremities present a "waxy appearance"; the abdomen is scaphoid in shape, and the patient, as a rule, rests in the recumbent posture, so as to avoid all possible exertion. Palpation is generally negative, although in some cases slight tenderness may be elicited over the course of the colon. The pulse becomes weak, thready, and irregular, the beats numbering 110 to 140 a minute. The skin is cold and clammy, and in those cases in which prostration is extreme, the skin is beaded with drops of perspiration. Auscultation. — The heart-sounds are weak and rapid. There is a de- cided gurgling over the abdomen, and particularly along the course of the colon. lyaboratory Diagnosis. — At first the number of bowel movements varies from four to ten a day, and the dejecta contain many scybalous masses. Later the stools become mucoid in character, and finally they are mucopuru- lent, seropurulent, or bloody. The quantity passed at each movement of the bowels may be extremely small — not exceeding from one-half to four drams. Microscopically, the stool will be found to contain mucus, pus, and blood. If a severe type of infection is present, the watery stool contains many fat- globules and epithelial cells. Cultures from the dejecta will show the presence of the bacillus dysenterise in addition to many other bacteria. The urine is scanty, high in color, and of high specific gravity; it is rich in indican, and may display a trace of albumin. Blood. — Owing to the extreme depletion of liquids from the body the blood becomes concentrated, and during the height of the attack the number 730 ACUTE INFECTIOUS DISEASES. of red cells in a cubic millimeter is likely to be above the normal, but during convalescence the usual evidences of secondary anemia are present, and both the red cells and the hemoglobin are decreased. The Bacillus dysenterise (Shiga strain) has been recovered from the peripheral circulation. Serum Diagnosis.— In dilutions of 1 : 100 to 1 : 40 the serum of persons suffering from acute baeillary dysentery is capable of agglutinating the bacillus dysenteriae. Illustrative Case of Acute Catarrhal Dysentery. — C. C, female, twelve years of age. Family History. — Parents and two brothers living and in perfect health. Previous History. — The first record of iUness was that of whooping-cough at the age of three years; scarlet fever developed at seven years of age, and rneasles before the tenth year, but in none of these conditions did any complications arise. Social History. — Female, attending school during the fall and winter months, during which terms she was not compelled to be absent because of illness. Present Illness. — The patient had been in perfect health until August 15th, when, after having eaten unripe fruit, she developed a mild form of constipation, which was later followed by anorexia, abdominal pain, and diarrhea. The number of stools a day varied between 10 and 40; at first they were scybalous, later small in quantity, and consisted chiefly of mucus, blood, and serum. Extreme prostration and intense thirst were present. Pain was usually localized to the region of the umbilicus, but with each evacuation of the bowel rectal tenesmus was distressing. The temperature fluctuated between 99° and 102° F., and was of an irregular type. Physical Examination. — Oeneral. — The child usually rested for prolonged periods in one position, with the thighs flexed upon the abdomen, and showed no in- chnatioli to move about in bed. The mucous surfaces and skin were pale. She was rather stupid and the voice was husky. Local Examination. — Inspection. — Her expression was anxious, the cheeks were sunken, and the features were pinched. The respiratory movements were feeble, and the abdomen was scaphoid in shape. Palpation. — ^There was tenderness upon deep pressure along the course of the colon; the heart impulse was feeble, and the radial pulse was weak, small, and increased in frequency. Laboratory Findings. — The urine was diminished in quantity, of high specific gravity, rich in indiean, and contained a trace of albumin. The mucous stools were found to contain red blood-ceUs, leukocytes, desquamated epithehal cells, and granular debris. A bacteriologic study of the feces showed them to be rich in streptococci, staphylococci, and baciUi. Cultural studies showed the presence of the Streptococcus pyogenes and the colon bacillus. Course and the Effect of Treatment. — During the first twenty-four hours ab- dominal pain, rectal tenesmus, and the general symptoms progressed from bad to worse, but after the application of judicious treatment the pain was relieved and the number of mucous stools fell from fifty to six a day. Within the course of ten days the child had recovered sufficient strength to be able to sit in bed, and developed an appetite for certain light foods. By the end of the second week she was able to leave her bed, and an uninterrupted recovery followed. Complications. — ^Most serious among the complications are to be mentioned severe nervous symptoms, e. g., the various tj^jes of delirium, followed by coma; in which class of cases a fatal termination is imminent. Cardiac failure is an occasional complication, as are also general peritonitis, bronchopneumonia, and meningitis. Diflferential Diagnosis.— The maladies that simulate acute catar- rhal dysentery are extremely few, similar symptoms, however, being occa- sionally seen in persons suffering from strangulated hemorrhoids, syphilitic disease of the rectum, and rectal epithelioma. In all the previously named conditions there is no history pointing toward an epidemic of dysentery, and the onset is slow, and the course continues over an indefinite period. Physical examination of the rectum will always serve to differentiate organic rectal disease from true catarrhal dysentery. Cultivation of the Bacillus dysenterise from the stool makes the diagnosis positive. DYSENTERY. 731 Duration and Clinical Course. — ^Mild cases continue for from eight to ten days, whereas in the more severe forms the dysentery may last for three or more weeks. In the majority of cases the disease goes on to recovery in less than four weeks, and probably one-half of all cases are able to be about the room in from ten to fifteen days. If the type of infection during an epidemic is unusually virulent, a high percentage of deaths follows. Sequelae. — Relapses are extremely common, and each attack in- creases the patient's susceptibility to another. Constipation and other . gastro-intestinal disturbances are frequently seen to follow bacillary dysen- tery. Mitchell has seen paraplegia follow as a sequel to bacillary dysentery, and in a few instances stricture of the bowel has been reported. Pseudomembranous Dysentery. Pathologic Definition. — An acute inflammation of the colon with ulceration, caused by the Bacillus dysenterise, and characterized by the ac- cumulation of a grayish-yellow exudate upon the mucous surface of the colon, with necrosis of the epithelial cells. In mild cases this process may be limited to the upper surface of the folds of the colon. In virulent types of the disease the deeper layers of the bowel may be involved, and in this class of cases the mucous membrane is yellowish-brown in color. The entire colon may be implicated. As a rule, the disease attacks the flexures of the colon and the rectum. Extensive sloughing, with the formation of large ulcers, may take place. General Remarks. — This particular type of bacillary dysentery is seen more often in the tropics than in temperate climates, although epidemics and sporadic cases occur in practically all parts of the civilized world. Bxciting and Predisposing Factors. — ^The exciting cause is the bacillus dysenterise. Among the predisposing factors should be mentioned age, young adults being most susceptible to the disease; it may, however, be found at any time of life. Temperature also predisposes to this type of dysentery, and a warm climate probably facilitates infection, either from the drinking-water or from the ingestion of improper foods. Persons residing in barracks, asylums, and homes are not infrequently attacked, and those dwelling in cities are more often affected than are those residing in rural districts. Season. — Summer and autumn appear to furnish the greatest number of cases in subtropical districts. Principal Complaint. — There may be a history of some gastro- intestinal or obscure febrile condition antedating the attack of dysentery, but the rule is for acute pseudomembranous dysentery to begin abruptly, with the early development of severe local and general symptoms. The patient often gives a history of a mild chill, or, in rare instances, of a distinct rigor. Following the chill the patient observes that his face is flushed. The tem- perature will be found to register 100° to 103° F. within the first few hours. There is great weakness early, and in children deHrium develops within the first forty-eight hours, whereas in adults nervous manifestations appear later. There is diarrhea, the stools numbering ten to fifty or more a day. Cramp- like abdominal pain is present, followed later by rectal tenesmus. Physical Signs. — Inspection. — The face is flushed at first, but later there is a decided pallor of both the skin and the mucous surfaces. The tongue at first is red and glazed, but later may become brown and deeply 732 ACUTE INFECTIOUS DISEASES. fissured. The cheeks are sunken and the expression is anxious. The patient hesitates to move, and his respirations are hurried and shallow. Palpation. — During the first twenty-four hours the skin is hot and dry, but later, in severe types of infection, the skin may be cold and clammy and beaded with perspiration. There may or may not be tenderness, and, as the result of tympany, the abdominal wall is tense at times. The pulse soon becomes weak, rapid, small, dicrotic, and compressible. Percussion. — In selected cases a tympanitic note may be elicited over the course both of the colon and of the small intestine. Auscultation. — The heart-sounds are accelerated at first, but soon be- come feeble, rapid, and irregular. Decided gurgling is heard over the course of the colon and near the umbilicus. I/aboratory Diag'nosis. — The discharges from the bowel are num- erous, and with the unaided eye they are seen to contain shreds of slough- ing tissue, and even portions of casts of the lower bowel. These shreds of tissue are usually milky-white in color, but if there has been heniorrhage from the intestinal mucous membrane, they are dark or brownish, and emit a fetid odor. Blood, pus, and mucus are also present in the stool. Microscopically, the dejecta are found to contain shreds of mucous mem- brane, many epithelial cells, red blood-cells, blood-crystals, large numbers of leukocytes, and pus. Stained specimens of the mucus from the dejecta will display a profusion of bacteria. Slender bacilli, resembling bacillus ty- phosus in morphology (Bacillus dysenterise), and colon bacilli are present in great numbers. Cultures from the mucous or bloody exudate will develop the Bacillus dysenterise, which organism, when properly gro-ftm (see Widal reaction), will be found to agglutinate with the serum of persons suffering from this type of dysentery. Illustrative Case. — A. L. B., male, aged twenty-three years; previously healthy, had been indisposed during the day, and developed a distinct chill, followed by a temperature of 102° F. Within the course of a few hours there were present quite severe abdominal pains, with frequent stools, which at first were scybalous, but later consisted of mucus and blood and contained a few shreds of membrane. By the end of the first thirty-six hours great intestinal pain and rectal tenesmus were present. Mild deUrium appeared on the third day, and later the patient developed carphologia, sub- sultus tendinum, maniacal delirium at night, and finally became comatose. Both the naked eye and the microscopic examination of the feces revealed the characteristics of pseudomembranous dysentery. (See Laboratory Diagnosis.) The pulse soon became weak, and later it was rapid and thready, and there was a tendency toward circulatory collapse. The urine contained a trace of albumin. With the progress of the disease evidences of profound toxemia became more and more marked, the case terminating in death by the end of the fourth day. Summary of Diagnosis.— The diagnosis is made positive by the recognition of but few symptoms, for example: (a) The character of the stools and the presence of large shreds of brownish membrane; (b) the early development of nervous symptoms; (c) the tendency toward circulatory- collapse, and (d) a positive serum reaction. All these serve to distinguish pseudomembranous dysentery from other maladies in which diarrhea is a symptom. Complications. — Among these, special mention should be made of intestinal perforation, with the subsequent development of locaHzed or generalized peritonitis. Acute ulcerative endocarditis and pericarditis have been known to complicate this form of dysentery. Pleurisy, acute parenchy- matous nephritis, and bronchopneumonia may also develop. Myocarditis may occur in cases tending toward recovery. DYSENTERY; 733 Clinical Course. — ^The mortality rate is extremely high, many cases terminating fatally as the result of the profound toxemia. Permanent recovery may follow, although in these cases the disease runs a chronic course and restoration to health is protracted. Secondary Pseudomembranous Dysentery. Pathologic Definition. — A disease characterized by the forma- tion of a false membrane on the intestinal mucosa. Predisposing Factors.— Any condition that impoverishes the patient's general nutrition predisposes to the development of secondary pseudomembranous dysentery. The diseases during the course of which it is most likely to develop are: pneumonia, diabetes insipidus, pulmonary tuber- culosis, chronic interstitial nephritis, chronic parenchymatous nephritis, gastric carcinoma, chronic suppuration, hepatic cirrhosis, essential anemia, and valvular heart disease. In these conditions the dysentery belongs to the group of terminal infections. Chronic Dysentery. Pathologic Definition. — A chronic catarrhal and ulcerative con- dition of the colon, secondary either to acute bacillary or to amebic dysentery. In the majority of cases there are ulcerative changes in the colon, and in certain cases these ulcerations show a tendency toward healing after an acute attack of dysentery, whereas in other cases there is a tendency for the ulcer to heal and form a constriction of the bowel as the result of the formation of scar tissue. At the site of the ulcers the intestinal mucosa is deeply pig- mented, and displays a slate-gray or blackish color. There is generally some hjrpertrophy of the submucous and muscular coats of the colon, and the lumen of the bowel is frequently narrowed. In atypital cases actual ulcera- tion of the intestine does not occur, although there is extensive formation of fibrous tissue, with some puckering of the mucous membrane. Bxciting and Predisposing Factors.— Chronic dysentery is usually secondary to one or more acute attacks. The disease often follows an unusually mild grade of amebic dysentery. Among the predisposing factors are age and sex, the disease being more common in adult males than in women or children. Principal Complaint. — The patient complains of moderate pros- tration, loss of flesh, mental hebetude, and restlessness; when questioned closely, he will state that he is free from pain and rectal tenesmus. The majority of patients with chronic dysentery suffer from acute exacerbations of the condition every three to twelve months, and at such times there may be intestinal pain and tenesmus. The average number of stools is from three to twelve daily, but this is controlled largely by the character of the food taken. Much undigested food escapes with the stool, and when the patient is upon a diet rich in starches, the stool is white and covered with froth. During an acute exacerbation, there may be blood and pus in the stool. Intervals of constipation are fairly common, and the degree of constipation that exists in a given case depends upon the character and location of the disease of the colon. The patient may complain that he has a more or less constant sense of fullness in the abdomen, but this seldom becomes painful. The appetite is fairly good, although in some instances it is appreciably impaired. The patient often maintains that the character of food taken in no way influences the dysentery. When chronic dysentery has extended 734 ACUTE INFECTIOUS DISEASES. over a prolonged period, mental hebetude is apparent, and late in the disease the patient may become stupid. Thermic Features. — ^The temperature is normal, or possibly slightly below normal in the morning hours, except during an acute exacerbation, when there may be mild but irregular fever. Physical Signs. — Inspection. — ^There are evidences of emaciation, and the general appearance is that of asthenia. The skin is pale, and at times yellowish or dusky; the tongue is clear at one time, bright red and glazed (beefy) at another, and probably heavily furred at the next examina- tion. Palpation. — ^The surface of the skin is harsh and dry, and always feels cool. With the progress of the disease the pulse gradually weakens and later becomes rapid, irregular, and dicrotic upon slight exertion. Summary of Diagnosis. — ^The diagnosis rests first upon the history of a long-standing condition and the fact that there have occasionally been acute exacerbations. The number of stools a day — from four to ten — serves as a positive clinical evidence of chronic dysentery. Differential Diagnosis. — Chronic dysentery is to be distinguished from tuberculous ulceration of the mucous coat of the colon. The distinc- tive differences between tuberculous enteritis and chronic dysentery are: (1) In the former condition there is commonly a history of tuberculosis of the lung or of other portions of the body; (2) tubercle bacilli are present in the feces. (See Examination of the Feces, p. 518.) Duration and Clinical Course. — The duration of chronic dysentery varies between two and ten or more years. Dysentery, when it has not existed for a year, is generally considered as subacute. Cases will be en- countered in which a dysenteric condition has lasted over a period of thirty or more years, and yet such patients, although never enjoying good health, are able to go about, although they are unable to do any form of labor. The duration of chronic dysentery is also influenced by judicious treatment, a num- ber of cases terminating favorably in from one and one-half to three years. Complications. — ^The complications are practically the same as those described for acute dysentery. Death, as a rule, results from the develop- ment of some intercurrent condition, e. g., bronchopneumonia, pulmonary tuberculosis, and chronic kidney or liver disease. Chronic gastritis is a frequent complication. ASIATIC CHOLERA. Definition. — An acute infectious disease that may occur either sporadically or epidemically, excited by the baciUus cholera (Vibrio cholerse Asiaticse), and characterized clinically by copious watery discharges from the bowel, vomiting, intestinal and muscular cramps, suppression of the excre- tions, and collapse. Incubation Period. — ^This varies greatly, and may be from a few hours to four or five days. Clinical Types. — (1) Premonitory Diarrhea. — During the pro- dromal period the patient is, comparatively speaking, well, although he may exhibit sHght local symptoms, e. g., nausea, abdominal discomfort, and occasionally slight pains in the abdomen. The initial symptoms are some- what severe; languor is experienced at this time, and the patient becomes easily fatigued. (2) Mild Type — Cholerine.— In this type the symptoms are extremely ASIATIC CHOLERA. 735 mild, and in many cases they are less severe than in cholera morbus (see p. 548). Although the general clmical picture of cholerine simulates that of true cholera, none of the symptoms are pronounced. Mild muscular cramps, slight prostration, a trace of albumin in the urine, and a cold, clammy skin,' particularly of the hands and feet, are quite characteristic. It is important to bear in mind that in the mild type of cholera the stools are not character- istic, but, on the contrary, are "feculent in character. In uncomplicated cases the duration seldom exceeds from seven to ten days. (3) Usual Types. — The general clinical picture of this type will be given as the Principal Complaint. (4) Foudroyant or Asphyxic Type.— In this type the disease develops suddenly, and the symptoms are so severe that the patient dies within a few hours. _ Vomiting and purging may or may not be present. The viru- lence of this type of mfection is the only explanation offered for this clinical phase of the disease. Cholera sicca should also be included under this type. Exciting and Predisposing Factors. — Bacteriology. — An essential factor in the development of cholera is infection with bacillus cholera, and this bacterium may be isolated from the intestinal contents and from the watery discharges of persons ill with or dead of the disease. Infection from Without. — The bacil- lus cholera is found not only in the dejecta of persons suffering from the disease, but has also been isolated from drinking-water, and in 1892 Frankel detected it in flowing water during certain epidemic outbreaks. Geographic Distribution. — Those residing in the tropics are far more likely to develop the disease than are those in temperate and subtropical districts. Cholera tends to spread along the lines of commerce, conse- quently persons residing at or near the sea-coast and at prominent ports are jr,(, especially prone to acquire the disease. Excessive humidity has been said to cause a predisposition to cholera, and a high temperature certainly favors the development of the spirillum. Season. — Cholera prevails epidemically in subtropical districts during the warm months, although an epidemic may be continued well into autumn. The majority of European and American epidemics developed late during the summer months, and ended with the approach of cold weather. Individual Susceptibility. — Intestinal catarrh from whatever cause and particularly that following the ingestion of unripe fruits, and the like, materially predisposes the individual to infection with the bacillus cholerae. Rigid sanitation exercises a great influence, and those living amid such en- vironment are less likely to develop the disease than are others less fortu- nately surrounded. Age and Sex. — Age and sex appear to exercise but little, if any, influence upon the development of cholera. Previous Attack. — Persons having suffered from a previous attack of cholera are, as a rule, not immune to the disease. 275. — The BAClLLtrs of Cholera, (from THE Mouth); XIOOO (Gunther). 736 ACUTE INFECTIOUS DISEASES. Clinical Picture.— i. Usual Type, First Stage.— The stools are very frequent and painless.. In cholera sicca the serous diarrhea is absent, death soon taking place. ' Gastric symptoms develop early, and consist of vomiting and intense thirst. The patient has no desire for food; his tongue at first is moist and coated, but later, if much liquid has been ab- stracted from the body, the tongue is dry and parched. He experiences a feeling of pressure or of discomfort in the abdomen, but real pain is unusual. Intestinal cramp and rectal tenesmus are occasionally seen. Prostration is extreme. Nervous Symptoms. — The mental faculties may be retained until near death, but, as a rule, the patient is apathetic, or delirium may develop and coma ensue. The muscular symptoms are severe and occur early, cramps affecting the various muscles (calves of the legs and feet) being perhaps one of the most distressing symptoms in a mUd attack of cholera, although they are also severe in the more violent types of infection. Thermic Features. — Ordinarily, the temperature, as taken by the axiUa, falls to a subnormal level during the first hour, usually reaching 96° F. At the same time the rectal temperature will be found to vary between 101° and 105° F. Cardiovascular Features. — These form a prominent part in the clinical picture, and are given at length under Physical Signs. Physical Signs. — Inspection. — ^The expression is anxious, the face is pinched, the cheeks are sunken, the lips are pale and fissured, whereas the skin and tongue are dry and wrinkled. The eyes have a peculiar glare, and, owing to the high grade of cyanosis, the complexion is dusky or bluish. Cyanosis of the fingers is conspicuous. Palpation. — ^The skin is cold, dry, and rough to the feel. The abdomen is, as a rule, soft, but may be tense. Pressure over the calf muscles excites discomfort, and at times pain. The reflexes are diminished or absent. Early during the disease the pulse is rapid, — 120 to 140 beats a minute, — and when the degree of liquid excreted from the body is large, it becomes smaller and smaller, until at last it is almost imperceptible. Auscultation. — Owing to concentration of the blood the heart action becomes very rapid at the onset of the disease, and there may be distressing palpitation. Later the heart-sounds again become increased in frequency, the muscular quality being now absent, the sounds growing less and less distinct, until venous stasis occurs. Owing to dryness of the vocal cords and the other organs of speech the voice becomes feeble and husky. a. Algid Stage (Ordinary Type).— During this stage of cholera the clinical manifestations described under the first stage of the disease are practically all present, but are appreciably intensified. The patient may be regarded as being in a state of asthenia, and the pulse is imperceptible, the cyanosis extreme, the skin and extremities very cold, the respirations shallow and frequent. Coma is likely to develop within a short time. The copious watery discharges present in the first stage are here absent, although there is often a continuous dribbling of serous material from the rectum. No urine is excreted during this stage. 3. Stage of Reaction. — Reaction may follow the first stage of chol- era, in which case there is an amelioration of all the symptoms and the pa- tient goes on to recovery in from ten days to a few weeks. The kidneys again functionate, the cutaneous and rectal temperature approaches normal, the mucous surfaces become moistened, the heart action less rapid, the pulse ASIATIC CHOLERA; 737 stronger, and the voice clearer. It is to be borne in mind that reaction may possibly develop during the second stage. Cutaneous complications may develop during this stage, and among these are purpuric, roseolar, macular, and erythematous eruptions. The clinician should be ever alert for the development of serious nen'ous symptoms of a uremic character, since at this stage acute nephritis may be seen. I,aboratory Diagnosis. — All the secretions of the body are diminished, e. g., there are scanty sputum and an absence of saliva, and the urine is diminished or suppressed during the first and second stages of cholera. During the stage of reaction the flow of urine is increased in favorable cases, although such urine is at first albuminous. If true nephritis develops, the urine will be found to contain an abundance of albumin and many casts. Leukocytes and red blood-cells may be present. Stools. — At the onset the number of stools is great. Within a short time the stool presents a peculiar "rice-water" appearance. Microscopically, the small granules floating in the watery dejecta are composed of epithelial cells from the intestine. A bacteriologic study of the stool reveals the presence of bacillus cholerse (Fig. 276). The colon bacUlus and other bacteria com- mon to the intestinal tract are also present. Blood. — If the number of watery discharges from the bowel has been large, the blood becomes concentrated, and the number of red cells in a cubic millimeter will be found to range between 8,000,000 and 12,000,000. The hemoglobin percentage of such blood is above the normal. After convales- cence has been established the number of red cells falls to the normal, and later a decided anemia occurs. The vomitus, which is also of the "rice water" type, contains the bacillus cholerse. Illustrative Case. — E. X., male, aged twenty-two ears; formerly a resident of England, and now a private in the English army, has been in India for six months, during which time he has suffered from a mild attack of dysentery. For the past three weeks he has been in comparatively good health, except for indigestion. He was seized suddenly by violent muscular cramps, profound vomiting, and copious watery discharges from the bowel, which were not accompanied by intestinal pain. During the first hour the patient's features became pinched, the expression anxious, and the pijJse weak, the beats numbering 140 a minute. The cutaneous temperature fell below the normal, whereas the rectal temperature was 102.6° F. By the end of the third hour of his illness there was anuria, accompanied by a continuous dribbUng of watery material from the bowel. Mental hebetude soon advanced to mild coma, and all the mucous surfaces became extremely dry. The dejecta presented a rice-water appearance, and these rice-like nodules were composed of desquamated epithehal cells. The bacillus cholerse and many other bacteria were also present. The clinical picture of the patient now indicated a most critical condition, when, suddenly, there was a cessation of the symptoms previously described, the pulse became stronger, the cutaneous temperature rose steadily to the normal, and the tongue and other mucous surfaces became moistened. The kidneys now began to functionate, and convalescence was comparatively soon established. Summary of Diagnosis. — A history of exposure or of residence in a district where cholera is epidemic, or even endemic, is of great importance. The diagnosis is based largely upon the character of the stools and of the vomitus, together with the existence of muscular cramps, a small, rapid pulse, and the earl}'- tendency toward collapse, marked by subnormal tem- perature, anxious expression, mental dullness, and coma. Recovery of the bacillus cholerse from the dejecta and from the vomitus renders the diagnosis 47 738 ACUTE INFECTIOUS DISEASES. positive, but the acme of the disease is often reached before such cultural studies can be completed. DIFFERENTIAL DIAGNOSIS BETWEEN ASIATIC CHOLERA AND CHOLERA MORBUS. Asiatic Cholera. Cholera Morbus. 1. History of an epidemic or of exposure 1. History of dietetic errors, e.g., eating in tropical districts. unripe fruit or decomposed foods. 2. Diarrhea and vomiting are not aecom- 2. Intestinal colic a prominent symptom, panied by severe intestinal pain. 3. First vomitus contains particles of 3. Vomitus contains food, and mucus food, but soon resembles rice-water. may be present. 4. Vomitus contains the bacillus cholerse. 4. Bacillus cholerse absent. 5. Stools, although frequent, are without 5. Odor very offensive, stools feculent, odor, and resemble rice-water in ap- pearance. 6. Rectal tenesmus extremely un- 6. Rectal tenesmus may be prominent. common. 7. Collapse develops early and coma is 7. Collapse develops later and coma is common. unusual. 8. Axillary temperature becomes subnor- 8. Temperature seldom below normal, mal. 9. Anuria the rule. 9. Anuria very rare. 10. CompUcations somewhat common. 10. CompUcations unusual. Clinical Course. — Cholerine terminates in recovery in practically all cases. The asphyxic type, which represents the other extreme of the disease, usually terminates in death. The mortality rate is foimd to vary greatly in different epidemics, ranging between 20 and 80 per cent. During the algid period, and still more often during the period of convalescence, nephritis and limg complications increase the gravity of the disease. Cholera is extremely fatal in the asthenic, in those suffering from chronic disease, in alcoholics, and in the aged. The mortality rate is greatly dimin- ished in those epidemics in which it is possible to institute treatment early. Complications. — Complications are, as a rule, due to secondary infection. Septicemia and pyemia may develop, and pseudomembrane formation occasionally involves the mucous surfaces, e. g., colon, throat, and vagina. In those cases in which the nervous symptoms are prominent bronchopneumonia is common, whereas pleurisy and parotitis are occa- sionally seen. SPRUE (PsiLOsis). Pathologic Definition. — A chronic disease characterized by atrophy of the walls of the bowel. Exciting and Predisposing Factors.— The exciting cause is unknown, yet facts prove that it is most probably of microbic origin. Resi- dence in the tropics is the chief predisposing factor. Clinical Features. — ^Manson groups these as irregular action of the bowels, with characteristic stools, i. e., stools that are copious, pale, drab, frothy looking, and that emit an offensive but sweetish odor. The patient becomes cachectic and the skin is somewhat bronzed; mental hebetude and loss of strength are common. A characteristic feature of sprue is soreness of the mouth and of the rectum. Sprue is not essentially a fatal disease. TYPHOID FEVER. 739 TYPHOID FEVER. Pathologic Definition. — An infectious disease characterized by con- gestion, proliferation and ulceration of Peyer's patches and the solitary fol- licles. There are associated bronchitis, enlargement of the spleen, con- gestion and moderate enlargement of the liver, and a tendency toward such complicating conditions as bronchopneumonia, nephritis, intestinal perfora- tion, and phlebitis. Clinical Remarks. — There is bacteriemia excited by infection with the Bacillus t5^hosus, characterized clinically by an incubation period of from ten to twenty-five days, and by three stages: (a) Invasion — a gradual daily rise in temperature, headache, lassitude, muscular pams, weakness, nose-bleed, constipation, followed by slight diarrhea. (6) Fastigium — marked by continued fever, characteristic eruption, Widal serum-reaction, diarrhea, dilated pupils, pronounced neivous symp- toms, abdominal tenderness, tympanites, and a tendency toward complica- tions (iatestinal hemorrhage, intestinal perforation, nephritis, and broncho- pneumonia). (c) Stage oj defervescence — in which there is a gradual decline in the fever and an amelioration of all symptoms, followed by convalescence. Exciting and Predisposing Factors.— Bacteriology.— The bacillus typhosus is the exciting cause of typhoid fever, although there are certain steps in the "postulates of Koch" that have not yet been completed, e. g., the iaoculation of an animal with a given organism, known to have ex- cited the disease in another animal suffering from or dead of the disease, and recovering this organism from the second animal's tissues after inoculation, and at a time when it displays the symptoms of the disease in question. Loris-Melikoff in studying the anaerobic bacteria of the intestines in typhoid fever found the Bacillus satillitis almost constantly present. This bacillus is agglutinated by serum from typhoid patients (1 : 100). Animals infected by this organism show lesions similar to those seen in man. The Bacillus satilhtis has also been recovered from the stomach of healthy oysters. Another anaerobic organism commonly found associated with the Bacil- lus satillitis is the Bacillus perfringens. This organism, like the Bacillus satillitis, is capable of producing indol and phenol, as well as hyperemia and congestion of Peyer's patches. It has been demonstrated that the Bacillus perfringens produces ulcer- ation of the intestine. These anaerobic bacteria appear clinically to be potent factors in the production of typhoid fever. Confirmatory experi- ments are needed in order that we accept one or both of these organisms as exciting or contributing factors in the production of the many signs and symptoms that go to make true typhoid fever. "The Bacillus edematis maligni and Bacillus sporogenes have also been found by Loris-Melikoff in the dejecta of typhoid fever subjects. Distribution of the Organism in the Human Body. — The bacUlus is found in the lymph-glands, the contents of the intestines, the spleen, the liver, the blood, the bile, the rose-spots, the urine, the sputum, and the nasal secre- tions. (See Laboratory Diagnosis, p. 750.) Distribution Outside of the Body. — The bacillus cannot readily maintain a permanent existence outside of the body. From time to time, however, the conditions indispensable to the growth and development of the bacillus ty- phosus prevail, and corresponding with such periods, more or less extensive 740 ACUTE INFECTIOUS DISEASES. epidemic outbreaks of the disease may occur. It is known that the typhoid bacillus may retain its virulence for from seven to fourteen days m water. It disappears from water after this time, however, on account of the sapro- phytic organisms present. Multiphcation of the bacilli may take place m water, in milk (very rapidly), and in the soil, where, under favorable con- ditions, they may live for an indefinite period. Freezing does not kill them, and they may live in ice for several months. According to the experiments of M. P. Ravenel, bacillus typhosus was not killed even by exposure to the temperature of liquid air — 240° F. below zero. In a paper entitled "History of " Ty- phoid Fever," one of us (Anders) set forth the evidence offered by the different epi- demics that occurred in armies in Europe, Africa, and America, and showed that typhoid fever did not remain in a camp when all the sick were removed, the bed- ding and linen used by such camp being destroyed by fire or left behind, and the healthy members of the army removed to new quarters. These facts indicate strongly that typhoid bacilli must have the power of existing upon clothing, and that they may be transmitted from such clothing to healthy persons, and in such persons excite the disease. It has been shown that in armies the number of cases of typhoid was greatly reduced when all the patients suffering from the disease were safely screened from the attacks of flies and other insects. Much evidence has been adduced that goes to support the belief that the house- fly acts as a carrier of the organisms con- cerned in the production of typhoid fever. The habits of the fly, particularly that of alighting upon dejecta, soiled linen, and food-stuffs, would certainly appear to be a possible means of infection, and one of the methods by which this disease is transmitted. Dejecta known to be rich in typhoid bacilli, when thrown into small streams, may in turn find their way to the water- supply of towns and cities, and this method, although it was formerly be- lieved to be the most common means by which bacillus typhosus gained access to the human body, still has many ardent supporters, yet bacteriologic research contributes but moderately toward strengthening this original view. So far as we are aware, bacillus typhosus has never been found in the drinking-water used in the city of Philadelphia, yet there is probably no other city in the world that furnished so large a percentage of typhoid fever cases before the introduction of filtered water. Our own studies have shown that bacillus typhosus is unable to live in Philadelphia water for more than ^ 1 ||jnN|fE9iMAfl,k-F,LiM*y|rfUNE|jlJ(.,|fllJI,l5(PT|oLTtH0V DEL|[ || fioo I'J5. ,„ /\ T15 / \ TOO \ H5. 6 SO (,15 tOD 515 S50 ^^f> ,Min .11^ 500 4« 175 4% 450 ■11? 41s 10D \ / 3T5 V^ \ / 3.Sf) \ \ / 35D V. \ L 7 ^l'- 300 j 300 2W \ US ns J-Ifi 2^ m m .7. I5D 150 ns lOO JOO 75 Sn 2S ,^ L _ _ _ _ _ _ __ Fig. 276. — Average Number of Caseb OF Typhoid Fever Occurring Dur- ing Each Year. Statistical Analy- sis OF 68,943 Cases (Sallom). TYPHOID FEVER. 741 from two to ten days, and that the number of l^acilh present is greatly diminished after the first forty-eight hovu-s. Typhoid Carriers. — Persons who have had tj-phoid fever and recovered from it may show the exciting organism of the disease for an indefinite period after all symptoms have subsided. Some persons, doubtless, are hosts of the typhoid bacillus, while being themselves immune to the dis- ease. Consequently such persons at times act as carriers of the bacilli and thus become responsible for the spread of the disease. It is believed that the habitat of the organism in the body of such carriers is chiefly the gall- bladder, whence they escaped by way of the bowels. In some cases bacilli are discharged in the urine for many years after convalescence from typhoid. Geographical Distribution. — Typhoid fever is found to prevail, for the most part-, throughout the temperate zone, and in America it is the most important of infections. Epidemics of the disease, however, have been re- ported as far north as Nonvay and Iceland. Typhoid fever is unusually common throughout the northern portion of the United States and in Canada, but is less frequently seen along the Gulf of Mexico and in the southwestern Fia. 277. — Chart Showing the Numbeh of Gases and Mortality of Ttphoid Feveb by Months. Statistical Analysis of 68,943 Cases (Sallom). part of this country. The disease is far less common in Europe than in Amer- ica, and, owing to its infrequency, is greatly dreaded in European countries. In large cities typhoid fever prevails endemically, with one or two epi- demic outbreaks each year. Epidemics in the rural districts are not uncom- mon, but the disease seldom prevails endemically in such sections. Season. — Available statistics go to show that the greatest numljer of cases are reported during the summer and autumn months — August, Sep- tember, and October. More cases are frequently seen to occur during the late autumn and early winter months than during the spring. Sallom's analysis of 68,94.3 reported cases of typhoid fever for Philadelphia gives the largest number of cases as reported in February (see Fig. 276). The epi- demology of typhoid fever is well shown in the accompanying chart (Fig. 277). Temperature figures prominently as a predisposing factor, since epi- 742 ACTPTE INFECTIOUS DISEASES. demies of typhoid fever are unusually common after a long spell of hot and dry weather. It must be remembered that extensive epidemics of typhoid fever may occur at any time during the year, and that the so-called " house epidemics," developing in hotels, apartment-houses, colleges, asylums, etc., are but slightly influenced by season. Clinical Varieties. — (l) The usual form of typhoid fever wiU dis- play a temperature of from 100° to 103° F., and a pulse of from 100 to 120, which later tends to become dicrotic. The tongue is at first moderately coated, but this coating grows more intense with the progress of the disease, and by the seventh to the tenth day the organ is heavily furred. Constipa- tion obtains during the first two to four days, when it is relieved by a moderate grade of diarrhea, the stools numbering from two to ten a day. Some mental dullness, continuous headache, and mild delirium at night may be present. A slight amoimt of abdominal tenderness and tympany may also be present late during the first week. The spleen is enlarged, readily palpable and tender, and in from seven to nine days the characteristic rose- spots appear over the lower portion of the trunk and abdomen. From the seventh to the fourteenth days mental diillness is more marked; the headache, which is prominent during the first week, gradually subsides, the pulse quickens, the temperature ranges from one to two degrees higher than during the preceding week, and tympanites is present. The mouth is dry and the tongue is dry and parched, the teeth and lips are covered with sordes, and all the symptoms previously described are intensified. From the fourteenth to the twenty-first days the fever of 100° to 102° shows a moderate decline, although the pulse remains at about the same rate (90 to 110). Weakness is now extreme, and emaciation is noticeable. Between the twenty-first and the twenty-eighth days the fever usually falls gradually to near the normal, the diarrhea subsides, the quantity of urine is increased, abdominal distention from tympanites disappears, the mouth becomes moist, the tongue clears, the patient becomes rational, and, in addition, develops a ravenous appetite. This variety of typhoid fever is, as a rule, free from complications, al- though it may be well to state, in this connection, that no case of typhoid fever is so mild that serious complications may not develop during the third and fourth weeks of the disease. (2) Severe Form. — In this variety all the symptoms described under the mild form of typhoid are intensified from the onset. The temperature soon reaches 104° to 106° F., the tongue is dry early, and by the second week becomes brown and deeply fissured; its surface may be bleeding, and in fact the organ may be coiled upon itself well back in the oral cavity. The fever remains high, and at times does not reach the normal level before the beginning of the sixth or the seventh week. Nervous symptoms develop early, and carphologia, subsultus tendinum, and low muttering delirium are present. The urine and feces may be ex- pelled involuntarily, and coma in many instances ends the scene. The pulse becomes rapid by the end of the first week, and by the four- teenth day it is often 140 a miaute, displaying a tendency toward dicrotism. Diarrhea develops early, although obstinate constipation is an equally serious symptom. The heart-sounds are weak and distant, and suggest myocardial degen- eration. There is a distinct bronchitis, and numerous fine r^les are audible oyer the greater portion of the lungs posteriorly. The urine is scanty, of high color, of high specific gravity, and contains albumin. TYPHOID FEVER. 743 The mortality rate in this variety of typhoid fever is extremely high, and in those cases that tend toward recovery convalescence is always protracted and complications are extremely common. (3) Mild Form. — In this variety the disease seldom continues for more than two weeks, and by the twenty-first day at the longest the patient is able to leave his room. The onset is insidious and all the symptoms are mild. The temperature seldom, if ever, exceeds 103° F., and in many cases ranges between 99° and 101.1° F. The eruption, a characteristic symptom, is, as a rule, scanty, and there may be but a single crop of rose-spots. Splenic enlargement is moderate, and slight tenderness is elicited only upon firm pressure. There is but slight, if any, tenderness over the cecum, a more constant sign being that of distinct gurgling in the region of McBumey's point. The Widal serum reaction is present in the majority of these cases, but may not appear until the third or the fifth week of the disease, or even after convalescence is well established. (See Laboratory Diagnosis, p. 750.) (4) Latent (Walking) Typhoid. — ^The symptoms described during the first week of the usual form of typhoid are so mild in this tj^e that they do not even arouse suspicion as to the nature of the disease until the second or third week, when certain of the symptoms of typhoid appear. Many of these cases go undetected until some complication arises, when a careful study re- veals the true nature of the condition in question. , The eruption is said to appear in the majority of cases of walking typhoid, and this sign, together with the Widal serurriHreaction, may be the only feature to indicate the nature of the malady in question. When a patient suffering from walking typhoid has been permitted to go about his duties until the tenth or fifteenth day of the disease, he may then develop characteristic symptoms of the usual form of typhoid, and, indeed, it not infrequently happens that these patients at this time present many of the symptoms known to the severer form of the disease. Complications frequently develop in cases of latent typhoid when the disease was not detected until the second or third week, but when the true nature of the condition is recognized early, cases of latent tj^hoid usually make an early and uninterrupted recovery. (5) Typhoid Fever of the Aged.— When typhoid fever develops in persons after the fifth decade, it is characterized by mild fever, marked cardiac weakness, and a decided tendency to develop complications. The symp- tomatology of this form of typhoid is misleading, since the eruption and splenic tenderness are often absent. The Widal serum-reaction, however, is fairly constant. (6) Afebrile Typhoid. — This type is certainly rare, although there are authentic records of such cases. Afebrile t5rphoid is said to present mild headache, slight weakness, some impairment of the appetite, questionable splenic enlargement, and a slow pulse. A typical eruption has been ob- served. Strictly speaking, this should not be considered as afebrile, but as a mild form of typhoid, the rule being for the patient to develop a temperature of from 99° to 101° F. during the afternoon and evening hours at some time during the disease. (7) Nephrotyphoid. — In a small percentage of patients suffering from typhoid infection the most alarming lesions appear to be in the kidneys, taking the form of an acute parenchymatous nephritis. Symptoms develop abruptly; the urine becomes scanty, highly colored, rich in albumin, and contains hyaline, granular, and blood casts. Both red and white blood-cells 744 ACUTE INFECTIOTTS DISEASES. are present, and, indeed, hematuria may be one of the most prominent fea- tures of the disease. The bacillus typhosus may be cultivated from the urine. Nervous symptoms appear early and are of a serious nature, the patient eventually developing uremia. The temperature varies between 100° and 104° F. The pulse does not become weak and dicrotic early, as is the case in the severe type of typhoid, showing the same nervous symptoms, but at first resembles the pulse of uremia. In nephrotyphoid the prognosis is decidedly unfavorable. (8) Cerebral Typhoid. — Here the disease is ushered in by intense headache, facial neuralgia, nausea, vomiting, photophobia, twitching of the muscles, rigidity of the cervical muscles, with some retraction of the head and, rarely, convulsions. Extreme stupor and coma may end the scene. This form of the disease is to be distinguished from epidemic meningitis, the distinction being made positive by lumbar puncture or by the Widal serum-reaction; spinal puncture is negative in typhoid fever, whereas the Widal serum-reaction is negative in epidemic meningitis and positive in typhoid fever. (9) Laryngeal Typhoid. — This type of typhoid infection p*ursues a mUd course, the invasion being unusually gradual; abdominal symptoms, e. g., tympanites, tenderness, and diarrhea, may be slight or absent. The fever is not high, and the degree of prostration is only moderate. Between the second and fourth weeks involvement of the larynx gener- ally occurs, characterized by harshness of the voice, a hard, rasping cough, some soreness of the throat, and at times dyspnea. Ulceration may be present on the mucous surface of the larynx, epiglottis, or adjacent struc- tures. (See Tonsillotyphoid, p. 744.) Cultures made directly from the ulcerating mucous surface, as a rule, show the presence of typhoid bacilli. There are authentic records of aphthous patches having appeared on the mucous membrane of the mouth and nose, the result of typhoid infection. Perforation of the nasal septum may result from typhoid ulceration. Typhoid of the upper respiratory tract, as a rule, tends toward recovery, the most imminent danget being infiltration of the larynx and interference with respiration. (10) Tonsillotyphoid. — During the course of typhoid infection the only evidence of such lesions may be an infiltration of the mucous membrane of the tonsils. Small kidney-shaped, superficial ulcers may occur on the buccal mucous membrane from the seventh to the tenth day of the disease, and may be present in any clinical variety of typhoid fever. These ulcera- tions are usually bilateral, located on the fauces just above and to the outer side of the tonsil (so-called "Bouveret" ulcer). The concavity of the ulcer is usually directed toward the median line, the ulcer varying greatly in size from i to | inch in length, and from J to | inch in width. Ordinarily these ulcerated surfaces are covered by a grayish slough. Their duration varies from that of a few days to one week. Clinically they are of diag- nostic importance, since they are present before the appearance of the Widal reaction in about 5 per cent, of cases. Bouveret ulcers have been reported by Johaims and Devic, who observe them as a precursor of tjrpic typhoid relapses. Tonsillotyphoid is, as a rule, mild in nature, and com- monly runs a short covu-se, with a slight tendency to develop comphcations. In all these special types of typhoid infection of the throat and upper respiratory tract the Widal serum-reaction and the recovery of the bacillus typhosus from the ulcerated surface are the most distinctive chnical features. TYPHOID FEVEK. 745 (11) Pneumo typhoid. — One occasionally encounters typhoid fever in which the leading symptoms are referable to the lungs, and there is a some- what severe acute bronchitis that develops early during the attack, which is likely to be followed later by bronchopneumonia, lobar pneumonia, or acute pleurisy with effusion. Pneumotyphoid, as a rule, displays somewhat marked nervous and circulatory symptoms, and the prognosis in this type of the disease is but guardedly favorable. (12) Typhoid Septicemia. — Here the general clinical picture is that of profound sepsis, and the symptoms of this condition usually progress from bad to worse until a fatal termination is reached. The prognosis in the so- called septic type of typhoid is imfavorable, but a small percentage of the cases going on to recovery. All the symptoms described in the usual type of the disease are greatly intensified in this septicemic form. (13) Typhoid of Children. — The typhoid of childhood is a fever charac- terized more often by nervous than by intestinal symptoms. The onset is sometimes sudden, with well-marked symptoms, e. g., fever, prostration, emaciation, and vomiting are not uncommon. The disease is also seen to begin with lassitude, headache, coated tongue, anorexia, and a gradual rise in temperature. In cases developing abruptly it often appears as though acute indigestion had been the means of precipitating the attack. Vomiting is, as a rule, the initial symptom. Epistaxis may occur, but is less common in children than in adults. The course is mild, as a rule, and the mortality low. Diarrhea. — There is no constant relation between the severity of the intestinal lesions and the condition of the bowels. Diarrhea is present in about 50 per cent, of cases, the average number of stools being from two to four a day. There is nothing about the stool that may be said to be charac- teristic. Constipation is a feature in many cases in which typhoid develops before the tenth year, and according to Morse's statistics, over 60 per cent, of children manifest constipation during typhoid infection. Constipation is the general rule at the onset of the fever, a condition equally true of typhoid in the advilt. Abdominal distention, due to tympanites, is less constant in children than in adults, and tympany, when present, is usually a feature of those cases showing diarrhea due to colonic ulceration and marked catarrhal enteritis. Other abdominal features of typhoid, e. g., gurgling and tenderness in the iliac fossa, are not constant. Eruption. — An eruption appears in approximately 60 per cent, of all cases, but children, as a rule, develop but slight eruption, and there may be only a single crop of rose-spots. In the relapsing typhoid of children an eruption occurs with each relapse. Thermic Features. — The temperature will be found to vary from that described under the t3T)hoid of adults in the following features: In children under three years of age the fever lasts for from eight to fourteen days. Wolberg's analysis of 277 cases shows that the fever was of less than fourteen days' duration in 70 per cent, of cases, and in 2.8 per cent, of these, it did not continue for more than eight days. A subnormal temperature is the rule dur- ing the first week in those cases in which typhoid develops insidiously. Marked elevation of temperature during the second week of the disease is suggestive of complications. The nervous symptoms are in direct relation with the degree of fever, and the severe forms of delirium so common in the adult are extremely rare in children. 746 ACUTE INFECTIOUS DISEASES. Principal Complaint. — Stage of Incubation. — The average length of this period, until the first definite symptoms of t5T)hoid appear, is not definitely isnown, but is probably, in the majority of cases, between seven and ten days, although in rare instances it may be three or more weeks. The patient at first appears to be in good health, but as the disease pro- gresses, definite symptoms develop, and he complains of prodromes, e. g., languor, anorexia, headache, nose-bleed, muscular pains, nausea, and constipation, which continue for from three to seven days, when a mild diarrhea begins. Clinical Stages. — For convenience of study, typhoid fever is divided into three distinct stages; thus, in the moderately severe cases the first week represents the stage of development; the second and third weeks, the fastig- ium; and the fourth week, the stage of decline. (1) Stage of Development. — The period of invasion is, as a rule, gradual, the symptoms being chilliness and slight fever, with an increase in the severity of the prodromal symptoms. At or about this time epistaxis may reveal the nature of the disease. Headache is continuous. The symptoms described are quickly followed by prostration marked enough to compel most patients to take to their beds. It is best to regard the time of occurrence of the previously mentioned symptoms (elevation of temperature, with its attendant discomforts) as the stage of onset, since many patients continue at their accustomed voca- tions for days after the first symptoms appear. The onset may be marked by symptoms resembling influenza, and muscular pains and pharyngeal irrita- tions are by no means uncommon at the onset. With the progress of the initial period the symptoms usually increase in severity daily; the temperature (Fig. 278) is higher each day, until the fourth or sixth day, when the fastigium is reached. The appetite is lost, there is intense thirst, the face is flushed, the skin is hot and parched, and there may be profuse sweating in the axilla and groins. Distinct flushings, alternating with chilly sensations may occur. The symptoms and signs of a mild bronchitis are present in more than 50 per cent, of aU cases. The jyulse has gradually increased in frequency with the progress of the disease, until it is full and strong, the beats numbering from 90 to 110 a minute. Upon palpation tenderness is often detected in the right iliac region, and distinct intestinal movements can be felt at this point. Moderate splenic enlargement is the rule, and the organ is often quite tender. (2) The Fastigium. — In typical cases this begins on the fifth to seventh day of the disease, and lasts about two weeks. During the first week of the fastigium (the second of the disease) all the general symptoms become in- tensified. The evening temperature ranges between 103° and 105° F., and approaches the continued type. The pulse is accelerated, but full and of fair strength. Headache, a prominent symptom during the first stage, gradually disappears, and in its stead there are seen mental hebetude, slow- ness of speech, and a moderate degree of deafness. There may be delirium, which is most likely to occur at night. Cough with the physical signs of bronchitis are present, and there is, at times, slight expectoration. Diarrhea — from two to eight stools daily — is present during this stage. Inspection.— The cheeks are somewhat sunken, the lips are dry and fis- sured, and the tongue is heavily coated, and often brown and bleeding. Sordes is seen on the lips and the teeth. The abdomen is distended, and TYPHOID FEVER. 747 there may be profuse sweating and urticaria. About the eighth day of the disease A number of rose colored spots appear on the trunk. The rose spots of typlioid fever disappear when tlie skin is stretched or wlien pressure is made upon them, iDut they reappear when pressure is relieved. Palpation. — The abdomen is moderately tender, peristaltic movements of the bowel are prominent in the right iliac fossa, and the spleen is readily TEMP. CEN TIGRADE CO r^ TEMP. CENTIGRADE :- O a Qo r^ ^ ■* "1 CTI (r> LLl - - _ - " 1 ; » 5 - - ^ J _ Lj. _ -^ 2 j: - - - ■ 1 H 1- [^-^ ^ - - i ^-^ ^ 1 M ' -i \ r :" .. ?:: ^ ^ ' ■ ""^ hr=i-. i^ u 1 1 _i___^__ --j-,- 1 > ""> H =) ±: ' iifi ::: ::: _: _"^=- a g ::::::::::a^.— L^r4^^^__ ± L. i 1 £ :::::::::::^^^^t;4::;:l Q ^ ^^^ 1 1 1 _i_|_' , . i^J- ^ ±x-n-t^S:E ^=^ 03 cr :::::-.:::::IHj^=^^ J-=h= --- ~- X 1 ^ ^=T-J_i_i_^J___ H X -|-r n ~ ^n~S:^ rn~ "1 " — ^ : ij: ^£:-^g: 5 ---^^^4it^^_3: s =» -~^= — V\^' 1 1 1 ' 1 1 Q :-- + ^2 ' 5 ' l-iii-^^fr--^-- !::::::::::::::::: ^ 1 riM feH- -^ -J : ' _ _ 1 > 1 1 ' ■ ^^ . ' 1 1 ■ ■ : ■ ' : [ ! .1 - J-U . :::::Sx^--^ ' ~M~i ~rr X~T ~ ~^~' ■ ' ' ' ■ ' ' IH =F ,- 1-f^ ~h^- -M-- - - ^ ^ -- -^ ^^-rr---^--HH±x ^ ::::::± -' - rT- T^ i± ^' a: --±t x-±i±:E = :^::y^:±::::: U. X _J^ u. --±\±. :::::: T r-^S^ 1 U_l — _|^ -H-:— ^t^-i^ f^ ^^_rtxG:-±--:^""^:::M±^::::: O O O c ll3HN3aHv'! O 0> -1 CO '^ un -t fn CN — O Oi-ico^ OOOOOOOJ Oi ^ II3HN3aHVd 'dwai 1 H I palpaljle and may extend some distance — two to four inches — below the costal margin. At the close of the second week complications are most likely to occur. (See Complications, p. 755.) The third week of the disease, and the second week of the fastigium, finds the symptoms previously detailed at their height, and other more serious symptoms and even complications may be added. 748 ACUTE INFECTIOUS DISEASES. (3) Defervescence. — At the end of the second stage, and about the twenty- third day of the disease, the fever begins to decline in favorable cases, and with this change the other general and local symptoms become gradually ameliorated, which improvement continues for one week and is followed by an establishment of convalescence. In protracted and unfavorable cases the fourth week of the disease may present the same clinical indications as did the third, and, in fact, when the type of infection is unusually virulent, the symptoms outlined during the third week may be greatly intensified. In unfavorable cases the pulse may range between 120 and 140 beats a minute, and become weak, dicrotic, compressible, and irregular. Nervous symptoms are also likely to be pronounced, all types of delirium and coma being occasionally seen. The abdomen is greatly distended, and the in- voluntary discharge of urine and feces is occasionally observed. The fever may remain high during the fourth week, and we have seen cases in which the fever continued above 102° F. during the fifth, sixth, and seventh week of the disease. Instances are recorded in which the fever has continued for a period of fifty and even seventy days. In those cases in which convalescence is established late, relapses, as well as recrudescences, are extremely common. (See Figs. 278 and 279.) Clinical Picture. — Thennic Features. — In typical cases the tem- perature rises gradually during the first week, reaching 103° to 104° F., with morning remissions of one to one and one-half degrees. (See Fig. 278.) During the third and fourth weeks the morning temperature becomes normal, but there is a persistence of fever during the evening hours, which in uncom- plicated cases is from one to two degrees above the normal. By the end of the fourth week this evening rise of temperature has entirely subsided, and the morning record is subnormal, whereas the evening registers at or below the normal line. Atypical Temperature. — (1) The Inverse Type. — A low evening and a high morning temperature are occasionally displayed. (2) The fever may terminate at the end of the second week, the temperature declining somewhat rapidly, and reaching the normal in from forty-eight to seventy-two hours. (3) An abrupt development of fever is seen in children and in those cases in which the disease is ushered in by a chill or a series of chilly sensations. (4) Intestinal perforation and hemorrhage are marked by a sudden fall in the temperature when the thermometer registers below normal. (5) A rapid rise in temperature during convalescence is the result of dietetic error, con- tipation, overexertion, or mental excitement, and is, as a rule, of but short duration. Such thermic exacerbations are generally regarded as a "re- crudescence" — fever without the other symptoms of typhoid. (6) In those cases in which there is questionable involvement of the bones, joints, pleura, gall-bladder, or other portions of the body, an evening temperature of 99° to 100° F. may continue indefinitely. (7) During relapses the fever is sel- dom as high as it was during the initial seizure, unless the primary attack has been abnormally light, is of shorter duration, and, like all the other symptoms, is of a mild nature. Gastro-intestinal Symptoms. — Anorexia is present early during the course of the fever; nausea and vomiting are . occasionally present as the disease progresses, but are by- no means constant. Vomiting indicates either a severe grade of infection or the development of serious complications. Diarrhea is a fairly constant symptom, although in the majority of cases it appears during the second week of the disease. The stools are thin, semi- TYPHOID FEVBH. 749 liquid, or pea-soup-like in consistence, and vary in the average cases, from two to six daily. The stools may be more frequent, and in those patients suffering from either severe gastro-intestinal catarrh or extensive ulceration in the colon there may be ten or even twenty movements a day. Stools containing blood are seen to occur during the third week, and even during convalescence. When the hemorrhage into the bowel is large, the stool may contain clotted blood, which is of a bright red color, but, as a general rule, the blood is retained in the bowel for some hours, when the dejecta have a tar-like color and consistency. Chemically, the stools contain minute quantities of blood in the majority of all cases of typhoid fever. Constipation is present during the first week, as a rule, and may con- tinue throughout the course of the disease. (See Typhoid of Children, p. 745.) Circulatory Symptoms. — The pulse is, as a rule, but moderately ac- celerated, and the rapidity of the heart-beats is not in proportion to the de- gree of fever present — e. g., a pulse of 90 beats a minute may accompany a temperature of 100° to 104° F. The pulse may occasionally become weak early during the course of the fever. In severe types of infection there is a tendency for the pulse to become thready, dicrotic, and compressible. The heart-sounds also bear a close relation to the character and frequency of the pulse. (See Physical Signs, p. 749.) Respiratory S3rmptoms. — The respirations are slightly increased in frequency, _ and a harsh, non-productive cough, that may, though rarely, become quite annojdng, is present. (See Complications, p. 755.) Epistaxis is one of the early symptoms, and is common, particularly in the typhoid of young adults. Bleeding from the nose may be profuse, but in the average case there are three or four attacks, the patient losing but a small quantity of blood. Epistaxis may occur during the fastigium, and may then prove serious. Nervous Symptoms. — Persistent headache is prominent during the prog- ress of the disease, but by the end of the second week it gradually disappears, and at this time a moderate amount of mental apathy and stupor is apparent. The patient's hearing is somewhat dulled, his speech is thick, and his words are hesitating. As the acme of the disease is reached the various types of delirium are likely to develop — e. g., low, muttering delirium, which is present only at night, carphologia (picking of the bed-clothing), tremor (both fine and coarse), subsultus tendinum, and maniacal seizures may develop. Following the previously described types of delirium, the patient may fall into a semi- comatose state, or coma-vigil and profound coma may follow. Convulsions are imcommon, except in those cases in which there is in- volvement of the kidneys or of the meninges. In typhoid of the meningeal type (see Varieties), strabismus, photophobia, ptosis, and hyperesthesia are to be seen. Physical Signs. — Inspection. — Throughout the entire course of the fever the face is flushed, unless the patient has had severe intestinal hemor- rhage. The expression is somewhat dull and the pupils are moderately dilated. At first the tongue is slightly furred over its superior surface, but later it becomes heavily coated, and in severe cases it may be bright red and deeply fissured, and portions of the surface may be brown from minute hemorrhages. It is not uncommon, during the height of the disease, to find the tongue somewhat rolled upon itself, the patient being unable to 750 ACUTE INFECTIOUS DISEASES. protrude it beyond the teeth. The lips become fissured when the tempera- ture continues high and the teeth are covered with sordes. Swelling and congestion of the tonsUs and of the pharynx are occasionally seen. (See Varieties, p. 742.) Between the seventh and ninth days a crop of small, circular or lenticular rose^pots is seen upon the abdomen; these disappear upon pressure and on stretching the skin, but immediately reappear after such pressure is removed. The eruption of typhoid is likely to occur every two or three days in successive crops. We have studied several cases in which the eruption was profuse and covered almost the entire body. In seven such cases studied at the Philadelphia Hospital, intestinal hemorrhage was a complication in six, and the remaining case showed severe nervous symptoms. From this smaU collection of cases, however, it cannot be positively asserted that a profuse eruption is always followed by severe symptoms. The abdomen is distended, the patient usually resting upon his back, and showing a disinclination to turn from side to side. In aU cases of typhoid the respiratory movements are somewhat quickened, and the impulse of the apex-beat is, as a rule, diffuse. Late during the course of the disease pulsa- tion of the vessels of the neck, at the epigastrium, and in the second inter- costal space may be detected. Palpation. — The skin of the face and abdomen is usually dry and hot early. As the patient becomes decidedly prostrated, the axiUary and in- guinal regions are bathed in perspiration. By the beginning of the second week of the fever the spleen is felt below the costal border, and in severe tj^es of infection it may extend to or even below the umbihcus. The spleen is, as a rule, somewhat tender, although this pecidiarity may be absent. There is also moderate hepatic enlarge- ment. There may or may not be distinct localized tenderness ia the right in- guinal region and along the course of the ascending colon. On placing the hand gently over the right Uiac region, a distinct gurgling movement of the bowel is often felt, but its clinical significance is limited. Percussion. — Tympanites is the rule, and when present, an increased area of fiver and splenic dullness may not be detected. In the absence of gaseous distention the area of splenic dullness is perceptibly and often greatly increased, and there may be a moderate increase in the area of fiver duU- ness. Percussion over the region of the bladder is an important measure when defirium is present, since by this means retention of the urine, which is an occasional compficating feature, may be detected. Auscultation. — Borborygmus is heard over the entire abdomen, but is more pronounced in the right iliac fossa and along the course of the as- cending colon. The heart-sounds are at first increased in frequency, but the muscular quality is normal. With the progress of the disease, and in protracted cases, the first sound of the heart becomes greatly weakened, and, indeed, the first and second sounds may be very sunilar during the third and fourth weeks of the disease. A variable degree of bronchitis is always present, so that both moist and dry rales are audible over the chest. I,aboratory Diagnosis.— The Widal serum-reaction is present at some time during the course of an attack of typhoid fever in from 95 to 98 per cent, of all cases. As a rule, this reaction may be obtained about the TYPHOID FEVER. 751 end of the first week of the disease. Rarely, indeed, it is absent until the second or third weeks, and we have seen cases in which it did not appear until convalescence was well established. (See Serum-reaction, p. 344.) Leukopenia is the rule in typhoid fever, the number of leukocytes in a cubic millimeter of blood being, in a typical case, between 5000 and 6000. When inflammatory compHcations are present, such as bronchitis, pleuritis, and bronchopneumonia, a slight leukocytosis may be found. The differential count of the leukoc}d;es shows a relative increase in the number of lymphocytes and a diminution in the number of pol}Tnorphonuclear neutrophile cells. The leukopenia is often most marked during convalescence. During the first week the red cells are but slightly altered in number, but as the disease progresses, and during convalescence, the number is diminished. In those cases in which there are complications that embarrass the circulation and produce cyanosis the number of red cells in a cubic mUhmeter may be greater than normal. The alkalinity falls to a point below that indicated by the color-index prior to the appearance of the Widal reaction. The hemoglobin is diminished and the color-index is low. Cultures from the blood will be found to develop typhoid baciUi in from 20 to 30 per cent, of all cases. Prendergast's Vaccine Reaction* — Take 1 drop of ordinary typhoid vaccine and to it add 20 drops of sterile saline solution. Mix thoroughly, and then introduce into the skin, by means of an ordinary hypodermic, a few drops of this mixture. Direct the needle so that the solution when injected will be located near the surface of the skin, and endeavor to pro- duce with the solution a rather conspicuous blister. Within twenty-four hours following the introduction of the diluted vaccine into the skin patients not suffering from typhoid will display an area of redness sm-round- ing the site of the injection, while typhoid patients show no evidence of such reaction. Practically, all evidences of the typical reaction disappear within forty-eight hours. Generally speaking, the urine is that ordinarily regarded as febrile in character. The quantity voided during the twenty-four hours is at first slightly increased, but with the increasing fever it is lessened, of high color, and of high specific gravity. A trace of albumin is ordinarily present, and in severe types of infection casts, leukocytes, and red blood-cells are found. Indican is present throughout the greater part of the febrile period; the diazo-reaction may be obtained during the first week of fever, commonly continues throughout the febrile period, and may even be seen after con- valescence has been established. A baderiologic study of the urine will show the presence of the Bacillus typhosus in about 20 per cent, of all cases. Bile. — Certain clinicians attach importance to an early bacteriologic study of the bile in the recognition of typhoid fever. Kiralifi has called attention to the fluid of the duodenmn being practically free from bacteria in health, and he further claims that bacteria of the colon group are present in great numbers during the early stage of typhoid. Test. — Give the patient 200 c.c. of sweet oil (olive oil) (in event of the pylorus being relaxed duodenal fluid is regurgitated into the stomach). Recover the oil-test-meal, by means of the stomach-tube, and examine it bacteriologically. Brinton has found that by administering into the stom- * Medical Record, Dec. 30, 1911. 752 ACUTE INFECTIOUS DISEASES. ach 400 to 600 c.c. of sterilized water practically the same results are obtained as are given under the oil-test breakfast. Both Kiralifi and Brin- ton's tests are valueless tuiless there be relaxation of the pylorus at the time of their application. Feces. — During the prodromal stage of typhoid constipation is the rule, but as the disease progresses from four to six semiliquid stools a day, like pea soup, are the rule in mild types of infection. In severe forms of typhoid the number of movements from the bowel may be greatly increased, and during the second and third weeks intestinal hemorrhage may occur. Hemorrhages may be frequent and small in quantity; but in unfavorable cases hemorrhage is often profuse. Occult blood is present. Cultures from the feces during any stage of typhoid will show the presence of typhoid bacilli. Illustrative Case of Typhoid Fever.— D. D., male, aged twenty-three years; weight, 146 pounds; height, 5 feet 8^ inches. Family History. — Parents, three sisters, and a brother Hving and in apparent health. Previous History. — ^The patient has had the diseases of childhood, but has no recollection of having had either scarlet fever or diphtheria. He has not been compelled to consult a physician in the past five years, but prior to that period he had occasional attacks of tonsillitis. Social History. — The patient is single; he has lived in the country until six weeks ago, when he moved to the city. A clerk by occupation, his work requiring that he be confined indoors during the greater part of the day. His habits in regard to eating and drinking are good. Present Illness. — ^This began October first, when he observed that his appetite was failing and that he felt greatly exhausted after his day's work. For a period of one week before consulting his physician he suffered from malaise and aching of the muscles of the legs and of the back, a variable amount of headache, and two mild attacks of epistaxis. During this time he also suffered from constipation and from ill-defined sensations over the abdomen. At the beginning of the second week of the disease the patient experienced, an acute lancinating pain in the region of the spleen, and although this severe pain lasted for six hours, it was not accompanied by any decided fall in the temperature or slowing of the pulse. Upon his admission to the hospital on the eighth day of his illness, he had a slight cough, which was unaccompanied by expectoration. Headache, which became worse upon exertion, was present. Mild delirium and restlessness were present during the night from the eighth to the fourteenth day after admission, whereas from the fourteenth to the twentieth days delirium continued during the greater portion of the twenty-four hours, but at no time was it maniacal. The temperature upon admission was 101° F., but within the course of two or three days it had reached 103° to 104° F., during the evening hours, with slight remissions during the early morning hours, but in general it was more or less of the continued type, until the twenty-first day, when it fell gradually, and reached the normal by the end of the fourth week. When the temperature remained above 102.4° F., for a period of one or two hours the patient was given a cold pack or sponged with alcohol and water, and with either treatment the temperature fell from one to two degrees. Physical Examination. — General. — Upon admission the patient was pale, his gait was feeble, and he rested his head upon his hand while sitting. When placed in bed, he assumed the supine position, with the thighs moderately flexed upon the abdomen. On extending the hands, there was distinct trembling. Both skin and tendon reflexes were approximately normal. Local Examination. — Inspection. — Upon admission the abdomen presented nothing abnormal, but two days later there was a distinct typhoid eruption. From the fif- teenth to the seventeenth da^ys of the disease the abdomen became markedly distended as the result of tympanites. The skin was commonly bathed in perspiration, and those portions of the body upon which the patient rested most of the time became reddened. The tongue was coated early and later became brown and fissured. The conjunctivse were congested. Palpation. — Throughout the greater part of his illness the abdominal wall was more or less tense. The spleen could be felt to extend for a distance of two finger-breadths TYPHOID FEVEH. 753 below the left costal margin, and upon making firm pressure over this area tenderness and even pain resulted. The pulse was of good volume at first, the beats numbering 90 to 100 a minute, but during the third week of the disease, and at that time when deUriimi was present, the number of pulse-beats varied between 110 and 120 a minute. The force of the pulse was greatly lessened at this time, and there was a tendency toward intermittence and dicrotism. On palpating the abdomen in the right iliac fossa dis- tinct gurgling could be detected from the beginning of the second until the middle of the tmrd week of the disease. Percussion. — During the early stage of his iUness the percussion-note was practi- cally normal over the abdomen, but when tympany existed, it was greatly altered. The area of cardiac dullness and that of pulmonary resonance were not altered. Auscultation. — On placing the stethoscope over the colon it was possible to detect an unusual amount of gurgling during the first and second weeks after his arrival at the hospital. During the third week of the disease the first sound of the heart appeared to have lost its booming quality, yet there was no evidence of endocardial disease. Fine sibilant rales were heard over both lungs posteriorly. Laboratory Findings. — The blood count showed that the number of leukocytes in a cubic miUimeter was below normal; the red cells numbered 4,100,000 m a cubic nullimeter and the hemoglobin content was 80 per cent. The Widal reaction was positive during the first week of his stay in the hospital. The number of bowel movements a day varied between three and thirteen during the second and third weeks of the disease, and a small quantity of blood twice escaped with the dejecta. The urine was high in color, and contained a trace of albumin during the febrile period. Diagnosis by Induction from Clinical Data. — The age of the patient and the existence of prodromal symptoms, such as pains in the muscles, headache, and epistaxis, were considered as favoring the possible existence of typhoid. Later in the course of the disease the temperature became characteristic, and at this time the positive Widal reaction was considered sufficient to warrant a diagnosis. Differential Diagnosis. — During the height of the disease the nervous symptoms, the pulse, and temperature suggested the possible existence of acute miliary tubercu- losis, from which malady the condition was distinguished by the following clinical facts: (a) The blood gave a positive Widal reaction; (6) the temperature had risen gradually, and showed a conspicuous decline after the eighteenth day; (c) diarrhea became a prominent feature during the second week of the disease; (d) epistaxis ap- peared during the prodromal stage; and (e) tympanites was present. Course of the Disease. — By the beginning of the fifth week of the disease the patient was able to sit up in bed, and continued to make an iminterrupted recovery. Summary of Diagnosis. — The diagnosis of tjrphoid is made positive by — (a) The history of the patient having never before suffered from ty- phoid; (6) the characteristic temperature-curve; (c) the splenic tumor; (rf) the characteristic eruption; and (e) a positive Widal reaction. Many other symptoms, previously mentioned, go far to support a diagnosis of typhoid fever, but are not essential to the recognition of the disease. Season, the presence of an epidemic, and the age of the patient, although they are often of great value in strengthening a doubtful diagnosis, are equally likely to mislead the clinician. Differential Diagnosis. — Typhus fever is to be differentiated from typhoid fever by the presence of an epidemic, by its sudden onset, the presence of stupor, the dulled expression of the features, conjunctivitis, and the pin-point pupils, all of which conditions are but rarely, if at all, seen in typhoid fever. Typhus is characterized by a macular eruption that appears upon the fourth day and may become petechial. The fever, as a rule, runs a shorter course in typhus than in typhoid, and the Widal serum-reaction is negative. Acute miliary tuberculosis is frequently mistaken for typhoid fever, and the distinctive features between these two conditions are shown in the accompanying differential table: 48 754 ACUTE INFECTIOUS DISEASES. TABLE SHOWING THE DIFFERENTIAL POINTS BETWEEN TYPHOID FEVER AND ACUTE MILIARY TUBERCULOSIS. Typhoid Fevek. 1. History of an epidemic or of change of residence from the country to the city. 2. Fever rises gradually, in step-like form, reaching its height in from seven to eight days, and declines dur- ing the third or fourth week. 3. Respirations are moderately increased, with few riles over the lungs. 4. Cough may develop early, but is mild, and usually abates during the second week of the fever. 5. Cyanosis is observed only late in the disease, when there is cardiac failure or pulmonary comphcation. 6. Tenderness in the right iliac Tympanites and from two to six semi- Uquid stools daily. 7. Widal serum-reaction positive after the first week. 8. Characteristic eruption appears over the abdomen about the end of the first week of the fever. 9. Cultures from the blood show the presence of typhoid baciUi in from 20 to 30 per cent, of all cases. 10. Pupils are moderately dilated early during the course of the disease. 11. Feces contain the bacillus of Eberth. 12. Intestinal hemorrhage and intestinal perforation may compUcate typhoid fever. Acute Miliary Tuberculosis. 1. May be history of cough or of a tuber- culous ulcer, abscess, fistula, etc. 2. Fever rises more abruptly, and re- mains high (continued type) until ■ death. 3. Respirations from 40 to 60 a minute, with numerous crackling rales and at times increased respiratory murmurs over both lungs. 4. Cough increases gradually throughout the disease, and there may be blood- streaked sputum. 5. Cyanosis early. fossa. 6. Constipation the rule. 7. Serum-reaction negative. 8. Eruption absent. 9. Culture may develop tubercle bacilli if proper culture-medium is employed. 10. Pupils less likely to be dilated and tu- berculous retinitis common. 11. Tubercle baciUi often present in the feces. 12. Intestinal hemorrhage and perforation absent. Malarial Fever. — Typhoid fever is distinguished from malarial infection by an examination of the blood alone. The protozoa of malaria are always present in both the fresh and the stained blood, and their detection indicates the type of infection present. The Widal serum-reaction is also absent in malaria. One seldom finds a case of malaria in which abdominal symptoms and signs resembling those of typhoid fever are also present. The tempera- ture of malaria seldom assumes the form characteristic of typhoid, although in estivo-autumnal types of malarial infection a continued type of fever is common. Meningitis exhibits hyperesthesia, intolerance of light and of sound, altered reflexes, and rigidity of the neck muscles. Vomiting and constipa- tion are common in both epidemic and tuberculous meningitis. The tem- perature remains at a lower level, on the average, and is more irregular. The eruption is not continued in character or in time of appearance, and never resembles that of typhoid. The nervous symptoms assume greater promi- nence early during the course of meningitis, which is in striking contrast to the nervous manifestations of typhoid. In cases suffering from tuberculous meningitis tubercles may be found upon the choroid. In either acute or subacute meningitis lumbar puncture will recover fluid containing some bacterium. TYPHOID FEVER. 765 The Widal serum-reaction is also negative in both epidemic and tuber- culous meningitis. In epidemic meningitis a leukocytosis of from 12,000 to 25,000 is to be expected, whereas in uncomplicated tjrphoid fever leukopenia (6000 to 2500) obtains. In tuberculous meningitis a differential leukocyte count is likely to show an increase in the percentage of lymphocytes present. In the meningeal type of typhoid fever lumbar puncture, estimation of the number of leukocytes in a cubic millimeter, and the Widal serum- reaction are essential to the formation of a correct diagnosis. Dysentery. — During the Spanish-American War typhoid fever was frequently mistaken for dysentery — a fact amply proved by the history of the many soldiers treated in the hospitals of Philadelphia. In dysentery the temperature is, as a rule, moderate and more irregular than is that of ty- phoid, the stools are more frequent, and the degree of prostration becomes marked early. In typhoid prostration is not profound until the second week of the disease. The Widal reaction for typhoid fever is of great im- portance in distinguishing between these two conditions, and a serum-reac- tion, with the bacillus of Shiga, while less commonly employed, is also of service in determining the existence of bacHlary dysentery. Absence of the characteristic eruption strongly favors dysentery. Prognosis and Duration. — These are dependent upon three dis- tinctive conditions: first, the severity of the type of infection; second, whether or not treatment, including nursing, can be carried out systematically in certain individual circumstances; and third, the presence or absence of complications. A severe type of infection is usually marked by high fever. A tempera- ture of 105° F., if prolonged for more than three days, renders recovery unlikely. A fever of 106° F. generally proves fatal. Marked nervous symptoms, delirium, etc., are also expressions of a severe type of infection, and make the prognosis guardedly favorable. Relapses tend somewhat to lessen the favorable outlook, but a recrudescence is seldom of serious moment. When typhoid fever is recognized early and appropriate treatment is estabhshed and continued throughout the disease, the mortality-rate is greatly lessened. CompUcations of whatever nature render the prognosis less favorable. Bronchopneumonia, lobar pneumonia, nephritis, intestinal hemorrhage, and intestinal perforation, the latter in particular, are of serious prognostic moment; other less serious complications likewise proportionately lessen the probability of recovery. Uncomplicated cases of the ordinary type of the disease go on to recovery in from four to eight weeks. Complications. — Complications may consist of an exaggeration of a symptom or of symptoms other than those known to the severe type of typhoid fever. Exaggeration of an Ordinary Sjrmptom as a Complication.^ — Ex- cessive tympanites, when it embarrasses the action of the heart and respira- tion, forms a complication of serious moment. By stretching the intestine, tympanites favors intestinal perforation and intestinal hemorrhage — ^two serious complications. Severe diarrhea greatly depletes the patient, and favors the development of other serious complications. Gastro-intestinal and Abdominal Complications. — ^The ulcers of typhoid are rarely found in the esophagus, pharjmx, and on the tonsils. Suppuration of the parotid gland, although extremely unusual, is a grave complication. Cholecystitis is marked by the development of jaundice and other symp- 756 ACUTE INFECTIOUS DISEASES. toms, and this complication may rarely be followed by the formation of gall- stones or by hepatic abscess, both of which conditions are of serious moment. Rarely, indeed, the greatly enlarged spleen may rupture, and shock follow. Intestinal hemorrhage occurs during the third or fourth week in from 3 to 5 per cent, of all cases, and is fatal in probably 30 per cent, of such vic- tims. The indications of hemorrhage are a sudden fall in temperature, with signs of collapse and the passing of bloody or tarry stools. In profuse hemor- rhage death may occur before the blood escapes from the rectum. Intestinal perforation may occur at any time after the middle of the second week, and has been known to take place after convalescence was ap- parently well estabhshed. In more than 70 per cent, of cases with perfora- tion this accident is accompanied by sudden acute abdominal pain. In many instances collapse is the first symptom of perforation, and in prac- tically all such cases there is an abrupt fall in temperature, which, however, tends to rise again some hours later. Several hours after the acute pain due to perforation there are abdominal rigidity and tenderness, the result of the associated peritonitis. Leukocytosis speedily develops. In those cases in which tympanites and delirium are prominent features, it is quite difficult to detect perforation until peritonitis has developed. The former exceedingly high death-rate from this accident has been somewhat reduced by timely surgical intervention. Respiratory Complications. — ^The so-called "laryngeal typhoid" seldom occurs until after the third week of the disease. When associated with marked edema of the glottis and of the adjacent structures, the prognosis is decidedly unfavorable, and tracheotomy or intubation may be necessary. Lobar pneumonia occurs quite commonly during the second or third week. Dullness, weakened voice-soxmds, and moderately fine moist r^les at the bases during inspiration, are found not infrequently in the later stages, and the respirations are quickened. Bronchitis, which is also present, may extend to the smaller vesicles of the lung, and result in bronchopneumonia. Occasionally, portions of the lung become atelectatic. Pulmonary abscess, gangrene, and pulmonary hemorrhage are among the rarest of complications. Pleurisy with effusion is occasionally seen. Ulcers of the nose occur, and perforation of the nasal septum may follow. Nervous Complications. — Paralyses, while extremely uncommon, may develop during convalescence, and appear in the form of paraplegia, four such cases having come under our notice. Hemiplegia and monoplegia are less common. There may be only temporary loss of control of the sphincters. Neuritis may be either local or multiple, and is characterized by pain, tender- ness, foot-drop, and wrist-drop. Myelitis is unusually rare. Any or all of the aforementioned nervous complications renders the prognosis decidedly unfavorable. The so-called typhoid spine develops during convalescence, and is ushered in by extreme tenderness and pain upon movement of the limbs. There is no additional fever, and the actual pathology is doubtful. Meningeal symptoms of typhoid may be prominent in the so-called "nervous type" of the disease, but true meningitis may develop as a compli- cation, at which time practically all the characteristic symptoms of menin- gitis (p. 838) are displayed— e. g., rigidity of the muscles of the neck, photo- phobia, hyperesthesia, strabismus, and an irregular temperature. Menin- gitis, when present, may be due to typhoid infection of the meninges or to a mixed infection. The fluid obtained by lumbar puncture will be found to contain typhoid bacilli and also the pneumococcus and the meningococcus. Meningitis complicating typhoid fever is an extremely fatal condition. PARATYPHOID FEVER. 757 Circulatory Complications. — A variable degree of myocarditis is present during the later stage of every severe case of typhoid. Acute endocarditis occasionally develops, and manifests itself by an infrequency in the heart action and the presence of a distinct endocardial murmur. Pericarditis, although less common than endocarditis, may also cause unusual irritability of the heart. Thrombosis of one of the femoral veins gives rise to swelling and tender- ness of the corresponding foot as the first symptom. The left vein is oftenest involved, but both femorals, and even the axillary veins, may be the seat of such complications. Thrombosis of the spermatic vein and orchitis, al- though extremely rare, deserves mention. Embolism of the femoral artery is still less common than are complications of the veins. Embolus of the brain and localized paralyses have been reported. Renal Complications. — Acute nephritis may develop early during the course of the fever (nephrotyphoid) , but it is more likely to complicate typhoid at the height of the disease or during convalescence. Moderate albuminuria, however, is not to be regarded as a complication. Hemoglobinuria and hematuria occur in cases displaying profound nervous symptoms. The presence in the urine of a large amount of albumin and of numerous granular and bloody casts renders the prognosis unfavorable. Pyelitis and cystitis may occasionally complicate typhoid fever. Ear Complications. — Otitis media has been seen to develop at any time during the course of the fever, but is most likely to appear at the f astigium. Otitis media is frequently overlooked by the clinician until there is a dis- charge from the ear. The acute pain of otitis media is of no value during the development of this complication, since the general stupor prevents the pa- tient from appreciating this symptom. The temperature serves as the best guide to acute inflammation of the middle ear, and an increase of from one to two degrees takes place with the development of the auditory complication, and continues until rupture of the membrana tympani occurs. ' Eye Complications. — Conjunctivitis, iritis, and corneal ulcer are among the rarest of complications. Oculomotor paralysis has been reported. Cutaneous Complications. — ^Multiple abscesses of the skin form an occasional complication in those cases displaying the so-called "septicemia of typhoid." Bed-sores are frequently responsible for a rise of temperature of one or two degrees for days or even weeks after other symptoms have subsided. They affect by preference the back, buttocks, and heels. Complications Affecting the Bony Structures. — Necrosis of the tibia has been reported, and is more likely to occur in the typhoid of children. Acute arth- ritis may complicate typhoid at any stage of the fever, but is oftenest de- tected during the third or fourth weeks. As in bed-sores, so in bone and joint complications, the convalescence is protracted. Periostitis with abscess for- mation is fairly common. PARATYPHOID FEVER. Definition. — This term is applied to an infection with an organism of the colon-typhoid group, which resembles bacillus typhosus, but is not identical with it. Predisposing and Bxciting Factors. — The conditions that pre- dispose to paratyphoid are practically the same as those given for typhoid fever. The exciting cause is a bacillus belonging to the colon group (Bacil- lus paratyphosus enteritidis). Melkish has studied this bacillus in con- nection with a disease known to rats. Symptomatology. — Generally speaking, the period of incubation is 758 ACUTE INFECTIOUS DISEASES. short, and the onset is more abrupt than is that of typhoid fever. At the beginning the headache is more intense than in typhoid. Nervous s3rmptoms develop early; thus, during the first week of fever it is not uncommon to find the dfiferent types of delirium pronounced. (See Nervous Manifestations of Typhoid, p. 749.) Gastro-intestinal Features.— Constipation usually obtains throughout the febrile period, although diarrhea is not unknown. Thermic Features. — By the third or fourth day the temperature is likely to rise to 103° or 104° F. Such rise does not display the peculiar, step- like ascent characteristic of true typhoid. The duration of the temperature, as also its mode of decline, is uncertain, although in the majority of instances the temperature falls by rapid lysis. Convalescence is seldom interrupted, and therefore the temperature, after it once reaches the normal, is likely to remain at or near that level. Physical Signs. — Inspection. — The face is flushed, the expression is dull, the tongue is heavily coated, and the lips are dry and fissured. A rose-colored eruption resembling that of typhoid fever may be seen upon the abdomen and trunk. In certain cases the eruption very closely simulates that of typhoid, both in appearance and in its mode of recurring in successive crops. The rule, however, is to have an atypical typhoid eruption. Palpation. — There is but slight abdominal distention, and the abdominal walls are not tense. Splenic enlargement is a constant feature, and the de- gree of such enlargement varies widely in different cases. Clinical Course and Duration. — In the majority of cases the temperature reaches the normal earlier than it does in true typhoid, and re- covery is less likely to be protracted in paratyphoid. There are exceptional cases, however, in which convalescence is delayed for a prolonged period, such delay being due to some complicating condition (bronchopneumonia, melena). I/aboratory Diagnosis. — The differentiation of paratjrphoid fever from typhoid fever can be made only by laboratory methods. A case pre- senting the symptoms of typhoid fever with a negative agglutination test with bacillus typhosus in all probability belongs to the group of paratyphoid fever. Agglutination tests with paratyphoid or paracolon organisms will sometimes give positive results. In other cases cultural methods must be resorted to, inoculations being made of the blood, the feces, or the urine, the last being the most convenient, and the characteristics of the organism re- covered being carefully determined. TYPHUS FEVER (Ship Fever, Camp Fever? Jail Fever). Predisposing and i^xciting Factors.— Age.— Typhus is a dis- ease of childhood and early adult life, although it may appear at any age. Sex is without influence where both males and females are alike exposed. Season appears to figure prominently, epidemics being more common during the winter months. Unsanitary surroundings usually prevail where there is an outbreak of typhus, consequently filth, poverty, famine, and over- crowding serve as potent predisposing factors. Typhus is also commonly encountered among the occupants of institutions, jails, and prisons, and it likewise affects the crews of ships, especially when they have been at sea for a prolonged period. Typhus does not occur spontaneously in a community where the disease has never before been known, but is always transported to such locality, yet TYPHUS FEVER. 759 the exact mode of conveyance of the infection is not definitely understood. In certain selected epidemics the disease appears to have been transported by means of clothing, whereas in other cases mere association in the room with those known to be suffering from the disease serves as the only possible means of dissemination. The medical profession has not as 3'et' accepted any known specific etiologic factor in the protluction of typhus. " Period of Incubation. — This varies from nine to twelve days, during which period there maj^ be mild prodromal symptoms, e. g., anorexia and malaise, but in the average case prodromes are not distinct. Principal Complaint.— Preeruptive Stage.— The initial symptom Fig. 280. — Petechial Eruption of Typhus Fever; Patient Recovered (Welch and Schamberg). may be a series of chills or one severe rigor, following which the patient com- plains of headache, muscular pains, vertigo, tinnitus aurium, and profound weakness. An annoying bronchial cough with slight expectoration may be present. Anorexia develops early, and there is an inordinate thirst. Vo7nit- ing is present, and may be an annoying symptom. Nervous Syynptoms. — These appear early, and maj^ even be present with the subsidence of the chill. Delirium is, as a rule, at first mild, but later active, and may terminate in stupor and eventually in coma. Eruptive Stage. — From the third to the fifth day quite a characteristic eruption develops, and with its appearance there is an appreciable decline in the fever. The rash appears first upon the trunk, and then extends over the entire body. It is seldom seen on the face. Two or three days later the crimson red maculae become petechial, and the skin presents a spotted ap- pearance on account of the coalescence of the isolated patches. Some of the maculae do not change their hue, but remain as rose-red spots for several days — a feature commonly seen in mild forms of typhus. Again, in the milder form of the disease certain of the rose-spots may disappear upon pressure or on stretching of the skin. The true petechial patches, on the other hand, are unaltered by such manipulation. A variable degree of hyperemia may involve those portions of the skin between the petechiae. Nervous Symptoms. — As in the former stage, the nervous symptoms are inten.se during the stage of eruption, and maniacal delirium is the rule in well-marked cases, and is frequently followed by the various types of coma, 760 ACUTE INFECTIOUS DISEASES. among which coma vigil is common. Even in the milder forms tremor, subsultus tendinum, and caiphologia are prone to occur. Owing to the patient's delirious state he persists in resting upon his back. Unusually mild cases of tjqshus are seen ia which both the eruption and the nervous symptoms are not well marked, and the t}^ical clinical picture may not be present at any time during the disease. Multiple neuritis with paralysis of the extensor muscles is an occasional complication, and meningitis is rarely encountered. Thermic Features. — Quickly foUowiag the onset the temperature will be Fig. 281. — Typhus Fever Cuhve (Register). found to rise to from 102° to 105° F., reachuig the latter height by the second or third day; during the preeruptive stage the fever is of the continued t\Tpe. During the eruptive stage, which begins between the third and fifth days, there is not likely to be an appreciable decline in the fever, but between the fourteenth and seventeenth days of the disease, m favorable cases, the fever termmates by crisis. (See chart,, Fig. 281.) ImmecUately before the crisis occurs there is likely to be a sudden rise in the temperature, and some- times the crisis is interrupted by slight exacerbations. In favorable cases there is a decided amelioration of the sj^mptoms following the crisis. Physical Signs.— Inspection.— The face is flushed at first, and when coma is well developed, the expression may be dull, anxious, or staring. The cheeks are flushed, the conjunctivae are congested, the face is expres- sionless, and the pupils are markedly contracted. From the third to the fifth days the characteristic eruption will appear. (See Eruptive Stage.) The tongue is thickly coated with a yellowish-white fur. Palpation. — In the majority of cases the spleen is appreciably enlarged, and may even be felt below the costal margui. From the onset the pulse shows decided acceleration, and during the eruptive stage the beats wHl be found to number between 120 and 140 a minute. In those cases in which the nervous manifestations are prominent the pulse may be even more rapid, and is always weak, irregular, and shows a tendency toward dicrotism. There is tenderness oyer the shin bones and over various localized areas of the sub- cutaneous tissue. Embolic abscesses may also be present. Tenderness TYPHUS FEVER. 761 along the course of the nerve-trunlts is a rare finding, and indicates the exis- tence of neuritis. Gangrenous processes of the extremities may also follow extensive neuritis. Percussion may show the area of splenic and hepatic dullness to be moderately increased. Auscultation. — ^The heart-sounds are rapid, and in severe cases the first sound becomes greatly enfeebled with the progress of the disease. Both fine and coarse relies are heard over both lungs, and hypostatic congestion at the bases may be responsible for increased bronchial sounds over this area. Since bronchopneumonia is so commonly seen during the course of typhus, it is important that a physical examination of the lungs be made daily during the entire febrile period. I^aboratory Diagnosis. — The urine is scanty, of high specific gravity, high color, and may contain a moderate amount of albumin. In severe types of infection nephritis develops as a complication, and red blood- cells, leukocytes, casts, and albumin are present in the much-concentrated urine. The vomiting of blood is an occasional symptom, and the spitting of blood that accumulates about the teeth as the result of ulcers of the buccal mucous membrane is an occasional feature. Illustrative Case. — B. B., male; sailor by occupation, and native of Norway, landed at Philadelphia in 1897 with a history of having been sick for three dajrs. He was removed to the Philadelphia Hospital, where he came under our care for thirty-six hours, during which time — the fourth day of his illness — he developed a typical petechial eruption. Slight cough and the general evidences of bronchitis were present. The temperature ranged between 102° and 103° F. There was complete anorexia. Owing to the patient's inability to speak English, no satisfactory history of a chill was obtained. The following day he was removed to the Municipal Hospital, and from this time nervous symptoms, beginning with maniacal delirium, were well marked. The expression soon became greatly dulled, and the once flushed cheeks assumed a dusky hue. The condi- tion terminated in coma, and continued until death, which occurred on the tenth day of the illness. Autopsy showed nothing of special pathologic importance beyond hyper- plasia of the abdominal lymph-nodes and dilatation of the heart. Summary of Diag^nosis. — The presence of an epidemic or a clear history that the patient has recently dwelt in a district in which typhus fever prevailed is of great clinical significance. A further knowledge of residence amid unhygienic surroundings (see Predisposing and Exciting Factors, p. 757) is also to be carefully weighed in all diseases in which there is a pe- techial eruption. Prior to the development of the eruption the diagnosis is, as a rule, doubtful, but the sudden onset with chill, the rapid rise in tempera- ture, which remains of the continued type, together with fairly well-marked nervous symptoms and the presence of an eruption by the fifth day, makes the diagnosis positive. Differential Diagnosis. — It may become necessary to distinguish between typhus and epidemic cerebrospinal meningitis. The latter con- dition differs from the former in that the headache is usually more intense, there is rigidity of the muscles of the neck, with some retraction of the head, hyperesthesia, intolerance of light and of sound, strabismus, and a tendency to convulsions. Lumbar puncture and a bacteriologic study of the cerebro- spinal fluid also give positive results in cerebrospinal meningitis. (See Meningitis, p. 841.) In those cases of tj^hus fever in which nephritis is present as a complica- tion it may be necessary to distinguish between complicated typhus and the pure nephritic condition with uremia. A diagnosis of uremia may be 762 ACUTE INFECTIOUS DISEASES. made largely from the clinical history, headache having lasted over a pro- longed period. Uremia rarely develops in those who have been in perfect health, whereas typhus may attack practically any one. In uremia the temperature is seldom, if ever, as high as it is in typhus, and the fever does not fall by crisis. In uremia an analysis of the urine always reveals positive findings. The eruption also serves as a decisive point between typhus with nephritic complications and nephritis. Malignant measles bears a somewhat close resemblance to typhus fever. In the former the eruption appears first upon the face and then spreads to the trunk and extremities, whereas in typhus the eruption is first seen upon the trunk and may even spread to the extremities, the face being but spar- ingly affected. Koplik's spots are a precursor of measles and are unknown to typhus. Typhus fever is distinguished from typhoid fever by the abrupt onset and the high temperature by the end of the second day; the termination of the fever by crisis, together with the presence of a petechial eruption, is usually sufficient to rule out the existence of typhoid (see p. 753) and to establish that of typhus fever. Clinical Course. — ^This will be found to vary greatly in individual cases with the severity of the type of infection present. Uncomplicated cases show a tendency to go on to recovery after the fifteenth to the seventeenth day, and convalescence is usually uninterrupted. MUd forms of the disease are not attended with grave symptoms during any part of their course, and in these cases convalescence is often established by from the eighth to the twelfth day. In those countries in which t}^hus fever is common we find a mortality-rate of from 10 to 20 per cent. This rate is influenced largely by the frequency of complications in a certain epidemic. Relapses. — Relapses are extremely rare, and in practically all cases one attack establishes immunity for life. MALTA FEVER (Mediterranean Feverj Undulant Fever). Definition. — An acute infectious disease caused by the micrococcus mehtensis. No characteristic pathologic lesions have thus far been identified with this disease, although splenic enlargement and enlargement of the mesenteric lymph-nodes have been foimd. Clinical Remarks. — Irregular fever, muscular pains, marked pros- tration, profound sweating, and a tendency to relapses are the clinical char- acteristics of this disease. Clinical Varieties. — (1) Pernicious Malta fever is a type of the disease that is somewhat unusual in Mediterranean districts, but when it occurs, usually tends toward a fatal termination. (2) The undulant type is characterized by a repetition of exacerbations of fever that develop at irregular intervals. (3) The continued type of Malta fever, in which the febrile period per- sists for weeks and even months without well-marked intermissions. Exciting and Predisposing Factors. — Bacteriology. — ^The mi- crococcus melitensis is found in the blood and other tissues of those suffer- ing from Malta fever. The spleen particularly contains may of these cocci. Pure cultures of micrococcus mehtensis, when introduced into apes, is capable of producing toxic symptoms. European students have also found this micrococcus in the blood, imlk, and urine of the goats in infected regions. A residence along the shores of the Mediterranean Sea appears to be the most MALTA FEVER. 763 potent predisposing factor. The disease has also been found on the shores of the Gulf of Mexico and in the West Indies. It is occasionally transported along the lines of commerce, Musser and Sailer having studied a case in Philadelphia which originated in Porto Rico. The exact mode of infection is thus far somewhat questionable. The majority of investigators believe it is transmitted by using the milk of infected goats. The urine of those affected has l^een shown to contain the coccus. The theorj- / ' &^* has been offered that the disease / ' ,^^.1"' may be transmitted to man through the Ijites of a certain mosciuito. Period of Incubation. — The / ,' ". W ^' length of the incubation period *"•.. jsr%,>« •* \ ^ fluctuates greatly, and varies be- 1 .''.^^v' r"'v *•*♦•. ^■ tween that of a few days to twenty \* -'•-.'''••.. ^ *, '^ or even thirtij^ days. . ' » ^ » ^ * ' Principal Complaint.— ..., ^^''>'^ih. The symptoms develop gradually, -^'"^v, ^"^ ' ^ and, indeed, the early stage of •* '-^ Malta fever resembles closely that ^,^ •> "'%' of beginning typhoid. There are - •'^ ^ headache, malaise, moderate fe- Fig. 282. — Miorooocccs Melitensis (Jordan), ver, complete anorexia, occa- sionally slight chilly sensations, and mild attacks of shivering. Epistaxis may be an early symptom. There is, as a rule, well-marked constipation, and the stools may be streaked with blood. Diarrhea may occur in those cases that show marked prostration. Relapses are frequent, and, as a rule, last for from five to six weeks. The afebrile periods last for one or two weeks, during which the patient enjoys fair health. In each attack rheumatic pains may be sufficiently severe to prevent movement of any kind. Following the first relapse the condition may go on to recoveiy, or within a period of one or more months there may be another repetition of the febrile exacerbation. Thermic Features.— The fever is of the remittent type, and per- sists for one, two, or probably three weeks, when there is an absence of fever for two or more days, the period of apyrexia being followed by a relapse, when the fever continues high (100° to 10.3° F._), as in the initial paroxysm. In grave cases the temperature may be continuous rather than remittent, and when hyperpyrexia occurs, the outlook is grave. In selected cases the tem- perature may be decidedly irregular, in which case its diagnostic significance IS lost. Physical Signs. — Inspection. — The expression is somewhat anxious, the movements are sluggish, and when the muscular pains are severe, the patient may remain in one position. Palpation. — The spleen is tender, and may even be painful upon firm pressure. During the early stage of the disease the pulse resembles that of typhoid fever. Percussion shows the area of splenic dullness to be enlarged. I^aboratory Diagnosis. — A differential leukocyte count shows the polymorphonuclear elements to be increased. With pure cultures of the micrococcus melitensis the serum from persons suffering from Malta fever will be found to give a typical agglutination reaction. (See Serum-reaction, p. 343.) Blood culture will give a pure growth of the organism. 764 ACITTE INFECTIOUS DISEASES. Summary and Diflferential Diagnosis.— This is based largely upon the residence of the patient in districts known to be infected with Malta fever. The insidious onset, remittent temperature, and the tendency toward relapses serve to differentiate this condition from typhoid fever, although in the early stage of the disease a differential diagnosis is quite _ impossible, except upon application of the agglutination test. Polyarthritis and, at least, soreness in the region of the articular surfaces are features that strongly support the existence of Malta fever. Clinical Course. — ^The disease is of long duration, the febrile periods alternating with periods of apyrexia for two, three, or four months. RELAPSING FEVER (Febris Recxjrrens). Pathologic Definition. — An acute infectious disease caused by Spirochaeta recurrentis, and characterized by cloudy swelling of the heart, liver, and kidneys when death occurs during the febrile period. There may be hemorrhagic infarction of the viscera and extravasations into the serous sacs. The spleen is, as a rule, enlarged, but varies greatly in size in different cases. There is hyperplasia of the lymphoid elements of the bone-marrow, and occasionally the viscera, skin, and mucous surfaces are jaundiced. General Remarks and Parasitology. — In 1873 Obermeier first detected in the blood of man, then suffering from relapsing fever, a peculiar organism which has since been named the Spirochaeta recurrentis. Orig- inally, the spirillum of Obermeier was regarded as a true bacterium, but of recent years Schaundinn has classed it among the protozoa. Clinical Varieties. — Relapsing fever will be found to vary greatly in different individuals, a feature that is probably explained by the peculiar type of infection in a given case; consequently very mild cases occur, that consist of only one or two brief febrile periods. The so-called "bilious typhoid" is the other extreme in the clinical tj^es of relapsing fever. In this variety the symptoms are unusually severe, and the patient is likely to faU into the typhoid state, and, in addition, to develop jaundice, hemorrhage from the stomach and the bowel, and the symptoms of uremia with sudden coUapse. Septic and pyemic processes, including the deposit of septic emboli in different portions of the body, may be observed. Exciting and Predisposing Factors. — ^Relapsing fever is due to an infection with Spirochaeta recurrentis (Spirochaeta duttoni). Button and Todd found the horse-tick (Omithodorus moubata) (Murray) (Fig. 283), to be the intermediate host of the spirilla causing this disease. These ob- servers permitted the horse-tick to bite infected human beings, and subse- quently these infected ticks were foimd capable of transmitting the disease to monkeys. The above observations have been confirmed by Koch, Ross, and others. Age serves as quite a prominent predisposing factor, since the majority of those attacked are found to be between the twelfth and the twenty-fifth year. The disease is also more common in males than in females. Principal Complaint and Symptoms.— Following the period of incubation, the symptoms develop abruptly, with a distinct rigm-, or, in mild cases, a succession of mild chills. Extreme frontal headache is constantly complained of, and there are also -pains in the back, loins, and limbs, and extreme prostration and vertigo. The throat is often sore, and there may be considerable difficulty in swaUowiag. Anorexia becomes complete early RELAPSING FEVER. 765 te'cor^n^nTT °^ *'^V"^^^Y!' -""^ nausea, vomiting, and inordinate thirst aie common. Constipation obtains durnig the prodromal stage After the crisis the patient's general vitality is at a low eljl) conse- quently profuse sweating, menorrhagia, and intestinal hemorrhage may SkHtyaft^S^SiJ^l^^i""'^^^"^ ^^'"P*°"^^ ""'^^''^ -^ ^-^* FlQ. 283.— Ohnithodorus Mons.tTA. Tick th.^t Transmits African Relapsing FeVer. u, \'iewed from above; b, viewed from below (Murray and Doflein). Nervous Manifestations.— These are, as a rule, mild in character, al- though headache may persist for several days, during which time the patient IS more or less stupefied. Delirium is not usual in uncomplicated cases, although it may set in just prior to the crisis. In the average case the pa- tient may remain conscious throughout the attack. Fig. 2S4. — Relapsing Fever (Register). _ After an afebrile period, lasting about one week, all the symptoms pre- viously outlined are repeated, but with lessened severitv than during the mitial paroxysm. Thermic Features.— The temperature rises somewhat rapidly after the chill, reaching an elevation of 102° to 106° F. bv the end of the first or durincr 766 ACUTE INFECTIOUS DISEASES, the second day. The temperature is of the continued tj^pe for a period of about six days, when, just priorto tlie crisis, thefever may suddenly rise one or two additional degrees. This hyperpyrexia is a common precursor of the crisis, and is soon followed by a rapid fall to, or in many instances below, the normal. (See Chart, Fig. 284.) Each succeeding attack of fever is of shorter duration and milder in character than the preceding attack, and four or five such exacerbations may occur. Physical Signs. — Inspection. — The skin becomes pigmented and dusky in appearance and sooner or later acquires a dirty yellow tint, a con- dition that is frequently referred to as bronzing. The cheeks are flushed during the febrhe period, the eyes appear somewhat sunken, and the face is often beaded with perspiration; indeed, in certain cases sudaniina may be an annoying feature. Peculiar cutaneous eruptions are occasionally present, but are in no way characteristic of relapsing fever. Herpes labialis may be a common feature in certain epidemics, whereas in others it is practically absent. The tongue is at first covered with a moist, yellowish fur, but as the fever rises it l^ecomes brown, dry, and fis- sured, and sordes accimiulate al^out the teeth. Numerous small ulcers may be seen along the margins of the gums and upon the tongue, and con- gestion of iDoth the tonsillar and the pharyngeal mucous membrane is likely to be present. The frequency of the chest movements may be some- what increased, and the chest-wall may he seen to pulsate violently as the result of cardiac palpitation. Palpation. — The pulse is found to be increased in frequency whUe the temperature is rising, although this increase is seldom in direct pro- portion to the heightened fever. At first the pulse is full and strong, the beats numbering from 100 to 120 or of infection the pulse may exceed irregular, and even dicrotic. Fig. 285. — Spirochete o IN Human Blood (> Relapsing Fever 1000) (Boston). even 140 a minute. In severe types 140 beats a minute, and become weak. During the febrile paroxysm there is usually tenderness over the epi- gastrium, and even gentle pressure over the trunk elicits tenderness; cer- tain portions of the cutaneous surface also, as well as certain groups of mus- cles, may be hyperesthetic. On placing the hand over the precordium, the heart may often be felt to pulsate violently, and moderate excitement may mduce an attack of palpitation. Palpation over the region of both the liver and the spleen may show these viscera to be moderately enlarged. Percussion.— The area of hepatic and of splenic dullness may be moder- ately increased. Auscultation.— The sounds of the heart are, as a rule, full and strono- even though the pulse may be 120 to 140. In severe cases an appreciable portion of the muscular element of the first sound of the heart may be missing at the time of the crisis. A systolic murmur, probably hemic in character, IS occasionally audible over the heart. The physical signs of bronchitis are commonly present, and lobar pneumonia and hypostatic congestion are among the usual complications. YELLOW FEVER. 767 I/aboratory Diagnosis. — The vomitus is, as a rule, greenish in color, although at times it is black, and contains large quantities of bile; rarely do we find red blood-cells. The urine is highly colored, of high specific gravity, and may contain a trace of albumin. When jaundice is associated, which is quite a common occurrence, the urine is rich in bile and displays a heavy yellow froth. Blood obtained from the finger-tip or from the ear during the febrile period will be found to contain the spirochete. (See Fig. 285.) The spiro- chaeta may be readily studied in both the fresh blood and in stained prepa- rations. Summary of Diagnosis.— A history of an epidemic, or of the patient having recently resided in the tropics, together with the sudden onset, the continued type of fever with an abrupt termination on the seventh day, would strongly support the existence of relapsing fever. Again, the charac- teristic interval separating the febrile periods is known to no other disease. Examination of both the fresh and the stained blood during the febrile period makes the diagnosis positive through the detection of the organism. Clinical Course. — The duration of relapsing fever depends entirely upon the number of paroxysms the patient may have; hence should there be a single relapse, the febrile period will continue for but from twelve to sixteen days. In complicated cases, and particularly when lung and kidney complications are present, convalescence may be greatly delayed and con- tinue over several weeks. A fatal termination is seldom witnessed unless one or more serious complications are present. YELLOW FEVER. Pathologic Definition. — An acute infectious disease (epidemic and endemic), transmitted to man through the bites of infected mosquitos. The liver is anemic, although when death occurs early, the organ may be congested. It is pale yellow in color, and at times may have an orange hue. Punctate extravasations make the organ appear mottled. Fatty degenera- tion of the hepatic cells is the rule, although sections made from certain por- tions of the organ may be practically normal. The gastro-intestinal mucous membrane is the site of an acute catarrhal inflammation. The serous sur- face may display punctate hemorrhages, and hemorrhagic infarctions are frequently present in the solid viscera. The kidneys show the pathologic changes characteristic of acute diffuse nephritis (see p. 661) and the heart muscle is the seat of fatty degeneration. There is extensive fatty degenera- tion of the walls of the blood-vessels, and the red blood-cells are often dis- integrated and are found to have given up their hemoglobin. Clinical Varieties. — Several clinical varieties of yellow fever have been described, and each of these is characterized by the presence of one or more of its prominent features. Finley's classification of the disease per- mits of the following distinctive clinical types: (1) Acclimation fever or non-albuminuric yellow fever; (2) plain albuminuric yellow fever; and (3) melano-albuminuric yellow fever, characterized by the presence of blood or "black vomit" in the stomach or intestines. Predisposing and Exciting Factors. — Among the predisposing factors, season figures most prominently, yellow fever prevailing chiefly during the summer months; epidemics are, as a rule, arrested by the approach of frost. Age is also an important factor, since children are more susceptible to 768 ACUTE INFECTIOUS DISEASES the disease than are adults, because in a yellow fever district the adults are immune on account of an attack of the disease during childhood. Sex has a feeble influence, males being more often attacked. Race. — ^The disease is more common in white than in colored individuals. One attack establishes permanent immunity, so that the natives of a district in which yellow fever is endemic are less Hkely to develop the disease than a newcomer. The suggestion has been made that the native children develop yellow fever early in Hfe, and consequently have established an immunity before puberty. Exposure to Mosquitos. — In 1881 C. J. Finley pointed out that this disease was transmitted through the agency of the mosquito. It remained for the commission of the U. S. Army, made up of Drs. Reed, Carroll, La- zear, and Agramonte to furnish incontestable experimental proof that yellow fever is a mosquito-borne affection. These observers have shown that the Stegomyia calopus is probably the only carrier of the infecting agent. Twelve days after biting a yellow fever patient the bite of the mos- quito will infect a non-immune person. The insect is capable of infecting man for a period of several weeks. There is some evidence to show that the mosquito (once infected) is capable of transmitting the parasite for the remainder of its life. The patient's blood infects the mosquito only during the first three days of the disease. The clothing, vomitus, urine, and feces are believed to be non-infectious. The Stegomyia calopus has been found as far north as Philadelphia, and southward to the Rio de la Plata river; it is prevalent in Cuba. The larvae develop only in artificial collections of comparatively clean water, and this mosquito seldom breeds far outside a city's limits. Yellow feevr is thus a domiciliary infection. Both insects and larvae are killed by freezing. They inflict their bites principally late in the afternoon. They are not capable of long flights. Not all mosquitos that bite a yellow-fever subject become infected. They either fail to secure the parasite, or the parasite does not subsequently develop. Period of Incubation. — ^This varies from two to five days, and possibly a longer period may be required. During the stage of incubation headache, languor, and a poor appetite may be present. Clinical Stages. — Stage of Invasion. — Principal Complaint. — Given an average case of yellow fever, the onset is abrupt, being ushered in by a chill, which is seldom severe, and practically never prolonged. Fol- lowing the chill the patient complains of feeling hot, of headache, of distress- ing pains in the loins and legs, and later he becomes extremely restless, with some confusion of ideas. Photophobia is an early annoying symptom, and vomiting is common. The patient usually complains of a burning sensation and of _ marked oppression in the region of the epigastrium. The duration of the initial symptoms will be found to vary between six and eight hours in ordinary cases, although it may continue for two or three days, and a longer period has been observed. The stage of invasion is often unusually long in mild types of the disease. With the termination of this stage there is an appreciable subsidence of the fever and of all the symptoms and signs pre- sented by the patient. Nervous Symptoms. — In addition to the restlessness previously men- tioned, the patient may manifest well-marked dehrium, and maniacal out- breaks occasionally develop. Thermic Features. — Following the initial chill the temperature rises some- what abruptly to 103°, 104°, or 105° F. After the temperature has attained YELLOW FEVER. 769 its greatest height, it declines by lysis, showing slight evening exacerbations and morning remissions. Physical Signs. — Inspection. — The face is flushed, and soon gives evidence of jaundice, yellow pigmentation of the skin being the most characteristic sign of the disease. The eyes are markedly congested. The tongue may be furred, although this is by no means a constant finding. Palpation. — Abdominal tenderness is present, and firm pressure may elicit pain over the epigastrium. The relation of the pulse-rate to the tem- perature is an important diagnostic feature of yellow fever. This relation is seen imiformly in no other disease. As the temperature rises the pulse falls, so that it is frequently observed that a patient with a temperature of 104° F. or over will have a pulse-rate of 80 or lower. As convalescence progresses the pulse may fall to 50 a minute or below. In fatal cases there is either a progressive rise in the pulse-rate over several days, or a sudden rise for a few hours before death. Stage of Remission. — Following immediately upon the termination of the initial stage, convalescence may begin, and go on to recovery without interruption. -In the majority of cases, during this stage the patient displays certain symptoms and signs of impaired health, e. gf., prostration, jaundice, and choluria, all of which are likely to continue during the first twenty-four hours, at which time, unless convalescence is established, another more serious exacerbation — the stage of secondary fever — ^begins. Stage of Collapse (Secondary Fever) .^ — Here the patient's general condition is that of extreme prostration, the various signs of collapse being manifest. Nervous Symptoms. — Grave nervous symptoms, convulsions, coma, and the general clinical picture of uremia may be seen during this stage of the disease, and when present, are usually attributed to an associated nephritis. Physical Signs. — Inspection. — The features are pinched, the skin has a peculiar yellow or bronzed tint, and there may be numerous minute cutaneous hemorrhages. The expression is dull, the tongue is dry, brown, and often blackish in appearance; but in some cases the surface of the tongue may be smooth, bright red, and deeply fissured. The teeth and lips are covered with sordes. Palpation. — The surface of the body is cold. The pulse becomes weak, rapid, soft, irregular, and compressible. In certain instances in which the degree of infection is unusually severe the pulse may be slow and the beats not exceed 20 to 30 a minute. I^aboratory Diag^nosis. — During the initial stage the vomitus may be blood-streaked, or contain chocolate-colored particles of blood-clot. Rarely, indeed, does the patient vomit pure blood before the stage of re- mission. During the stage of collapse there is likely to be hemorrhage into the stomach, when the blood is ejected with the gastric secretion — the so-called "black vomit." Occasionally pure blood that has been unchanged by the gastric secretion is vomited. Blood is also expelled by the bowel, and, as a result, the stools are tarrj'. In severe types of yellow fever hemorrhage from the nasal and uterine mucous membranes is not unusual. The quantity of urine voided is usually decreased, even during the initial stage, and the fluid is of high color and of high specific gravity. During the stage of collapse the quantity excreted will be found to be much smaller than normal. The urine is bile-stained, displays a rich yellow froth, and may con- 49 770 ACUTE INFECTIOUS DISEASES. tain albumin, red blood-cells, and casts. In those cases complicated by- nephritis, anuria may be present. Summary of Diagnosis. — In formulating a diagnosis!* during the initial stage of yellow fever the following points should be carefully weighed: The existence of an epidemic, a sudden onset with a mild chill, pain in the back and loins, cephalalgia, slight yellowing of the skin, nausea with the vomiting of bile-stained material, and the characteristic pulse (t. e., a gradual decrease in the rate of frequency while the fever continues to rise); all these strongly favor the existence of yellow fever. During the third stage the diagnosis is comparatively easy, and is based upon the presence of severe jaundice, black vomit, the high color and dimin- ished quantity of the urine, together with the signs of collapse. In a mild type of yellow fever the diagnosis is often made with great difficulty, since the febrile period may last but one day. Differential Diagnosis. — See Differential Diagnosis of Dengue, p. 886. LOBAR PNEUMONIA (Croupous or Fibrinous Pneumoniaj Pneumonitis! Lung Fever). Pathologic Definition. — An acute infectious disease, usually ex- cited by the micrococcus lanceolatus, which produces a specific inflamma- tion resulting in consolidation of the lung. This inflammatory process is divided pathologically into three stages: (1) Stage of congestion; (2) stage of red hepatization; and (3) stage of gray hepatization. (1) Stage of Congestion. — Upon opening the chest, the portion of lung involved is seen to be dark red in color and somewhat firm to the feel, al- though it does crepitate. From the cut surface blood-stained serum oozes, and the capillaries are engorged with blood. Excised pieces of the lung float when placed in water. Microscopically, the alveolar epithelium is swollen, the capillaries are markedly distended, and the air-cells contain alveolar epithelium, red corpuscles, and a few leukocytes. The smaller bronchi may also contain some exudate. The duration of this stage is ordinarily from twelve to twenty-four hours. (2) Stage of Red Hepatization. — Here the involved area of the lung is solid to the feel, resembling in this respect liver tissue (Fig. 286). In- cised portions of the diseased organ do not crepitate and sink when placed in water. The cut surface of the lung is reddish-brown or of a mahogany color, and its surface is dry and somewhat mottled. The diseased part of the lung is larger than normal, and when the consolidation extends to the surface of the organ, indentations corresponding to the ribs are seen. Dur- ing this stage the diseased lung is airless, nor can it be inflated from a bron- chus. Thin slices of the diseased organ break readily, and the broken sur- face is more or less irregular and finely granular in character; by scraping the back of a knife over this irregular surface, minute plugs, composed of the inflammatory exudate, are dislodged from the alveoli. The dry exu- date occupying the air-cells soon softens, and in such instances a viscid fluid flows from the cut surface of the organ. The visceral pleura overlying the affected lung is covered with a fibrinous exudate. Effusion into the pleural sac is not unusual. Microscopically, the air-spaces are found to be filled by a fibrinous exudate which contains red blood-corpuscles, leukocytes, and alveolar epithelial LOBAR PNEUMONIA. 771 cells. At times the interlobular connective tissue shows infiltration. The pneumococcus is invariably present, and staphylococci and streptococci may also be seen. (3) Stage of Gray Hepatization. — With the beginning of this stage the fibrinous exudate loses its mahogany color and becomes grayish or granite- like in appearance (Fig. 287). There is now extensive fatty and granular ilegeneration, with softening of the inflammatory exudate, and from the cut surface of the diseaseil lung a yellowish-white, and at times almost puru- lent, frothy liquid exuiles. The pleura overlying the diseased lung is covered with fibrinous exudate. Microscopicalhj. the air-cells are found to be almost entirely filled with leukocytes, which is in striking contrast to the second stage of the disease, in which they contain red blood-cells, white blood-cells, and fibrin. Fir:. 2S6. — .4cutk Lobar Pneumonia (Second STAr.E). In unfavoralile cases there may be purulent infiltration of the lung tissue with extensive necrosis, or, as is occasionally seen, an absce.ss may develop. Resolution may be delayed, and the pulmonary condition remain imaltered for a variable time. Fibroid induration (see Chronic Interstitial Pneumonia, p. 113) may also be present in some cases. Certain pneumonic conditions in which resolution is delayed may be found later to be of a tuberculous nature. Pericarditis is present in a small proportion of cases, but endocarditis is more common. Clinical Varieties. — (o) The usual type of the disease will be u ------^^^^-— — ^^— — ^^i I > o > --•-----?'' p. M. TEMP. 108 107 106 105 104 103 102 101 100 99 NORMAL 98 97 > ■>- - — r-- ""^ ffl ~-, ~~'--^ t> ;::::::::::::::::::: :::5:;:::::::::::;::5" * '' ) ^^ '' ^. s • "^ ~- 4- s . _.^N. - - ^^"., a. .^- ::.._- ;:; - -^ ■=, V ' - - ' " ,'' ,'■*"' *-~ ^ $ :=■ ffl ^ * — ^ - 3 - --- - _S,^-_--_ ,''"' ' :::::::::;'::::::::::::::: :::^. ::::::::::: ■- , - < ::::: :: i.-.c: : :::i ^ i:^ ''v . ,._. _..;•_ _ - ..s . ^,- ,.---, --,- " -1 C- --- - - o - - ^ j-^^ .t £ ^::C) ■' ^ -.- a, - - *" '- ^ -.. ■^ - i ':■ - -- - ffl It" '^ IE;::.. « 5 --'-'''' " , " ^-'^ t> 1 . 4--r' ■ '-'~ ^ " " «3" r -■ o "*■- -^ -^^^ ~ z ~~---> " ~'~~ ^ * "? - = - = : -_ _ -_- " . :::::^::::::::::::: i^ *- " ^-__ ^,^ -^ 0= -•-... « ■ =- ^ ^ :::::::::_ _,,=[ - :. -= .1 = "" , "■ ■^ >< 5 r : 0) ? - ;,f -- _ r^ - - 2 " ______ -, ::::::::::::::::::::::____ ■^ X '^ - 1 ffl i\ ; :: « >..,---= . .- ;• __ " -'....'.'.'.- - " of one side of the abdomen may be present in pneumonia, and this is_ es- pecially true when the pain is reflected over that portion of the abdominal surface. 778 ACUTE INFECTIOUS DISEASES. Thermic Features. — The fever rises rapidly during the initial chill, so that ia from eight to ten hours the temperature reaches 102° to 105° F. It then remains high imtil the crisis, pursuing the continued tj^ie, with sHght nocturnal remissions of one or more degrees. In children, following the convulsion that commonly ushers in an attack, the fever rises rapidly, but seldom becomes so high as it does in the adult. The temperature has a lower range in the debiHtated, in aged persons, and in alcoholics than it has in previously healthy adults. On the fifth to the seventh day of the disease a pronounced fall of temperature may be observed, — the pseudocrisis (Fig. 288), — but the temperature again rises to its former height. This clinical feature may be seen before the fifth day, however. In rare instances a pseudocrisis may be seen more than once, and the temperature-curve bears a strong resemblance to the remittent or the intermittent type of fever. The temperature may be unusually high, — 106° or 107° F., — and such striking elevation is at times a precursor of the crisis. In certain cases hyperpyrexia may be a danger-signal. The characteristic fever of pneumonia terminates by crisis. The crisis may occur at any time from the end of the third to the fourteenth day, but in the majority of instances it occurs on the seventh or the ninth day. The temperature usually falls dur- ing the night, and the drop is accompanied by copious perspiration, so that by the following morning the thermometer is found to register normal, or more often a subnormal point — 98° to 95° F. The duration of the period of decline is usually from eight to twelve hours. It may be much shorter, but is commonly longer. When the temperature terminates by lysis, the clinician should suspect the existence of some com- plication. Following the crisis, in imcomplicated cases the respirations and the pulse-rate soon return to the normal. Cardiovascular Phenomena. — A careful study of the heart and pulse is an important point to be observed in pneumonia. The average pulse- rate in typical cases varies between 100 and 110 beats a minute, and when the beats exceed 120 a minute, there is sufiBcient cause for alarm. A marked increase in the pulse-rate within the course of twenty-four hours is believed to depend upon the action of toxins upon the heart or upon the presence of some complication. The pulse is, as a rule, small at first, a feature commonly seen when there is extensive consolidation; later, however, it becomes full and bounding, although at this time the pulse tension may be low. Dicro- tism, together with an irregularity in both volume and rhythm, is an \m- favorable feature, and may develop either before or after the crisis. The pulse will be found to vary greatly, depending upon the individual charac- teristics of the patient; e. ^., in feeble individuals the general characteristics may be absent throughout the course of the disease. The heart-sounds are in themselves fairly characteristic of this disease. (See Auscultation, Phy- sical Signs, p. 779.) Physical Signs. — For convenience of study, the physical signs have been arranged in the order in which they are presented during the successive pathologic stages of the disease. Stage of Congestion. — In the majority of cases the physician probably does not see the patient imtil after this stage has passed. When the patient is seen early, however, the following physical signs may be elicited: Inspection. — The movements of the affected side of the chest are often slightly restricted, especially if the base of the limg is involved, and upon mensuration it is found that expansion of the affected side is limited. If the patient is suffering from a double pneumonia, the costal type of breathing LOBAB PNEUMONIA. 779 may be seen, and pronounced movements of the abdominal muscles are also present. The face is flushed, and the so-called mahogany flush may involve the cheek of the affected side; the conjunctivas are also at times suffused The hps may, though rarely, show the beginning of herpes. The nostrils play violently, even though the degree of consolidation be but slight, and the patient frequently breathes with his mouth open. Palpation.— It may be possible to detect slight diminution in the move- ments of the affected side of the chest, and tactile fremitus is somewhat in- creased over the congested area. If the area of congestion is localized at the center of one lung, palpation gives negative results. Percussion.— The note may be normal over both lungs; as a rule, how- ever. It IS slightly shorter than normal, somewhat higher pitched, and, sur- rounding the congested area, it is tympanitic. Auscultation. — It is quite common for the inflammatory products to oc- cupy the smaller bronchi ; consequently subcrepitant rdles are usually audible over the area of congestion. The crepitant rdle is also heard during the latter part of this stage. The breath-sounds, while usually weak, are at times bronchovesicular in character, and especially so when the patient is directed to inspire deeply. The breath-sounds are slightly exaggerated over the affected lung. _ Stage of Consolidation. — Inspection. — If a large area of one lung is involved, the movements of the chest on the affected side are greatly dimin- ished, whereas on the unaffected side they are appreciably increased. Ex- ceptions to this general rule are quite common, and this is especially notice- able when the patient rests upon his back. If the greater portion of the base of one lung is involved, mensuration will show that side of the chest to be larger than the opposite, despite the fact that there is compensatory emphy- sema of the healthy lung. There may be abdominal distention. The face may still be flushed, the nostrils play violently, and the respira- tions may number between 40 and 60 a minute in the adult, and between 60 and 80 in children. In persons older than sixty years suffering from pneu- monia the respirations may not be greatly increased. At this time herpes labialis, involving the angles of the nose and lips, is quite common, and the lips are often dry and fissured. The tongue is heavily coated, and late during this stage it may become deeply fissured; its center is covered with a heavy yellowish or brown coat. Swelling and redness in the region of the large joints may be present, and indicate involvement of the synovial sacs. Palpation confirms inspection with reference to the expansion of the two halves of the chest. Tactile fremitus is increased in the majority of all cases, although in exceptional instances fremitus is diminished, and in the case of massive pneumonia, or when there is considerable pleural effusion, it may be absent. A distinct friction fremitus is often detected during this stage of the disease, and is due to involvement of the pleura. The abdomen is rather tense. (See Abdominal Tension, Figs. 201, 225.) The pulse is full, the beats numbering from 100 to 110 a minute, although great variation will be found in different cases. (See Cardiovascular Char- acteristics, p. 778.) Percussion. — Dullness will be found to vary at different times during this stage; e. g., before the lung is completely consoHdated a somewhat tympanitic note is obtained, but after complete consolidation has occurred, the note is flat. When the base of the lung is involved, absolute dullness is more commonly found posteriorly and in the axilla than upon the anterior surface of the affected side. Indeed, it is not uncommon to find dullness over the 780 ACUTE INFECTIOUS DISEASES. posterior portion of the lung, and a varying degree of tympany at the same level anteriorly. Considerable importance attaches itself to the degree of resistance offered to the pleximeter finger. If pleural effusion is present, the note over the affected side may be fiat, especially at the base of the chest, but the sensation offered to the finger placed against the chest-waU is de- cidedly different in the case of fluid in the pleural sac and when there is only consolidation of the lung present. In the case of a pneumonia developing at the center of the lung and advancing toward the periphery, the lung tissue surrounding the consolidated area is emphysematous, and may be interposed between the hepatized tissue and the chest-wall, in consequence of which a hyperresonant note is obtained upon feeble percussion, but upon deep per- cussion over the same area dullness may be elicited. Dullness appears to be a less conspicuous feature in the pneumonia of the aged. When there is an extensive pneumonia at the base or apex of one lung, the uninvolved portions of the lung may display skodaic reso- nance. The abdomen is moderately tympanitic. Auscultation. — The characteristic breath-sound is that of bronchial or tubular breathing, and is heard over the consolidated lung, especially when consolidation extends to the visceral pleura. When the large bronchus lead- ing to the consolidated portion of the lung is plugged with exudate, as is the case in the so-called massive pneumonia, bronchial breathing is absent. The voice-sounds are exceptionally well transmitted over the consolidated tissue, consequently bronchophony is obtained over the pneumonic area, but, as in the case of bronchial breathing, it, too, may be absent in some cases (plugging of the bronchus). In certain instances the sound conveyed to the ear is egophony. The whispered voice is also transmitted well over the consolidated area, consequently pectoriloquy here resembles the sound ob- tained over a pulmonary cavity. Subcrepitant rales are present, and probably depend upon the associated bronchitis, and the crepitant rdle may be audible at the end of inspiration, although this is more commonly heard during the first stage of the disease. A friction murmur may be present at any time during the stage of consolida- tion. Stage of Gray Hepatization. — Inspection. — With beginning resolution the exudate present in the alveoli begins to liquefy, so that air now enters them; consequently upon inspection the movements of the two sides of the chest gradually become alike. In this stage the playing of the nostrils diminishes progressively unless some complication is present. The lips, which were probably cyanosed during the stage of consolidation, gradually assume their natural color, and by this time herpes labialis tends to disap- pear rapidly. Palpation. — Tactile fremitus diminishes gradually from day to day until the normal is reached. Percussion. — The alterations in the percussion-note (e. g., dullness sur- rounded by a hyperresonant area and hyperresonance over the unaffected lung) gradually disappear, and are replaced by the normal percussion-note. It is important for the clinician to bear in mind that the percussion-note returns to the normal more slowly than do other physical signs previously outlined, and, indeed, a variable degree of impairment over the original area of consohdation may be present after convalescence is well established and after the patient is up and about his work. In those cases in which there has been extensive involvement of the pleura during the pneumonic process, the percussion-note may be impaired for an indefinite period. LOBAR PNEDMONIA. 781 Auscultation.— With the beginning of this stage, the crepitant rdle may- reappear ;_ the subcrepitant rdle, owing to the Hquef action of material in the air-cells, is also heard both on inspiration and on expiration (rale redux). Coarse bubbhng rales are heard over the bronchi. In certain cases rales are universally numerous during this stage. Bronchial breathing disappears gradually, and in its stead bronchovesicular breathing is heard, and later the normal breath-sounds appear. In those cases in which the toxemia has been pronounced, the first sound of the heart is lacking in muscular quality, whereas the accentuation of the second pulmonic sound has gradually diminished. In certain cases the heart is unusually rapid, especially after the crisis, which invariably marks the beginning of the stage of gray hepatization, and in such instances ar- rhythmia is conunon and may continue for days or even weeks. We have studied cases in both hospital and private practice in which a pericardial friction niurmur was audible during the greater portion of this stage of pneumonia. Endocardial murmurs are not common unless disease of the endocardium existed prior to the development of the pneumonia. An ex- ception to thisrule is found in those cases that develop acute endocarditis as a complication. (See Acute Endocarditis, p. 251.) The pleuropericar- dial friction-sound is also occasionally heard. (See Physical Signs of Pleu- risy, p. 139.) I/aboratory Diagnosis.— Sputum.— The patient expectorates a snail quantity of extremely tenacious, blood-streaked sputum. So marked is the tenacity of the sputum, that the cup containing it may be inverted without the contents escaping. Microscopically this sputum is found to contain the pneumococcus, which sometimes occurs in dense aggregations. Gram-positive diplococci, which are in all probability pneumococci, are sometimes found in normal sputum. In cases of so-balled Friedlander's pneumonia Friedlander's bacillus (Fig. 34) may also be present. We have examined the sputum of several cases displaying the clinical characteristics of pneumonia in which the predominant organism was the streptococcus. Many red blood-cells are present, and leukocytes and alveolar epithelium may be seen. During the third stage of the disease the quantity of sputum may be increased, but the rule is for the sputum to be scanty. Korelkin emphasizes the importance of albimiin in the sputum as a valuable feature in the recognition of centrally located pneumonia. The hematologic changes are quite characteristic, leukocytosis developing early and varying between 12,000 and 40,000 leukocytes in a cubic milli- meter. In uncomplicated cases, following the true crisis, there is a marked diminution in the number of leukocytes in a cubic millimeter. A differen- tial leukocyte count shows the increase in the number of white cells to be due chiefly to the polymorphonuclear elements. Eosinophilia is conunon after the true crisis. It is very important to remember that in extremely mahgnant types of the disease there may be a high leukocytosis, or, on the other hand, we may find that the number of leukocytes in a cubic milli- meter is below that of the normal. In average cases the hemoglobin and the red cells are but slightly, if at all, altered. When the pulmonary con- solidation is extensive and there is embarrassment of the circulation, with cyanosis of the lips, ears, and finger-tips, the number of red cells will be found to be between 5,000,000 and 10,000,000 per c.mm. The same con- dition — cyanosis — may cause the hemoglobin to register above the normal — from 90 to 120 per cent. During the third stage of the disease, and especially after the circulation has become nearly normal, there is an ap- 782 ACUTE INFECTIOUS DISEASES. preciable diminution in the number of red cells in a cubic millimeter, a reduction of 500,000 to 600,000 being common. Serum from persons suffering from pneumonia has been found to agglu- tinate the pneumococcus, but not in higher dilution than 1 : 60. In those cases showing pneumococcic septicemia and bacteriemia, the pneumococcus may be cultivated from the venous blood. The urine is that characteristic of the acute fevers; e. g., the quantity is somewhat diminished, the color is high, and the specific gravity is moderately increased— 1.020 to 1.025. A small amount of albumin is commonly present — the so-called febrile albuminuria. If nephritis develops as a complication, the urine becomes rich in albumin and contains both hyaline and granular casts, and at times red blood-cells are present. In those cases in which meningitis complicates pneumonia, glycosuria may be present. During the second stage the chlorids may be absent. Feces. — Rutz* has demonstrated that both the pneumococcus and the bacillus of Friedlander are present in comparatively large numbers in the feces of persons suffering from lobar pneumonia. The pneumococcus is commonly found after the third day of the disease. The serous sacs may become infected with the pneumococcus during the course of this disease, and in such cases the exudate obtained from the serous membrane (pleura, meninges, and synovial sacs) contains pneumococci. Illustrative Case of Lobar Pneumonia. — Family History. — Father living at the age of fifty-four; mother healthy at fifty-eight; three brothers and a sister living in apparently perfect health. No history of pulmonary disease, renal disease, or car- cinoma in ancestors for three generations. Previous Medical History. — The patient had the diseases of childhood, including diphtheria at the age of twelve, since which time he has enjoyed good health and does not recall having consulted a physician during the past five years. Social History. — The patient was a male, aged twenty-ei^ht years; he was married at the age of twenty-two and had two children living, who, with his wife, were in good health. He used no alcoholic stimulants, but drank one cup each of tea and coffee, daily. He was a traveling salesman by occupation, consequently "his work demanded considerable exposure to wet and cold; he did not take systematic exercise, had paid no attention to diet, and had always eaten hurriedly. Present Illness. — Two days before admission to the hospital he complained of a slight "cold," accompanied by moderate coryza. Twelve hours before admission he exjjerienced a severe chill, which lasted for approximately one-half hour, and following which he stated that he felt feverish and was unusually thirsty. There was lancinating pain in the left chest, and deep respiration intensified the pain. The cough was an annoying symptom; it was persistent, although voluntarily restrained, and was accom- panied by a slight amount of mucoid expectoration. Later, the sputum became tenacious in character, and presented the usual streaks of blood which are characteristic of rusty sputum. The temperature remained at 102° F., displaying but slight morning remissions until the seventh day, when, within the course of a few hours, it fell to 97° F., and re- mained subnormal for a period of four hours. Following the crisis the temperature did not rise above the normal limit during convalescence. Physical examination upon admission, and twelve hours following the chill, showed the following: General Examination. — The patient rested in bed upon his back and gave an expres- sion of pain whenever he was moved from side to side; he tended to incline toward the left side. Tho left side of his face was flushed, and there was distinct playing of the nostrils unless the patient breathed with his mouth open. Herpes of the hps and of the alse nasi was present. Local Examination. — At the time of the first examination palpation and percussion of the chest gave negative results, whereas upon auscultation a few fine crackling rales were audible over the left base posteriorly, and the respiratory murmur was somewhat exaggerated (bronchovesicular breathing). *New York Med. Jour., July 20, 1912, p. 113. LOBAE PNEUMONIA. 783 Durmg the second day of the disease, and approximately forty-eight hours follow- ing the chm, characteristic physical signs were present; e. g., the patient still elected to rest upon his back, and there was an appreciable diminution in the movements at the base of the left chest. The nostrils played freely, and the movements of the chest were rapid—approximately 40 a minute. The impulse of the heart was seen at its normal site, but the area of pulsation was greatly increased. Palpation confirmed inspection with reference to the cardiac pulsation and the rapidity and character of the respirations. The expansion of the two sides of the chest appeared to be nearly the same, except for a sUght (fiminution over the left base. There was a distinct increase in the tactile fremitus over the base of the left lung posteriorly. The jnUse was full and bounding, the beats numbering 110 to 120 a minute, and remained at this rate until the crisis occurred, although immediately after the pulse became weak, more rapid, and tended toward dicrotism. Percussion. — ^There was duUness over the lower third of the left lung posteriorly, and this dull area extended anteriorly as far as the midaxiUary line. A hyperresonant note was obtained over portions of the left lung not involved in the pneumonic process, and over the area of the right lung it was moderately hyperresonant. The area of cardiac duUness was not altered, and it was impossible to detect an increase in the area of splenic and of hepatic dullness. Auscultation. — ^The increase in the frequency of respiration was distinctly apparent over both the right and the .uninvolved portion of the left lung. Posteriorly, at the left base Oimited to the area of dullness), the breath-sounds were markedly increased and bronchial in character. During each respiratory act a peculiar grunting sound was also audible over this area, and as the disease advanced this sound was so pronounced as to be heard when standing at the bedside. A distinct friction murmur was heard over the left base on the morning of the third day of the disease, but this disappeared within the course of a few hours, and was not detected later. The heart-sounds were rapid, of good volume, and there was an appreciable accentuation of the second pulmonic sounds. Laboratory Findings. — ^The sputum was scanty, highly tenacious, and streaked with blood. Upon microscopic study the field displayed numerous dense aggregations of pneumococci. Red blood-ceUs and leukocytes were present. The urine gave a negative reaction for chlorids. An estimation of the leukocytes gave 21,200 in a cubic millimeter, and a differential count showed 82 per cent, of the white cells to be of the polymorphonuclear variety. Diagnosis by Induction from Clinical Data. — ^The histoiy of the patient, show- ing that he had been healthy for some years, the age, the recorcl of having suffered for the first few days from an acute cold, and the description of a severe chill twelve hours before admission to the hospital were of great clinical importance in formulating the diagnosis. Pain in the region of the nipple, and the fact that such pain was intensified by deep inspiration and by cough, gave positive evidence of an associated involvement of the visceral pleura. The cough in itself was somewhat characteristic, and was accompanied by a slight amount of tenacious, blood-streaked sputum that, upon micro- scopic study, was found to contain great numbers of diplococci. The temperature, which rose suddenly following the chiU and pursued a continuous type to the seventh day, when it fell by crisis, was a feature practically characteristic of pneumonia. The fact that the urine did not give a reaction for chlorids during the febrile period was con- sidered to support strongly the diagnosis of pneumonia, as did also the leukocyte count, which gave 21,200 cells in a cubic millimeter. Among the physical signs supporting the diagnosis were the following: (a) Impaired resonance over the area of lung involved; (6) bronchial breathing over the same area; and (c) transmission of both the whispered and spoken voice-sounds over the area of consolidation. Differential Diagnosis. — The existence of a cold, together with the occurrence of a severe chiU, the degree of prostration, cough, and fever, suggested the possible exist- ence of influenza, from which condition pneumonia was distinguished by the following clinical evidences: (a) Blood-streaked, tenacious sputum containing diplococci; (6) leukocytosis; and (c) the physical signs of pulmonary consolidation. Course of the Disease and Change in Physical Signs Following Crisis. — During the night of the seventh day of the disease the patient's temperature fell, within the course of twelve hours, to normal, and immediately following this crisis the pulse rose to 140 a minute; his respirations remained rapid, there was distinct cyanosis of the lips, face, and finger-tips, and the body became beaded with perspiration. All these features disappeared within the course of a few hours following the judicious appUcation of ex- ternal heat and of cardiac stimulants. Upon the eighth day of the disease the physical signs were materially altered, respirations numbered 26 a minute, and the pulse was 106. The area over which consolidation had been present still showed dullness, and tactile fremitus was less increased. Upon auscultation numerous subcrepitant and bubbling 784 ACUTE INFECTIOUS DISEASES. riles were heard over the base of the left lung, and the breath-sounds were not moder- ately intensified, in striking contrast to that of bronchial breathing, which had been present since the second day of the illness. Uninterrupted convalescence followed. Summary of Diagnosis. — When the disease attacks the robust and previously healthy, it is characterized by the severity of onset; thus there are chill, rapid rise in temperature, pain in the side, and distressing cough. The frequency of the respirations — 30 to 60 a minute — and the disturbance of the pulse-respiration ratio are quite characteristic of the disease, and especially so when this clinical phenomenon is coupled with the previously mentioned mode of invasion and symptoms. The sputum is an important feature in the diagnosis of pneumonia, and it is practically the only disease in which the quantity of sputum is small, and the expectoration itself is extremely tenacious and blood-streaked. A microscopic study of the spu- tum, with detection of many diplococci, is confirmatory of the other features, but is not essential to a diagnosis in typical cases. The continued type of the fever, with termination by crisis, and the signs of consolidation of a segment of one lung, or rarely of both lungs, are highly valuable diagnostic features. Playing of the nostrils and the peculiar expiratory grunt are also important, and the absence of chlorids from the urine and a leukocytosis of from 12,000 to 40,000 leukocytes in a cubic millimeter further support the diagnosis. Differential Diagnosis. — Lobar pneumonia is to be distinguished first from acute pneumonic phthisis. The distinctive features between these two maladies are shown in the accompanying table (modified from Anders) : TABLE SHOWING THE POINTS OF DIFFERENTIATION BETWEEN PRI- MARY LOBAR PNEUMONIA AND ACUTE PNEUMONIC PHTHISIS. Primary Lobar Pneumonia. Acute Pneumonic Phthisis. 1. There may have been prior attacks. 1. Inherited predisposition or previous tuberculous disease. 2. Onset sudden, with severe rigor and 2. Onset usually more gradual; repeated rapid rise of temperature. chilly sensations (rarely, severe rigor), often following exposure or "cold." 3. Fever of continued type, terminating 3. Fever of remittent type, often becom- by crisis. ing intermittent, without crisis. 4. No drenching sweats, except at time of 4. Drenching sweats common, crisis. 5. Herpes common. 5. Herpes unusual. 6. Emaciation slight or absent. 6. Rapid, progressive emaciation. 7. Sputum rusty, viscid, and sticky; may 7. Sputum may be blood-tinged; is more contain pneumococci. purulent and copious, and may con- tain tubercle baciUi and elastic tissue. 8. Duration of febrile stage, seven to 8. Duration longer, and may become in- nine days, terminating by crisis. termittent. No crisis. 9. Physical signs, as a rule, first referable 9. Physical signs first referable to apex, to base of lung, except in apical pneumonia. 10. Usually limited to one lobe or the 10. Commonly extends from apex to base, lower segment of one lung. 11. Signs of consoUdation, followed by 11. Signs of consolidation, followed by resolution. chiaracteristic signs of cavity forma- tion. 12. Apex of opposite lung not involved. 12. Apex of opposite side generally at- tacked. 13. Leukocytosis of 12,000 to 40,000 by 13. Leukocytosis after cavity formation, end of the first forty-eight hours. LOBAR PNEUMONIA. 785 Typhoid Pneumonia. — When the patient suffering from lobar pneu- monia presents the so-called "typhoid state," it is to be distinguished from pneumotyphoid (see Typhoid Fever, p. 745), and in this connection an ex- amination of the blood is of inestimable value, since in typhoid pneumonia leukocytosis is present, whereas in pneumot5rphoid leukopenia is the rule. After the end of the first week the Widal reaction is present in pneumotyphoid (typhoid fever simulating pneumonia), but absent in typhoid pneumonia (pneumonia displaying the typhoid state), unless the patient has at some previous time suffered from an attack of typhoid fever. After the first week other symptoms of typhoid fever, e. g., eruption, tympanites, and diarrhea, are likely to develop in pneumotyphoid. Pneumonia may at times simulate acute meningitis, a type of the dis- ease more commonly seen in children than in adults. In children the initial symptom may be a convulsion, and frontal headache is also common. In pneumonia accompanied by meningeal symptoms the pulse-respiration ratio is disturbed early, and the physical signs of pneumonia are, as a rule, present, although at times it is difficult to detect pneumonia in children by a physical examination. Lumbar puncture serves as a positive means of differential diagnosis. (See Epidemic Meningitis, p. 841.) A table showing the distinctive features between lobar pneumonia and pleurisy with effusion will be found under Differential Diagnosis of Pleur- isy, p. 151. Lobar pneumonia is also to be distinguished from bronchopneumonia, and this task is extremely difficult in those cases in which, in broncho- pneumonia, numerous small areas of consolidation unite to form one solid mass that may involve the greater portion of one lobe. Of further clinical importance is it to remember that lobar pneumonia is more common during early adult life, whereas bronchopneumonia is frequent in children and in the aged. (The distinctive features between lobar pneumonia and broncho- pneumonia will be found in a differential table upder the Diagnosis of Bron- chopneumonia, p. 112.) Clinical Course and Complications. — The clinical course, as well as the severity of the disease, is in a measure dependent upon the severity of the type of infection and the individual characteristics of the patient. They survive the disease best who have no organic changes in the heart or the kidneys, and in whom complications are absent. In hospital practice, 25 per cent, of cases go on from bad to worse until a fatal termina- tion is reached, whereas in private practice approximately 15 per cent, terminate unfavorably. In sthenic cases a severe type of infection is mani- fested by a severe rigor, high temperature, and marked nervous symptoms, whereas in milder types of infection all these features are likewise mild. Irrespective of the area of lung involved, in typical cases the temperature falls between the fifth and ninth days (usually, the seventh or the ninth day) and following the crisis the respirations soon become normal. Pain and cough are aggravated symptoms early during the disease, but become less prominent after the second day, and are usually absent following the crisis. The strength of the heart, as indicated by the pulse, is probably the most important clinical feature in pneumonia, and in the average imcomplicated case the pulse remains fairly strong and regular at about 110 until the time of the crisis, when the number of beats a minute may reach 120 or more; at this time the pulse is likely to become dicrotic, com- pressible, and intermittent. The greater the area of lung involved, the less completely is the patient's blood oxidized; consequently in that class of 60 786 ACUTE INFECTIOUS DISEASES. cases in which a large portion of the lung texture is consolidated, severe nervous symptoms are present, and practically all types of delirium may be seen, including coma, which, in unfavorable cases, may continue until death. The respirations, however, although always rapid, are of less im- portance than is the strength of the heart. With extensive involvement of the lung, cyanosis of the lips, face, ears, and fingers is common, and seldom exists for any great length of time without an appreciable weakening of the pulse. Following the crisis, convalescence becomes established in those cases that terminate favorably, although, when complications are present, con- valescence is greatly delayed. Typhoid pneumonia, previously referred to under Clinical Types, p. 771, presents no symptoms that are in themselves distinctive, yet the clinical course is often longer than is that of typical lobar pneumonia, and convales- cence is usually prolonged. In the absence of complications, ordinary cases go on to recovery, the patient being able to leave his bed by the end of the third or fourth week; singularly enough, however, complications arise in 50 per cent, of cases, and, regardless of the character of the complication in question, there is usually an increase in the pulse-rate and there may also be alterations in the fever and respirations. Pleurisy with effusion is a somewhat common complication, but if pleurisy is limited to the side affected by pneumonia, it is less serious than when the opposite pleural cavity becomes filled with fluid. Pleurisy always retards convalescence, and the patient is usually confined to bed for from six to ten weeks. Empyema not infrequently follows lobar pneumonia, and although it is a serious complication, it often terminates in recovery. It is a more common complication in children than in adults. In practically every case of pneu- monia there is a certain degree of bronchitis, especially of the larger tubes, but if an extensive bronchitis develops the symptoms are intensified, there is marked tendency to heart weakness and cyanosis, and the clinical course is greatly prolonged. Pericarditis may result from direct extension of the inflammatory process through the pleura to the pericardial surface, and this complication materially lessens the chances of recovery. It is also accompanied by the characteristic physical signs of pericarditis. (See p. 238.) Ulcerative endocarditis is probably the most serious complication known to pneumonia, since the peripheral vessels in the various viscera may become plugged with thrombi and bacteria, and septic phenomena supervene. When endocarditis develops, the clinical course is that of a bacteriemia. (See Ulcerative Endocarditis, p. 255.) Pulmonary abscess (see p. 121) and pulmonary gangrene (see p. 118) are occasionally seen to follow lobar pneumonia, and both these con- ditions appreciably retard convalescence, although they are not of necessity fatal. Pulmonary edema may develop at any stage during the course of pneu- monia, and this complication is characterized by increased rapidity of the heart, with a weak, thready, and irregular pulse, profound cyanosis, and rapid respirations. Acute nephritis, when present, may subside at the time of the crisis, although in unfavorable cases the albuminuria persists. A mere trace of albumin in the urine is not to be regarded as of serious moment, but when, in addition to a large amount of albumin, granular casts and both red and white blood-cells are present, the patient's condition is alarming. The THE PLAGUE. 787 presence of nephritis delays convalescence, although many patients have come under our observation in whom the kidney condition completely dis- appeared during their stay in the hospital. THE PLAGUE (Bubonic Plague, Black Death). Pathologic Definition.— An acute infectious disease, due to bacillus pestis, and characterized pathologically Ijy enlargement of the superficial lymph-nodes, with the formation of bul^oes, isolated areas of gangrene of the cutaneous and subcutaneous tissue, or pneumonia. There may also be mi- nute hemorrhages into the mucous sur- faces (stomach, intestines, lungs) . Both the discharge obtained from the lesions and sections of the pneumonic organs will be found to contain the Bacillus pestis. Exciting and Predisposing Factors.— Bacteriology.— In 1S94 Ki- tasato and Yersin both discovered the presence of the bacillus pestis in plague, and this organism is now conceded to be the exciting cause of the disease. The bacillus stains more deeply at its ex .'l,»"^'-'---- j./.^^"* . .«• , .,-™-..., ,:.. ;ii^:- tremities than at its central portion, n... l^so.-Bach.i.usopBubomcPlaoue which gives it an imperfect, coccus-like (Yersin). appearance. The point of entrance for bacillus pestis is through the punctures made by fleas and probably bedbugs in biting their human hosts. In some cases of primary plague pneumonia the bacillus may gain access to the lung with the inspired air. D. T. Verjbitski* has conducted a series of experiments through which he has permitted the bedbug, Cimex lectularis, to feed upon animals suffering from plague, and to later bite uninfected guinea-pigs. The cimex was known to convey the disease through its bite to uninfected guinea-pigs for a period of five days after sucking blood from infected ani- mals, while the flea communicates the disease for a period of approximately three days. If the bacillus gains access to the body through the puncture made by a flea in biting, the nearest lymph-nodes become involved. The infection may stop here, and the bubo thus produced may suppurate, and, after a prolonged period of discharge, the sinus may close and the patient recover. In more than half the cases, however, a general septicemia results and the patient dies. Recent studies have shown that the human epidemic of plague is pre- ceded by an epizootic among the rats of the locality. Clinical Varieties. — There are three clinical types of plague: (1) The bubonic form; (2) the septicemic form, and (3) the pneumonic form. (1) The Bubonic Form. — After an incubation period of from two to eight days the chsease begins suddenly with fever and prostration. The face is * Manning, Medical Record, July 27, 1912. 788 ACUTE INFECTIOUS DISEASES. said to be peculiarly drawn and swollen in appearance; sometimes there is a look of horror. Nause, vomiting, and diarrhea are noted in some cases. There is loss of co-ordination (staggering gait), and thick and stammering speech. Delirium, on the one hand, and stupor, on the other hand, may oc- cur. The bubo is first noticed usually within the first twenty-four hours; sometimes it does not appear until the fourth or fifth day. In 70 per cent, of the cases the saphenous lymph-nodes are affected; in about 20 per cent, of cases the bubo is in the axillary region; and in about 10 per cent, of cases it is found in the cervical region. The buboes are usually single; they vary in size from that of a walnut to that of a goose-egg. Hemorrhages into the skin, epistaxis, hematemesis, hemoptysis, melena, and hematuria are common symptoms. In favorable cases the constitutional symptoms improve after the formation of the bubo. The fever ends by lysis; the bubo ""softens and opens spontaneously, or it may be incised, and a chronic suppurating sinus results. Death usually occurs between the third and fifth days from exhaustion, hemorrhage, heart failure, convulsions, or coma (Manson). (2) In the septicemic form there is no bubo formed. The disease is septi- cemic from the start. A general enlargement of the lymph-nodes has been demonstrated at autopsy, however. The temperature is not very high; there are marked toxicity, hemorrhage, stupor, coma, and death. (3) In the pneumonic form there is a consolidation of the lungs, indicated by the usual physical signs, with the presence of large numbers of bacillus pestis in the sputum. This form is very fatal. Abortive cases of plague are called pestis ambulans, and Choksy has described a cellulocutaneous form, characterized by local necrosis of the skin and the subcutaneous tissue.* lyaboratory Diagnosis. — In cases of bubonic plague the puncture of the bubo with a sterile hjrpodermic syringe and examination of smears made from the contents of the lesion will give short. Gram-negative bacilli show- ing polar staining. In septicemic cases blood culture will show bacillus pestis. In pneumonic cases examination of the sputum will show large numbers of the short, polar-staining bacilli, which at first look like diplococci. The Gram stains will differentiate micrococcus lanceolatus, which is Gram- positive, from bacillus pestis, which is Gram-negative. Summary of Diagnosis.— The history of an epidemic or of the patient having resided in tropical or infected districts should always be given careful consideration. The rapidity of the onset, the increasing fever, with ten- dency to an early formation of a bubo, invasion of the lymphatics, should, at least, suggest the possibility of plague. Hemorrhage from the various mu- cous surfaces and petechise, both of the skin and of the mucous membranes, together with a high grade of prostration, are cardinal features of bubonic plague. The detection of the bacillus pestis in the sputum, in the fluid obtained from puncture of the involved glands, or in pus recovered from abscesses makes the diagnosis positive. INFLUENZA (La Grippe, Epidemic Catarrhal Fever). Pathologic Definition.— An endemic and epidemic, acute infectious and transmissible disease, said to be excited by the bacillus influenza, and characterized by a catarrhal inflammation of the respiratory and alimentary tracts. There is a special tendency toward the development of the patho- * Trans. Alner. Soc. of Tropical Medicine, 1909. INFLUENZA. 789 bronchopneumonia, and myo- logic changes kno-noi to acute bronchitis, carditis. Predisposing and Exciting Factors.— Practically all persons are likely to contract the disease. Age exercises but moderate influence. The greater numl^er of cases, however, develop in young adults between the ages of twenty-five and thirty-five years. The disease is far less common before the tenth year. Influenza is a disease that commonly attacks those in whom the general nutrition is impoverished, consequently it is prone to arise as a secondary condition in the ill nourished. Bacteriology.— In 1892 Pfeiffer described the influenza baciUus at length. This organism is obtained from the sputum and nasal secretions during the febrile periotl of the disease, and Pfeiffer declares that the bacillus enters the bronchial tissue and may even penetrate the pulmonary coverings and enter the pleural sac. (See Laboratory Diagnosis, p. 792.) The rela- tion that probably exists between in- fluenza, ordinary colds, measles, diphtheria, scarlet fever, and other acute infections, when seen in chil- dren, is by no means clearly under- stood, yet the fact remains that in- fluenza is a frequent complication in such infectious conditions. Modes of Infection.— The various modes by which the disease may be transmitted from one per- son to another are not well under- stood, although several theories have been offered in explanation. A single attack does not bestow immunitij, and, indeed, subsequent attacks are quite common, the dis- ease recurring from eveiy one to five years. Certain uidividuals con- tract the disease with the appear- ance of each epidemic; therefore, it is not unusual to encounter those who have suffered from two or more attacks. Clinical Varieties. — (1) Respiratory Type. — In this variety the earl}^ and more prominent symptoms are those referable to the respiratory tract — e. g., coryza, pharyngitis, laryngo tracheitis, and bronchitis. A more or less general aching of the throat and prostration are also present. When the respiratory symptoms predominate, it is not unusual to find broncho- prieumonia as a coexisting condition. Persistent cough is a constant symp- tom, and violent paroxysmal coughing may be present. (2) Gastro-intestinal Type. — The initial symptoms of this type may be practically identical with those of the respiratory form, except that they are milder in degree and are somewhat masked by the severe symptoms referable to the gastro-intestinal tract, namely, abdominal pain, nausea, vomiting, and profuse watery diarrhea. Prostration is well marked in this as in prac- tically all types of influenza. (3) Typhoid Type. — In a small percentage of all cases continued fever, with delirium, may be present. The lips are brown and fissured, the tongue is parched and heavily coated, and the general condition of the patient is Fig. 290. — Bacillus of Influenza, from a Gela- tin Culture (X 1000) (Itzerott and Niemann). 790 ACUTE INFECTIOUS DISEASES. that known as the typhoid state. The fever may be remittent or even inter- mittent, and this feature, together with the repeated occurrence of chills or of chilly sensations, often suggests to the clinician the possible existence of malarial infection. (4) Cardiac Type. — Certain cases of influenza are seen in which the cardiac features constitute the most prominent symptoms. The pulse is rapid, feeble, and irregular, and there is a tendency toward heart failure with cardiac dilatation. (5) Nervous Type. — The nervous symptoms are fairly prominent in most clinical varieties of influenza, but cases are occasionally encountered in which they are unusually prominent; for example, atrocious headache, muscular pains, stiffness of the joints, and the early development of delirium may serve as the leading features in this type of the disease. In the cerebral type of influenza symptoms quite identical with those of meningitis develop rather suddenly and persist for a period of one, two, or more days when, in favorable cases, they disappear suddenly. (6) Rheumatoid Type. — The rheumatoid type differs from the foregoing one in that the predominant feature is extreme muscular pain involving the greater portion of the body. (7) Apyretic Form. — As the name implies, this variety of influenza may simulate in general any one of the previously described clinical pictures, and is that of the respiratory tj^pe of the disease, except that fever is absent. (8) Ambulatory Type. — ^This form is of special importance, because of its tendency to spread the disease. Period of Incubation. — This is, as a rule, brief, and does not ex- ceed two or three days. Principal Complaint and Symptoms. — In the majority of cases the onset is sudden, the disease being usually ushered in by a rigor or at least by a repetition of chilly sensations. Profound prostration is charac- teristic, and develops early in the majority of all cases. In typical forms of the disease the initial symptoms may be vertigo, bilious vomiting, and epis- taxis. Dyspnea is often a conspicuous symptom, and may persist even for days in uncomplicated cases, and profuse sweating is at times troublesome. The nature and degree of severity of this condition are decidedly variable; at times the symptoms are so severe as to advance rapidly to a state of collapse, while within the course of a few hours the symptoms of broncho- pneumonia may be displayed. Complications may arise and escape ob- servation until they are well advanced, being masked by the severe symptoms already present. Congestion of the various viscera and edema of the ex- tremities (see Cardiac Complications) are not uncommon. In an average case of the pulmonary type of influenza the symptoms of severe bronchitis are present — cough, with possibly shght expectoration, coryza, with sneezing, and increased secretion of the lacrimal glands. In children the gastro-intestinal manifestations of the disease are often prominent, and frequent attacks of vomiting are likely to occur; rarely there is hemorrhage from both the stomach and the bowel, the general clinical picture being that of severe acute gastro-intestinal catarrh. Nervous Symptoms. — Probably the most constant nervous symptom is perineuritis, which may be so severe as to induce profound suffering. Pain. — Headache is almost constant in the early stage of influenza, and may be frontal, temporal, or occipital. In some patients the pain is most severe in and between the eyes. Muscular pains, affecting the loins, lumbar IKFLUENZA. 792 region, back, arms, and limbs, are intensified by the slightest movement. Neuralgic pains are occasionally present, and sharp, lancinating, or stitch- like pains may be felt over various portions of the chest and abdomen. The pain may at times be referred to as burning in character, and here it is limited chiefly to the cutaneous surfaces, whereas in the same patient there may also be deep, boring pain in the back. Hysteric outbreaks are occasionally seen in those of a neurasthenic temperament. In grave forms of the disease there is at times active delirium, but such severe nervous manifestations seldom appear unless compHcations are present. The nervous symptoms are greatly intensified in those cases in which such complications as bronchopneumonia, nephritis, and otitis media develop. Pleuritic pain may be present for one or more days, when the patient's complaint is quite identical with that given for acute pleurisy, although the other features of pleurisy are absent. Thermic Features. — Following the chill, the temperature usually rises somewhat abruptly to 102° to 104° or 105° F., depending upon the severity of the type of infection, and may assume a remittent course. The tempera- ture is in no way characteristic, and in uncomplicated cases will be found to reach the normal by the end of the first week. It is to be borne in mind that the temperature is influenced largely by the presence of compHcations, and we are inclined to regard influenza as an infection in which complications are most common. Physical Signs. — Inspection. — The face is somewhat flushed at the onset, but later, and after cardiac failure, there may be paUor. Cyanosis involving the face, lips, tongue, and extremities is present. The tongue is coated, and should the fever continue high for several days, the lips are likely to be fissured. The movements of the chest are increased even in mild cases, and are further increased in proportion to the severity of the bronchitis or of the pulmonary complications present. Swelling of the feet and of the hands is present only when heart failure or renal complica- tions occur. Jaundice, as the result of duodenal catarrh, may develop at any time during the course of influenza. In those cases of the disease in which the clinical picture resembles that of cerebrospinal meningitis, there may be inequality of the pupUs and a fixed position of the head, and one or more of the extremities may be held firmly in one position. Palpation. — Upon making firm pressure over the loins, shoulders, and arms, the muscles may be foimd to be slightly tender, although muscle sore- ness is usually produced by movements of the patient. Edema of the ex- tremities may be detected, but is a feature only of complicated cases. The apex-beat is at first strong, but is soon found to weaken, and when the toxic S3Tnptoms are pronounced, the cardiac impulse is feeble and diffuse. In cardiac dilatation the apex impulse may be almost imperceptible. Areas of increased tactile fremitus may be foimd at the bases of the lungs pos- teriorly, and indicate the existence of the so-called "grip" pneumonia. The pulse is increased in frequency in proportion to the elevation of temperature. Certaia writers, however, describe bradycardia as a feature in many cases. In those cases in which the toxic substances appear to affect the heart, the pulse is Hkely to become rapid and irregular as to both time and force. In the aged the pulse is readily compressible, and tends to become dicrotic as the disease progresses. Percussion. — In uncomplicated cases percussion is negative. Auscultation. — ^The heart-beats may be increased somewhat as to frequency, although in the early stage the heart action may be comparatively 792 ACUTE INFECTIOUS DISEASES. slow in proportion to the degree of prostration. In severe and complicated cases the heart action is rapid, and the first sound appears to have lost its muscular quaUty. Auscultation of the chest reveals the signs of acute bronchitis. (See p. 88.) Bronchopneumonia is a common pulmonary com- plication. (See Bronchopneumonia, p. 107.) I/aboratory Diagnosis. — The urine may contain a trace of albumin, and in those cases in which true nephritis exists, the urine will be found to be rich in albumin and to contain leukocytes and casts. In the gastro-intestinal type of grip the urine may be rich in indican, and occasionally stained with bile. In uncomplicated and mild cases the number of leukocytes is not increased, although occasionally a leukocytosis of from 10,000 to 15,000 may be seen. Leukopenia may be present for a short period. The sputum, saliva, and nasal secretions, when studied in stained prepara- tions, contain numerous slender baciUi. These have received careful study by Pfeiffer, who suggests that they may be the cause of influenza. Special attention must be called to the striking resemblance between the laboratory characteristics of the baciUus influenzae and those of the organism described by Koch and Weeks as the exciting cause of acute conjunctivitis. (See special works upon Bacteriology.) Illustrative Case. — C. H. C, male, aged twenty-three years;_ clerk. Has enjoyed perfect health during the past ten years. Two days prior to his admission to the hospital he noticed some loss of appetite and languor, and sneezed several times dur- ing the day. Upon admission he stated that he had suffered from chilly sensations during the day, violent headache, marked pain in the orbits, and aching in the back, loins, and muscles of the limbs. Severe cough, dyspnea, and a temperature of 103° F. were present. Physical examination revealed nothing beyond that the respirations were hurried and that there were numerous fine rAles over both lungs. The pulse was weak but regular, although the degree of prostration appeared to be extreme. For a period of four days the temperature fluctuated between 99° and 102° F., reaching the higher elevation during the evening hours. The respirations became more and more hurried during this time, until he was breathing approximately 30 times a minute. The urine con- tained a trace of albumin, and constipation was sufficiently obstinate to necessitate the administration of a laxative. By the end of the first week the fever had fallen to the normal, and all symptoms were greatly ameliorated; from this day convalescence was not interrupted. Summary of Diagnosis. — This is seldom difficult except in ill-defined, sporadic cases. Great importance attaches itself to the presence of an epidemic, an abrupt onset, with alternating flashes of heat and mild chiUs, the short duration of the febrile period, the intensity of the headache, with severe pain in the eyes and orbits, and muscular pains. In addition to the foregoing clinical peculiarities, if the prostration is out of proportion to the catarrhal manifestations, the diagnosis is practically assured. A micro- scopic study of the sputum, having for its object the detection of the bacillus influerizEe, although essential to a diagnosis only in sporadic and atypical forms of the disease, should always be undertaken. Clinical Course. — The duration of the attack is brief, although special cases show great variations. In the milder forms severe symptoms exsit for but from two to four days, whereas in the more severe types of infection they are present for from seven to ten days or possibly two weeks. Influenza, when it attacks those who are already suffering from some acute or chronic malady, may continue for a longer period than it does in previously healthy subjects. Epidemic influenza usually continues over a period of TUBERCULOSIS. 793 from four to eight weeks, after which there may be, for a considerable period of time, more sporadic cases than usual. Complications and Sequelae. — Bronchopneumonia is probably the most common and severe complication known to influenza. Hyper- pyrexia may rarely develop, and diarrhea with hemorrhage from the bowel is also an occasional complication. Nephritis, pleurisy, and severe diffuse bronchitis, should they develop at any time during the disease, are to be regarded as of serious moment. Meningeal symptoms with maniacal dehrium that is followed by coma seldom appear in uncompli- cated cases of influenza, and these features are suggestive not only of a grave tj^e of the disease, but of the existence of other serious compHca- tions. Among the sequelm known to this affection are pulmonary tuberculosis, pulmonary abscess, pulmonary gangrene, and chronic bronchitis. Follow- ing an attack of influenza the heart may remain irritable, and tachycardia is common, whereas true angina of the precordial region is but an occasional feature. Subacute and chronic catarrh of the stomach and intestinal tract may continue for months, and following a somewhat protracted attack of influenza, we occasionally encounter chronic cystitis. Nephritis may con- tinue after the febrile period. Among the annoying nervous sequelae should be mentioned insomnia, headache, melancholia, suicidal tendencies, periph- eral neuritis, and ascending myelitis. Otitis media and even mastoid abscess may be seen to follow influenza, and ocular sequelae — e. g., choroiditis, acute glaucoma, and conjunctivitis — are somewhat more common. TUBERCULOSIS. Pathologic Definition. — An acute, subacute, or, more commonly, chronic infectious disease, caused by bacillus tuberculosis. The disease is characterized anatomically by the formation of a lesion called a tubercle. Tubercles, which may be formed in all the tissues of the body, are at first small — the so-called miliary tubercles; these tend to fuse, forming larger tuberculous masses of varying sizes, which undergo caseous degeneration, softening, and ulceration. With the softening of the tubercle the pyogenic organisms invade the lesion, provided it is so situated that they may gain access to it, and then a mixed infection results, with the production of pus. When the pyogenic organisms do not invade the softening tubercle, the purulent contents of the lesion is apt to be sterile. The tendency of the tubercle is to limit itself by the formation of a capsule of connective tissue, sclerosis, with, inspissation and subsequent calcification of the contents. In cases of disseminated infection a disease known as miliary tuberculosis is produced, ia which discrete tubercles of the size of a pinhead or less are found in nearly every organ of the body. Caseation is the term employed to denote a process of coagulation ne- crosis of the cells forming the tubercle, by which the ceUs are converted into a yellowish, structureless substance, Hke cream cheese. This process, which begins at the center of the tubercle and gradually extends toward the per- iphery, is probably due to the local action of the toxins of the bacillus. If a tubercle is properly situated, the caseous process may extend until an open- ing into a natural cavity is produced, such as a bronchus or a joint, and a tuberculous cavity results. Such a tuberculous cavity is very likely to be- come infected with the pyogenic cocci and bacilli. If a caseous nodule 794 ACUTE INFECTIOUS DISEASES. becomes encapsulated with fibrous tissue (sclerosis), it may be converted into a hyaline, fibrous material in which lime salts are subsequently deposited. Such a calcareous tubercle is harmless. The dissemination of tubercle bacilli is effected principally through the lymphatics; but in some instances the organisms are widely distributed by the blood-stream, in which case miliary tuberculosis results. In some cases the disease extends by contiguity, as when a tubercle on the viscerallayer of the peritoneum produces a tubercle on the parietal layer of the peritoneum just opposite to it. Also, in cases of tuberculous peritonitis the disease is disseminated along the surface of the peritoneum by the peristaltic move- ments of the intestines. Distribution of the Lesions. — In the adult the lung is most frequently the seat of tuberculous new-growths. Next in the order of frequency foUow the larjmx, intestines, peritoneum, genito-urinary organs, brain, spleen, liver, and heart. The pleura, meninges, and synovial membranes are frequently attacked. In children, the favorite sites of origin are the lymph-nodes, intestines, bones, and joints. Here the distribution, if we except the bronchial and mesenteric lymph-nodes, corre- sponds quite closely to that of surgical tuberculosis. The Elementary (Nodular) Tubercle. — This may develop in any tissue in which the tubercle bacillus has become lodged, and the presence of the bacillus is the sole distinguishing feature, since apparently identical growths are produced by other microorganisms — e. g., the actinomyces, Aspergillus glaucus, Aspergillus fumigatus — and even by irritation of foreign bodies — for example, podophyllum. Pseudotuberciilosis is caused by organisms other than the tubercle bacillus. The stages in the development of a tubercle are: (1) A proliferation of the fixed tissue elements (connective-tissue cells, endothelium of the capillaries, etc.) of the part infected, due to the local specific irritative action of the bacillus. These anatomic structures are transformed into epitheUoid and giant-ceUs. The epithelioid cells assume various shapes, chiefly rounded and polygonal, and sometimes contain tubercle bacilli in their cjrtoplasm. As the result of increase in their size and a repeated division of their nuclei, or from the union of contigu- ous ceUs, a certain number of the epithehoid cells are transformed iuto giant-cells. The giant-ceUs occupy the center of the tubercle and often con- tain bacilli. (2) Diapedesis of leukocytes occurs around the site of infection. It is "of the nature of a defensive inflammatory process. At first the leukocytes are of the polymorphonuclear variety; these are quickly destroyed; later, however, mononuclear leukoc5rtes appear. The granular elements described are immediately surrounded by a reticular stroma. Fully developed tubercles are small, nodular bodies, having a diameter of from I" to 2 or 3 mm. At first they are almost transparent, but as the result of further changes, they soon lose this quality. Tubercles invariably midergo degenerative changes, such as caseation and sclerosis. _ Bacteriology. — The bacillus tuberculosis (Plate I) is the sole ex- citing cause of the disease. The organism is a straight or slightly bent, non-motile rod, rather slender, with rounded extremities. It varies in length from one and one-half to five microns, or from one-fourth to one-half the diameter of a red blood-corpuscle. It is about 0.3 micron thick. It belongs to a group of organisms which are known as the acid-fast bacilli. These organisms have the peculiarity of retaining fuchsin in spite of sub- TUBERCULOSIS. 795 sequent treatment with a solution of a mineral acid. The tubercle bacillus is also alcohol-fast. Biology. — The bacillus tuberculosis is cultivated with difficulty. It will not grow at all on the ordinary laboratory media; but on various special media growth can be produced, although but slowly. Glycerin bouillon and glycerin-agar are the two media habitually employed for the cultivation of this organism. The other members of the group of acid-fast bacteria are bacillus leprae, bacillus smegmae, the bacillus of timothy grass, and the butter bacillus of Rabuiowitch. The following points differentiate bacillus tuberculosis from the other members of this group : (1) The tubercle bacillus grows very slowly upon glycerin-agar, glycerin bouillon, or glycerin potato. (2) Bacillus leprae and bacillus smegmas cannot be cultivated upon artificial media. (3) The bacillus of timothy grass and the butter bacillus grow readily on the ordi- nary culture-media. A method for determining the presence of the tubercle bacillus is to inoculate a guinea-pig with a portion of suspected tuberculous tissue that has been emulsified, or with scrapings from suspected tuberculous lesions. The animal develops tuberculosis within the course of from four to six weeks, and always succumbs to the disease; its body will be found to contain many tubercles. If the animal should die at an earlier date, its death cannot be attributed to the action of the tubercle bacillus. Bovine Tuberculosis. — ^Tuberculosis is common among cattle, as has been shown by the work conducted by the various health departments in practically all parts of the world. Ravenel, of Philadelphia, has per- formed conclusive and elaborate experiments with both bovine and human tubercle bacilli. His conclusions are, briefly, as follows: " (1) That the tubercle bacillus from bovine sources has in culture fairly constant and persistent characteristics of growth and morphology by which it may tentatively be distinguished from that ordinarily found in man. " (2) That cultures from the two sources differ markedly in pathogenic power, affording further means of differentiation, the bovine bacillus beiag much more active than the human for all species of experimental animals tested, with the possible exception of swiue, which are highly susceptible to both. " (3) The tuberculous material from cattle and from man corresponds closely in comparative pathogenic power to cultures of the tubercle bacillus from the two sources for all animals tested. " (4) That it is a fair assumption, from the evidence at hand, and in absence of evidence to the contrary, that the bovine tubercle bacillus has a high degree of pathogenic power for man also, which is especially manifest in the early years of life" (Anders). The sputum, feces, urine, and pus from ulcers and sinuses of tuberculous persons are among the various sources of infection, and in a series of experi- ments conducted by us at the Philadelphia Hospital we found that during the acts of coughing, sneezing, laughing, and talking patients suffering from advanced tuberculosis ejected a fine spray from the mouth that was found to contain virulent tubercle bacilli. Food-stuffs handled by persons suffering from tuberculosis of the respiratory tract are likely to become contaminated with tubercle bacilli, and are probably a potent factor in the spread of the disease. 796 ACUTE INFECTIOUS DISEASES. CHRONIC TUBERCULOSIS. Bxciting and Predisposing Factors.— In all types of the dis- ease the exciting factor is the tubercle bacillus, first described by Koch in 1881, and found in the blood-stream (in 10 per cent, of cases) and in the diseased tissues. Incubation Period. — In tuberculosis produced experimentally it has been found that the guinea-pig and other laboratory animals develop the disease in from' two to four weeks and die from it in from four to eight weeks. Race and Nationality. — Sears, in a study of 200 cases, found that 50 per cent, represented either the first or the second generation of Irish im- migrants. We have also observed that American children whose parents are of different nationalities show a marked inclination to develop pulmonary tuberculosis, this being especially true of immigrants from the Latin countries who marry natives of Ireland, England, and Scotland. Race also exercises a decided influence, the African being especially sus- ceptible to the disease when he takes up his residence in the northern States. We have also observed that an unusually high proportion of mulattos acquire the disease. Tuberculosis is common among the American Indians, a fact that may possibly be explained, in part, by their habit of eating uncooked meats. Some observers claim that an attempt to civilize the American Indian always ends in an increase in the number of cases of tuberculosis among them. The Mongolian race — the Japanese and Chinese — ^is prone to develop the disease on coming to America. Age. — Tuberculosis may develop at any age, but certain forms of the disease are especially frequent among children — e. g., meningeal, peritoneal, lymphatic, and bone (hip-joint and spinal) tuberculosis. Pulmonary tuber- culosis is most commonly encountered between the ages of twenty and thirty and is quite rare during childhood and in old age. Sex. — Females are said to be more susceptible to the disease than are males, yet this statement is not borne out by the statistics of Boston and Blackburn. When women affhcted with the disease become pregnant, the tuberculous process is likely to run an unusually acute clinical course. The fact that females take less outdoor exercise than males may, in a majority of instances, explain the frequency with which the former are afilicted with this disease. Previous Diseases. — Tuberculosis not infrequently develops as a sequel of some one of the acute infections, although it is impossible to say definitely that in such instances some obscure tuberculous lesion did not exist prior to the development of the acute infection. Influenza, measles, pneumonia, whooping-cough, colds, acute bronchitis, and typhoid fever are not infre- quently followed by the development of pulmonary tuberculosis. Tubercu- losis of the lung may occur during the course of such chronic maladies as hepatic cirrhosis, diabetes meUitus, chronic interstitial nephritis, and the anemias. Climate. — Humidity^ and excessive atmospheric moisture appear to increase the prevalence of the disease. Sudden variations in temperature probably predispose to the development of the disease more markedly than does any one other climatic condition, since such changes increase the sus- ceptibility to contract acute colds. Altitude produces immunity in the native born inhabitants, as is shown in Colorado and New Mexico, where tuberculosis among the natives is rare. An exceptionally dry climate of CHRONIC TUBERCULOSIS. 797 uniform temperature, such as that of southern California, is also unfavorable to the propagation of the disease. Heredity. — This is estimated by different authors as being a causal factor in between 10 and 40 per cent, of cases. A child born of and reared by a tuberculous parent may be free from the disease at birth, but the environ- ment certainly predisposes the child to infection. Children and other mem- bers of the same family are alike exposed to the disease. Tuberculosis is most likely to develop among the members of a family when the cooking is done by the afflicted person, since those suffering from pulmonary tuber- culosis are likely to carry tubercle baciUi to the food they handle. Again, those afflicted with both pulmonary and laryngeal tuberculosis are continually clearing their throats, and are likely, in this way, to contaminate the food of others. It has been shown conclusively, as previously stated, that such patients disseminate a spray containing tubercle bacilli during the acts of coughing, sneezing, laughing, and talking; hence it is fairly reasonable to suppose that food prepared by tuberculous cooks will be contaminated with tubercle bacilli. As an illustration of the truth of the foregoing, the follow- ing case, which came under our observation, may be cited: Seven resident physicians in a hospital in Philadelphia developed pulmonary tuberculosis within the course of two years, and investigations made to ascertain the source of such infection disclosed the fact that the colored cook who prepared the food for the resident staff was suffering from a chronic form of pulmonary tuberculosis, both his saliva and his nasal secretion showing the presence of tubercle baciUi. An inherited tendency to tuberculosis is more often transmitted through the mother than through the father, yet this statement, with reference to the transmission of the disease by the mother to her offspring, must be made guardedly. ', Women suffering from ill health at the time of conception and during the period of gestation are likely to produce offspring that show a special predisposition to develop tuberculosis as well as other infectious con- ditions. The children of syphilitics are very susceptible to the development of tuberculosis. Pulmonary tuberculosis developing during childhood is, as a rule, un- usually mild in form and is probably often overlooked until puberty or some later day, when the patient's general health becomes impaired, and permits the at one time encapsulated tuberculous process to assume an active stage, following which the clinical phases of pulmonary tuberculosis rapidly develop. Acute Catarrh, — Acute catarrh of the respiratory tract provides a fertile soil for the development of the tubercle bacillus, and in consequence of this tuberculosis frequently follows acute colds and attacks of acute bronchitis, pharyngitis, and laryngitis. Local Irritants and Wounds. — Factory employes are constantly ex- posed to the inhalation of particles of dust, and hence are prone to develop pulmonary tuberculosis; occupation, therefore, bears an etiologic relation- ship to this disease. As the result of the inhalation of irritating substances, glass-blowers, brass and metal workers, and coal-miners display a subacute or chronic bronchitis, following which tuberculosis* is likely to develop. A single tuberculous focus may appear in the lung, and for a time many of the clinical features characteristic of either bronchopneumonia or lobar pneu- monia may be present, tuberculosis being distinguished from these conditions largely by the fact that resolution does not occur. Pleurisy may be the exciting cause of a beginning tuberculous process that may, sooner or later. 798 ACUTE INFECTIOUS DISEASES. become more or less general. (See Pleurisy.) Local tuberculosis of the mediastinal and abdominal lymph-nodes is occasionally encountered in children, and is rarely seen after middle life. Traumatism, sufficient to cause abrasion of the skin, may be followed by local tuberculosis, and it may also follow injury to the articular surfaces of certain bones and to the syno- vial membranes. Modes of Infection. — (1) The ingestion of the meat of tuberculous animals, either beef or pork, is generally conceded to be one of the chief sources of infection. The milk of cows suffering from tuberculosis is a common source of infection in both children and adults. (2) The sputum and dejecta of tuberculous patients are a prolific source of infection, the bacilli being carried directly from them by flies and other insects and deposited on the food of healthy individuals. Again, dried and partially pulverized sputum is blown about by the wind and may settle upon the food or upon open wounds. There is some question as to the viru- lence of the tubercle bacilli present in dry sputum and dejecta. (3) As previously stated, the air of a room occupied by a person suffering from an advanced form of tuberculosis has diffused through it a fine spray that contains virulent tubercle bacilh. The inhalation of such spray is, in our opinion, capable of exciting tuberculosis. (4) In those suffering from tuberculosis of the kidney or of any other portion of the genito-urinary tract the urine may contain many tubercle bacilli, and this excretion, when it falls upon vegetation, may serve as a means of infecting herbivora. A great number of tuberculous patients have taken up residence in the southwestern prairie-lands and in the far west, and have lived out of doors on the frontier. It is possible that the urine and feces of such patients serve as the source of infection for the cattle of those sections. (5) Direct Inoculation. — Tuberculosis may result from the introduction of material containing the bacillus into open wounds, and this is the probable explanation of the origin of lupus. Ravenel has reported three cases of accidental inoculation of bovine tuberculosis in man. (6) Direct hereditary transmission of the disease to the fetus in utero is exceptional, although authentic reports of such cases have been published. In the light of our present knowledge it is impossible to assert that any one of the previously mentioned modes of conveyance is the chief source of infection in man, although it is at least fair to assume that the ingestion of tuberculous meats or of milk containing tubercle baciUi is one of the more common sources of tuberculous infection in man. Illustrative Case of Pulmonary Tuberculosis. — C. A., male, single, aged twenty-four years. An onljr child. Height, 6 feet 9 inches; weight since twenty years of age, 154 pounds, until the past four months, during which time his weight has fallen to 137 pounds. Family History. — Parents living and in good health. No history of tuberculosis in ancestors. Previous History. — The patient had the usual diseases of childhood before the age of twelve years; but between the twelfth and twentieth years he does not recall having consulted a physician. Since the age of twenty he has had repeated "colds," which, he states, he contracted readily, although he was not compelled to remain indoors at any time. Social History. — The patient is a clerk by occupation, although he states that it has been his custom to take abundant outdoor exercise. He is not addicted to the use of alcoholic liquors or narcotics. He states that he has been irregular in his habits as regards the taking of food, and that, for the past year, he has not felt any inclination to eat in the morning, but that he would be able to take a fairly good meal by the middle of the day or during the evening. CHRONIC TUBEECULOSIS. 799 Present Illness. — This probably dates from an attack of influenza, from which he suffered four months ago. Since this attack he has never fully regained his usual vigor, but, on the contrary, becomes easily exhausted, and although he is able to follow his usual vocation, he finds work extremely irksome. Violent exercise is followed by well- marked dyspnea, and for the past month he has been unable to wait against a strong breeze without suffering from extreme shortness of breath. Since the attack of influ- enza he has experienced a variable degree of dyspnea; ■ he has hiccoughs; feels uncom- fortable after the taking of food, and there is a decided distaste for fats. Pain and Cough. — There has been no distinct pain at any time, although he ex- periences a variable degree of soreness at the base of the chest, and at times complains of a sensation of tightness in the thorax. Cough is more or less constantly present, and exposure to wet and cold, as well as exercise, always aggravates this symptom. The expectoration has been scanty, thin, and glairy, and when collected in a glass, showed a heavy, beaded froth. Irrespective of actual cough, the patient is continually clearing his throat, and a change from a warm to a cold room appears to aggravate this annoying symptom. Changes in posture, that is, upon retiring at night or upon rising in the morning, give rise to a paroxysmal attack of coughing. Nervous Phenomena. — The patient declares that he is nervous and readily excited, and that he worries considerably over his physical condition. Thermic Features. — At present, the night and morning temperature, taken over a period of six days, is normal or subnormal during the morning hours, but shows a rise of one to one and one-half degrees as evening approaches. Physical Examination. — General. — The skin and mucous membranes are pale, and, as the result of emaciation, which appears to affect both muscles and adipose tissue, the skin is wrinkled. Local Examination. — Inspection. — The ears project quite prominently; there is distinct playing of the nostrils; the cheeks are sunken; the patient usually breathes with his mouth open, and at the angles of the mouth a small quantity of saliva can be seen while the patient is talking. The typical so-called "phthisical" chest is not pres- ent, but there is a distinct depression at the right apex, and the supraclavicular and infraclavicular spaces of the right side are much deeper than those on the left. The shoulders are drooped, somewhat rounded, and the right is approximately one inch lower than the left. Palpation. — At the apices of the lungs the two sides do not expand equally, there being some restriction on the right side. Tactile fremitus is slightly increased as low as the third rib at the right apex, and a distinct increased vibration is also felt over the right lung, between the vertebral column and the inner border of the scapula. The pulse is full and of fair volume, numbering 75 beats a minute, but becomes greatly accelerated upon slight exertion. Percussion. — There is slight impairment of resonance over the apex of the right lung anteriorly, extending as low as the upper border of the third rib. No appreciable difference in the percussion-note is obtained over the two lungs posteriorly. Au.scultation. — The breath-sounds over the left apex anteriorly appear to be nor- mal, but over the right apex, and as low as the third rib, breath-sounds are slightly bronchovesicular and roughened, and, when the patient is directed to clear his throat, a few, fine crackling rales are audible. The spoken voice-sound is abnormally well trans- mitted over the right apical area anteriorly, and along the inner border of the right scapula. Laboratory Findings. — Repeated examinations of the sputum over a period of two and one-half months gave negative results as to the presence of tubercle baciUi. A guinea-pig to which a portion of the sputum was fed developed tuberculosis and died of the disease six weeks later, and at about the same tune tubercle baciUi were first detected in the patient's sputum. Cahnette's ophthalmotuberculin reaction was positive four weeks before it was possible to confirm the diagnosis through the feeding experiment, and von Pirquet's needle-track tuberculin reaction was also positive. Diagnosis by Induction from Clinical Data. — Certain facts set forth in the clinical history figured prominently in reaching a correct diagnosis; among these are: a young individual who had previously been in good health lost 17 pounds in weight within a comparatively short period. He had also been subjected to repeated attacks of what he termed "acute colds," the present illness dating, in the patient's estimation, from an attack of influenza. He was unable to eat at the morning meal, had a distaste for fats, and was often nauseated upon rising after a night's sleep. He further com- plained of a sense of fuUness after the ingestion of food, and, indeed, symptoms of gastro- intestinal catarrh were present. Dyspnea had developed gradually, and was often accompanied by violent coughing. "The fact that he coughed after a night's sleep and 800 ACUTE INFECTIOUS DISEASES. on change of position was also suggestive of tuberculosis. Again, importance was attached to the fact that during exacerbations of coughmg he frequently vomited. Although tuberculosis was suspected early, it was impossible to confarm such a diagnosis by microscopic examination of the sputum, but when the sputum was fed to a healthy- guinea-pig, tuberculosis was produced in the animal, a piece of evidence that confirmed the diagnosis; later, the detection of tubercle baciUi in the sputum made the diagnosis posi ]J?ggj.gj^^.^j Diagnosis.— The symptoms of gastro-intestinal catarrh were promi- nent during the early course of the disease, and, indeed, practically overshadowed the other features of beginning puhnonary tuberculosis. A correct diagnosis was attained by the foUowing facts: (a) Progressive loss in weight; (6) such loss loUowing an attack of influenza; (c) ahnost constant cough and clearmg of the throat; (d) the patient dis- played an intolerance for fats; and (e) healthy animals fed upon the sputum developed tuberculosis, and later tubercle bacilli were found in the patient s sputum. Course of the Disease.— This was influenced entirely by judicious treatment, the patient being immediately removed from the city to the mountains, and there placed under the care of a physician. One year later this patient was nd of all annoying symp- toms, cough, weakness, shortness of breath, etc., and weighed 160 pounds. Physical examination still showed impairment of the percussion-note at the right apex, and over this area the breath-sounds were still slightly bronchovesicular, yet there was no evi- dence of an active inflammatory process m the lung. The patient returned to the city and has remained in good health. ACUTE TUBERCULOSIS. General Remarks. — A fact to be emphasized in connection with this variety of tuberculosis is that an old tuberculous focus is present within the body. Apart from this primary lesion, the pathologic lesions consist of widely disseminated tubercles. Their most frequent seats are in the lungs, liver, and spleen, and less commonly in the marrow of the bones, the heart, the kidneys, the choroid, and the meninges. This form of tuberculosis is characterized by the rapid development of miliary tubercles in many and widely separated parts of the body. In certain cases the tubercles are quite evenly distributed throughout all the organs of the body, manifesting the symptoms of an acute general infection. In other instances there is a tendency to localization of the tuberculous lesions, e. g., in the lungs (pul- monary variety) or in the meninges (meningeal variety). The fact that miliary tubercles may exist in different organs of the body Giver, heart, etc.) without giving rise to definite symptoms is a clinical fact of considerable moment. MILIARY TUBERCULOSIS (Acute General Tuberculosis, Acute Disseminated Tuberculosis). General Remarks. — ^This type of the disease probably results, in the majority of cases, from the rupture of a tuberculous nodule into a vein (rarely into a lymphatic vessel), following which tubercle bacilli are dis- seminated by the blood-stream to all parts of the body. Irrespective of the site of origin, the condition is at first an acute, generalized infection, and may continue as such for an indefinite period; but later in the course of the dis- ease the symptoms pointing toward tuberculosis become more or less local- ized — ^that is, meningeal or pulmonary symptoms are Hkely to develop. In some cases meningeal symptoms may be the first positive evidence of the existence of tuberculosis, whereas in others pulmonary symptoms may be pronoimced from the onset. Clinical Varieties. — (1) General or typhoid form; (2) acute tuberculous meningitis (see Diseases of the Meninges, p. 1125); (3) acute mUiary pulmonary tuberculosis; (4) chronic tuberculosis, and (5) tuber- culous adenitis. MILIARY TUBERCULOSIS. 801 General Miliary TuBERCULOsiscTTphoidForm). Clinical Features. — ^The general condition of the patient points conclusively to a severe grade of infection, which resembles a severe type of typhoid fever. The patient complains first of malaise, weakness, chilly sensations, impairment of appetite, and may occasionally experience one or more mild attaclis of epistaxis. At times the disease develops abruptly, the patient becoming very ill by the end of the first forty-eight hours. There may be cough, with shortness of breath upon exertion, but expectoration is, as a rule, scanty or absent. Prostration soon becomes extreme, and within the course of a few days there may be diarrhea, mental dullness, delirium, and stupor. Thermic Features. — ^The fever rises more rapidly, as a rule, than in typhoid, although there may be a gradual daily elevation until the tempera- ture reaches 103° to 104° F., when there is likely to be well-marked morning remissions, although an evening remission with a morning exacerbation is occasionally observed. Rarely, indeed, the fever is not a conspicuous fea- ture, and a subnormal temperature may be present. Physical Signs. — Inspection. — ^The face is flushed; the patient, as a rule, Hes upon his back; the tongue is heavily coated, and as the disease progresses it becomes brown, fissured, and often bleeds. Sordes accumulate about the teeth and lips. The respirations become somewhat hurried as the disease progresses, and late during its course there is evidence of cyanosis of both the mucous surfaces and the extremities. Jaundice is rarely seen, as is also a petechial eruption. An ophthalmoscopic examination may reveal the presence of choroidal tubercles. If the peritoneum becomes studded with miliary tubercles, abdominal distention follows, and a cyanotic areola may be seen surrounding the umbilicus. Palpation. — ^The pulse increases gradually with the progress of the dis- ease, reaching 120 to 160 a minute, and becomes weak, dicrotic, and compres- sible. The spleen is moderately enlarged, and can usually be felt beneath the costal border. Abdominal tenderness is, in typical cases, conspicuous by its absence. Percussion shows the area of splenic dullness to be increased, and there may be a moderate increase in the area of hepatic dullness. Auscultation. — Numerous fine crackling and moist rales are usually audible over the base of the lungs posteriorly. The heart's action is rapid, and, late in the disease, the muscular tone is deficient. I/aboratory Diagnosis. — With the progress of the disease there may be a moderate amount of sputum in which tubercle bacilli are rarely present. Tubercle bacilli may also be present in both the feces and the urine through- out the entire course of the disease. As a rule, they are commonly present in the circulating blood, a clinical fact that can best be proved by inoculating a guinea-pig with a small quantity of the patient's blood. Diflferential Diagnosis. — It is at times extremely difficult to distinguish between acute ulcerative endocarditis and this form of miliary tuberculosis. The extreme irritability of the heart during the early stage of the illness favors the existence of endocarditis, whereas a cultural study of the blood makes the diagnosis of endocarditis positive in the event of pathogenic bacteria being cultivated from the venous blood. The venous blood in miliary tuberculosis is capable of producing tuberculosis in animals. Leukocytosis is commonly foimd in endocarditis, and is unusual in uncom- plicated cases of tuberculosis. The distinctive features between the typhoid 51 802 ACUTE INFECTIOUS DISEASES. form of miliary tuberculosis and typhoid fever have been discussed at length imder the Differential Diagnosis of Typhoid Fever. (See p. 754.) ACUTE TUBERCULOUS MENINGITIS. This type of tuberculosis may be localized to a certain portion of the meninges, or there may be a miliary tuberculous involvement of the greater portion of the meningeal surface. The symptoms, however, vary in direct ratio with the degree of pathologic change that takes place in each given case. (For clinical characteristics of tuberculous meningitis see p. 1125.) ACUTE MILIARY PULMONARY TUBERCULOSIS. Pathologic Definition. — A pathologic condition resulting in the production of disseminated tubercles, principally throughout one or both lungs in a generalized infection. Clinical Picture. — In those cases in which the miliary infection is chiefly localized to the pulmonary tissue the onset may be sudden. More commonly, however, the symptoms of a general infection are present, to which are added cough, increased respiration, and pleural pain. The sputum becomes mucoid and mucopurulent quite early in the disease, and in certain cases rusty and blood-streaked sputum is seen in which tubercle bacilU are present. Thermic Features. — ^The fever develops early, and usually fluctuates between 102° and 103° F., although more marked remissions and exacerba- tions are occasionally shown. Physical Signs. — Inspection. — The patient displays extreme pros- tration and profound dyspnea, and cyanosis appears upon even the slightest exertion. The respirations are rapid, panting in character, and usually number between 40 and 80 a minute in children. Palpation confirms inspection in regard to the frequency of respirations. The pulse is rapid, even during the first few days of the illness, and continues to increase in frequency as the disease progresses, reaching 120 to 140 or even 160 beats a minute. Percussion. — In typical cases percussion reveals no definite signs as to the pulmonary condition, but in those cases in which small areas of consolida- tion are present percussion may show localized areas in which the note is impaired, and it is customary to find a hyperresonant zone immediately sur- rounding the area of impairment. The area of splenic dullness is enlarged, and may even extend below the costal border, and in some cases the area of he- patic dullness is also increased. It is possible, at times, to have effusion into the pleural cavity as a coexisting feature of this tj^pe of tuberculosis, in which event the physical signs are confusing and demand careful analysis. (See Pleural Effusion, p. 136.) Auscultation. — At first the breath-sounds are merely increased in intensity, and there is but little change in character, but as the disease pro- gresses numerous dry and moist riles are heard. If the pleura is involved, a distinct pleural friction murmur is audible, and occasionally a pleuro- pericardial murmur, synchronous with both the heart and the respiratory sounds, is present. I^aboratory Diagnosis. — The sputum may or may not contain tubercle baciUi; but the baciUi are more likely to be found late than early in the course of the disease, and they may also be present in the feces, the urine, and in the peripheral blood. (See Tuberculin Reactions, p. 806.) ACUTE PULMONAKT TTJBEECULOSIS. 803 Summary and Diflferential Diagnosis.— The severity of the dyspnea, the rapid respirations (60 to 80 a minute), and the extreme cyanosis, when present in adults, point strongly to the existence of acute miliary tuberculosis of the lungs. Failure of the fever to terminate by crisis differ- entiates this condition from lobar pneumonia, and an absence of the pre- existing conditions known to antedate bronchopneumonia is also serviceable in differentiating these diseases. The detection of tubercle bacilh in the sputum, urine, or feces should always be regarded as conclusive evidence of the existence of tuberculosis of the lung. Clinical Course. — The disease progresses from bad to worse, ending in a fatal termination in from eight to twelve weeks. ACUTE PULMONARY TUBERCULOSIS {Acute Pneumonic Phthisis). Varieties. — Two clinical varieties are recognized: (1) The pneu- monic form, in which the clinical features of the disease are those of an ex- tensive lobar pneumonia, the disease running its course, in typical cases, in from two to six weeks, although rarely it may be protracted to from twelve to sixteen weeks. Diagnosis. — This particular type of tuberculosis is to be distinguished from lobar pneumonia ; the distinctive clinical features between these two conditions have been set forth in the table on p. 784. Bronchopneumonic Type. — Clinical Picture. — Here the patient is likely to have a chill, or possibly a series of chills, followed by high fever of an irregular type. Coincidentally with the development of the chill and fever the pulse-beats and respirations are greatly increased. Hemoptysis may be an early symptom, and is soon followed by extreme prostration, rapid loss in weight, and profuse night-sweats {galloping phthisis). Early during the disease cough may be an annoying symptom, but it is not accompanied by expectoration. Later, however, the expectoration may become profuse, and may contain both elastic tissue and tubercle bacilli. Physical Signs. — These are indefinite during the early stage of the disease, and, indeed, only the signs of bronchitis may be present until the disease is well advanced, when, as a rule, there are evidences of the formation ef small areas of pulmonary consolidation — impairment of the percussion- note, bronchial and bronchovesicular breathing, accompanied by numerous rdles. The physical signs just mentioned may be unilateral or bilateral, the latter distribution existing in a large proportion of all cases. As the disease progresses the evidences of softening and cavity-formation appear, and the patient may go into the so-called typhoid state. Differential Diagnosis. — Bronchopneumonia simulates closely the bronchopneumonic form of tuberculosis, and the distinction between these conditions is made, first, from a clear history of the absence of tubercu- losis in other members of the family, or of association with those afflicted with the disease; and, second, upon the detection of tubercle bacUli in the sputum or excreta. The signs of cavity-formation, when they develop, are almost conclusive evidence of the existence of pulmonary tuber- culosis. Typhoid Fever. — When this disease is accompanied by an unusual de- gree of bronchial irritation, tuberculosis may be suspected. The presence of the Widal reaction, the absence of tubercle bacilli in the sputum, and the 804 ACUTE INFECTIOUS DISEASES. prominence of abdominal symptoms (iliac tenderness, gurgling, diarrhea, and t3Tiipanites), together with the history of an existing epidemic, would war- rant a diagnosis of typhoid fever. During the past year we have studied three cases (all negroes) in our hospital service in which typhoid fever and acute pneumonic phthisis were present in the same individual; in each instance the diagnosis was confirmed at autopsy, and in each the ophthalmo- tuberculin reaction and the Widal reaction were present.* CHRONIC PULMONARY TUBERCULOSIS (Chronic Pulmonary Phthisis). Remarks. — In this form of the disease the onset is gradual, and at times insidious. In exceptional instances one of the acute types of tuberculosis previously described may merge into the chronic form. Clinical Varieties. — (l) Initial or incipient phthisis, in which both the physical signs and the symptoms are indefimte until tubercle bacilli appear in the sputum. This clinical form may continue for months or even years, and if judicious treatment is instituted, may terminate in recovery. (2) Advanced tuberculosis is a condition that prevails after the develop- ment of definite physical signs referable to the pulmonary system, although during this stage many symptoms more or less characteristic of the disease are displayed. INQPIENT PHTHISIS. Clinical Picture. — ^The patient usually complains of an increased sense of languor, weakness, and moderate but progressive loss in weight. He may also experience chilly sensations at different times during the disease. The appetite is poor, and fatigue and dyspnea follow even slight exertion, and the patient has for months, and probably years, been unable to take food rich in fats. A distaste for fats is a highly significant symptom. Not infrequently gastric disturbances — e. g., anorexia, with nausea and possibly vomiting after a night's sleep, epigastric distress, eructations of acid sub- " stances, and flatulency — are among the early symptoms, and, indeed, it is often for these that the patient consults the physician, believing that he is suffering from gastric disease. Jacob's report f of 92 cases shows gastro- intestinal symptoms to be present in 91 per cent, of his series. We have studied a large number of cases of beginning pulmonary tuberculosis in which the gastric symptoms practically overshadowed all evidence of disease of the respiratory tract, and in which the associated anemia and 'laboratory investigations made the diagnosis possible. Occasionally slight pleuritic pains are experienced, and if prostration is well marked there is profuse sweating at night. Cough is a common symptom, although in many cases it is but slight, and may be accompanied by but a moderate amount of glairy expectoration. In selected cases the first symptom to arouse the patient's alarm is the expectoration of blood and blood-streaked material, a symptom that, in North America, is highly suggestive of the existence of pulmonary disease. Thermic Features. — SUght fever is ordinarily present at some time dur- ing the twenty-four hours, and in certain cases chills, followed by exacerba- * See also "The Relation of Typhoid Fever to Acute Tuberculosis," J. M. Anders, Amer. Jour. Med. Sci., May 4, 1904. t New York Med Jour., Fe;b. 8, 1913. INCIPIENT PHTHISIS. 806 tions of temperature and profuse sweating, are present; it is in this par- ticular class of cases that the disease in a measure simulates malaria. Physical Signs.— These may be indefinite at the onset, Init within the course of a comparatively short time — a few weeks or months — they be- come plainly manifest. Inspection. — The characteristic phthisical chest, which is abnormally long and narrow, with widened interspaces, altered angle of the ribs, a con- spicuous degree of flattening at the anterior surface of the chest, is often present; but by no means do all those developing tuberculosis display this type of thorax. In the African negro and in mulattos and quad- roons the chest is generally very flat. Expansion is usually limited to one or other apex, and depres- sion of the supraclavicular and in- fraclavicular spaces is often pres- ent early, and, as a rule, more marked upon one side (Fig 291). The mucous membranes may be anemic, and evidences of emacia- tion, with extreme pallor, may also be manifest. Palpation. — In those cases in which the initial site of pul- monary inflammation is at one or the other base, nothing positive is revealed by palpation until a later stage in the disease is reached. If the apex of one lung is involved, the tactUe fremitus is appreciably increased early, especially if the involved area is near the anterior surface of the chest-wall, or situ- ated near that portion of the chest posteriorly that is uncovered by the scapulte. As the disease progresses the fremitus may be increased over a large portion of the surface of the chests Tactile fremitus may be increased as the result of pleural adhesions, a clin- ical fact of considerable moment, especially when the increase is over dis- tinctly localized areas at different portions of the chest. Mensuration. — In the vast majority of cases the chest expansion is be- low that of the normal; this is true even of the earliest cases, and later de- ficient expansion of one side of the chest becomes marked. Chronic pleui'isy also influences the measurements of the chest. (See Pleurisy, p. 156.) Percussion. — Resonance is impaired over the affected area, and as the disease progresses distinct dullness will be elicited when sufficient con- solidation has resulted. Impairment of the percussion-note is more likely to be detected at the right than at the left apex. In selected cases the im- pairment may first become manifest along the spine and just within the inner border of the scapulae when the arm is drawn well across the chest. Auscultation. — Extremely fine, moist, craclding rales are audible directly over the area of involved lung, and are heard most distinctly at the end of inspiration. Slight prolongation, roughening, or hoarseness of the expiratory murmur are among the earliest signs of pulmonary involvement. Fiy a comparatively thick Fig. 298. — Plkthisy on' the Right Side (Pfahler). A, Old tubercle; B. disease at the left apex. wall of consolidation, is present. Wintrich's change of note (see p. 62) and the cracked-pot sound, if a superficial cavity communicates with a bronchus or is partially filled with fluid, are valuable signs. (6) The presence of tubercle bacilli in the feces and urine support the diagnosis, although their recoveiy from these excretions should not be re- garded as sufficient evidence on which to base a diagnosis of pulmonary tuberculosis, but would favor a diagnosis of a tuberculous lesion either of the alimentary or of the genito-urinary tract. (7) After cavity-formation has occurred the x-ray diagnosis gives posi- tive information. (See p. 815.) Diflferential Diagnosis. — In the incipient stage the differential diagnosis is of serious moment, and, as a rule, its making is attended with 52 818 ACUTE INFECTIOUS DISEASES. considerable difficulty. Here the clinical history, as previously mentioned under Diagnosis, together with a careful analysis of the signs and symptoms presented by the case in question, must be obtained in order that definite deductions may be drawn. The recovery of the tubercle bacillus from the sputum makes the diagnosis positive, and in the absence of this clinical evi- dence, the recovery of many tubercle bacilli in the feces should suggest, at least, the existence of tuberculosis. The employment of the cutaneous and ophthalmotuberculin reactions is to be considered in obscure cases. Bronchial catarrh (apical catarrh) may simulate advanced tuber- culosis in certain respects, the distinctive features of the former being that rales are heard over both apices, that tubercle bacilli are absent from the sputum, that there is but little fever, which is never hectic in character, and that emaciation and prostration are mild. Bronchiectasis. — It is to be remembered that if a portion of a bronchus is expanded, the physical signs of pulmonary cavity are present; consequently the differentiation is based entirely upon the symptomatology and course. (1) The naked-eye appearance of the sputum in bronchiectasis (see p. 101) is quite different from that of pulmonary cavity, and again in bronchiectasis tubercle bacilli are absent. (2) Nutrition is comparatively good in bron- chiectasis, whereas emaciation is progressive in phthisis. (3) Elevated temperature is rare in bronchiectasis, whereas in tuberculosis with cavity- formation hectic fever is the rule. Streptothricosis (pseudotuberculosis) may rarely be confounded with pulmonary tuberculosis, and the distinctive features between these two con- ditions have been detailed on p. 925. Actinomycosis. — This rare pulmonary disease may at times simulate tuberculosis, the points of difference between the two being discussed in detail on p. 922. Clinical Course. — In incipient tuberculosis the clinical course may not only be materially modified by judicious treatment, but recovery may follow when such treatment is instituted and continued for a sufficiently long period. Those cases that go on to the second stage of the disease will be found to linger over an indefinite period, the length of which is somewhat influenced by the age of the patient — the younger the individual, the more rapid and the shorter the course of the disease. When pulmonary tuberculosis develops after the age of fifty, the patient's life may be but slightly, if at all, shortened as the result of the pulmonary condition, whereas in early adolescence — from fourteen to twenty-five — a more virulent tj^e of infection is present and destructive changes in the lung develop early. Complications. — Pulmonary hemorrhage is probably the most frequent complication, and is always to be feared during the course of the disease. When it develops during the incipient stage, it may not be of serious prognostic import. On the other hand, it is followed at times by decided relief from local symptoms. Rupture of a cavity into the pleura, with subsequent development of pyopneumothorax, is a serious complication, and likely to terminate fatally, although in two instances coming under our observation recovery from the pneumothorax followed. Tuberculosis of the larynx compUcating the pulmonary type of the disease is a precursor of an early fatal termination, since nutrition is inter- fered with. Enteritis is followed by severe depletion of the patient, and materially shortens the course of the disease. TUBERCULOSIS OF THE SEROUS MEMBRANES. 819 Acute miliary tuberculosis may develop at any time, even during the incipient stage. (See Varieties of Miliary Tuberculosis, p. 800.) Tuberculous pleurisy may have antedated tuberculous disease of the lung, and is likely to recur as a complication after cavity-formation has taken place, when there may be added the characteristic signs and symptoms of pleural effusion. (See p. 154.) Amyloid disease of the liver, spleen, kidneys, and intestines is occa- sionally found at autopsy. Peripheral neuritis and acute endocarditis are rarely seen to com- plicate this type of tuberadosis. FIBROID PHTHISIS. Pathologic Definition.— A type of chronic phthisis, character- ized by the extensive formation of fibrous tissue at one and possibly at both apices. This fibroid change may continue for an indefinite period, until great deformity of the chest over the portion of the lung affected results. Clinically, expansion over the affected portion of the lung is limited or absent; the percussion-note is dull, and the heart may be uncovered as the result of extensive sclerotic changes, with retraction of the lung. In other cases the heart may be drawn well to the right side of the body from con- tracture of fibrous bands. The respiratory murmurs are bronchovesicular or bronchial in quality, and the various types of rales (see p. 69) are likely to be present at different stages of the disease. Vocal resonance is, as a rule, diminished, although in a certain proportion of cases the voice sounds may be increased in intensity. Diagnosis. — ^This is based largely upon the history of long-standing disease, with gradual deformity, and the detection of tubercle bacilli in the sputum. Clinical Course. — ^The case seldom, if ever, terminates in less than ten years, and cases of twenty years' duration are far from uncommon. TUBERCULOSIS OF THE SEROUS MEMBRANES. Tuberculous Meningitis. Pathologic Definition and Remarks. — A disease characterized by the development of tubercles on the pia-arachnoid of the brain and the spinal cord and by an increase in the quantity of cerebrospinal fluid, in which, in certain cases, tubercle bacilli may be found. (See Tuberculous Meningi- tis, p. 1125.) Tuberculous Pleurisy. Remarks. — In the majority of cases of acute pleurisy the tubercle bacil- lus figures as an etiologic factor. (See Predisposing and Exciting Factors, p. 154.) Tuberculous Peritonitis. Pathologic Definition. — A type of subacute or chronic inflamma- tion of the peritoneum caused by the tubercle bacillus, and characterized by the development of tubercles of varying size, and by the accumulation of fluid in the peritoneal sac, in which tubercle bacilli may be demonstrated. The fluid will produce tuberculosis when inoculated into susceptible animals. (See Tuberculosis of the Peritoneum, p. 560.) g20 ACUTE INFECTIOUS DISEASES. TUBERCULOUS ENDOCARDITIS AND PERICARDITIS. See Pericarditis, p. 237. Tuberculosis of the Liver, Pathologic Definition.— A disease of the liver in which tubercles of varying size are found disseminated throughout the hepatic tissue. Owing to both its anatomic and its physiologic relations, the liver serves as a mdus for the lodgment of tubercle bacilli that have gained entrance to the ar- terial, venous, or lymphatic channels; consequently tuberculosis of the hver is, as a rule, a secondary condition. Predisposing Factors.— Those suffering from any form of tuber- culosis are especially Hkely to develop tuberculosis of the liver. Hepatic tuberculosis not infrequently follows a similar condition of the alimentary tract, particularly when the lesion is situated in the colon. Bone tuber- culosis with caries serves as a marked predisposing factor to both the he- patic and the pulmonary types of the disease. Clinical Features. — Among the constitutional features of hepatic tuberculosis are emaciation, prostration, and fever; the last may be but slight, and of such nature as not to indicate the existence of tuberculosis. There is symmetric enlargement of the liver, which continues throughout the entire course of the affection. Pain is uncommon until the peritoneal covering of the viscus becomes involved, when the symptoms will usually simulate those of chronic peritonitis. (See Tuberculosis of the Liver, p. 595, and Tuberculosis of the Peritoneum, p. 560.) Renal Tuberculosis. This form of tuberculosis has been discussed at length imder the heading Disease of the Genito-urinary Tract. (See p. 685.) Tuberculosis of the Bladder, Prostate, and Ureters. Remarks. — These forms of the disease, while less common than tuber- culosis of other portions of the body, are often discovered at autopsy. They are more common in adults than in children. Their clinical characteristics have been detailed in the section on Genito-urinary Diseases, p. 705. Tuberculous Orchitis. The testicles may be the site of tuberculous disease, which occasionally occurs simultaneously with involvement of the peritoneum and the kidney. In tuberculosis of the testicles the epididymis is appreciably enlarged, and may equal or exceed the remainder of the gland in size. Pressure may ex- cite pain. Tuberculosis of the testicle is a purely surgical condition, and the reader is referred to works upon surgery and genito-urinary diseases for a complete description of this condition. Tuberculosis of the Ovaries and Fallopian Tubes. In this condition there is usually a family history of tuberculosis, but the other diagnostic measures within the scope of this volume are not sufficient on which to base a diagnosis of the condition. Later the symptoms be- come masked, as it were, by an associated tuberculous peritonitis, when the disease is treated by the physician as peritonitis. TUBERCULOSIS OF THE SEROUS MEMBRANES. 821 Tuberculous Arthritis. Pathologic Definition. — A subacute or chronic inflammation of the synovial membranes, due to the bacillus tuberculosis. Tuberculous arthritis is a surgical disease, and the reader is referred to special works upon surgery for an extended description of the subject. Some of the distinctive features between tuberculous arthritis and acute articular rheumatism, however, will be found on p. 896. I Tuberculosis of the Mesenteric Glands. These glands are, as a rule, involved secondarily to tuberculosis of the intestines, although in children the glandular type of the disease ap- pears to equal, and possibly may exceed, in frequency the truly intestinal type. Tuberculosis of the Tracheobronchial Lymph-nodes. Pathologic Definition. — A condition excited by infection of these structures by tubercle bacilli. Predisposing Factors. — This disease is more common in children than in adults, although it may be met quite frequently after middle life in those suffering from pulmonary tuberculosis. Tuberculosis of other lymph- nodes, such as the cervical and the axillary, is usually present. Symptomatology. — The most annoying symptoms are the mechanical ones, arising, as they do, from pressure excited by the lymph-nodes when they have become sufficiently enlarged. The mediastinal lymph-nodes are the ones usually affected, and if they should press upon the recurrent laryn- geal nerve, paroxysmal cough, aphonia, and paroxysms of dyspnea foUow. Pressure upon the superior vena cava is followed by extreme cyanosis, with swelling and edema of the face. Edema of the lower extremities may also result from pressure upon the circulatory apparatus. Fig. 133, p. 323, will serve to demonstrate the effect of pressure from mediastinal growths, as seen in a patient under our care. In most instances the patient complains of distress in breathing upon exertion, and in some cases there is pain in the chest; cough with free expec- toration may be a constant feature in those cases in which paroxysmal cough is absent. When cyanosis has continued for months, or even years, the parts of the body affected become distiuctly pigmented. Physical Signs. — it is usually possible to eUcit the physical signs of consolidation in the mediastinum, and these signs are often equally promi- nent, or even more marked, in the interscapular space, between the second and fifth thoracic vertebrae. The breath-sounds are at times weU transmitted along the borders of or over such enlargements; consequently the respiratory sounds are of but limited clinical value. I^aboratory Diagnosis. — The cough may be accompanied by the expectoration of an extremely tenacious sputum, although in those cases in which a bronchus is partially occluded as the result of pressure, copious ex^ pectoration is seen, and in these the symptoms may closely resemble those of bronchitis. (See p. 88.) Occasionally an enlarged lymph-node may break and rupture into a bronchus, such an accident being followed by the copious expectoration of caseous, semiliquid, blood-streaked material. Summary of Diagnosis. — Paroxysmal cough, hoarseness, swelling of the face and neck, with im(iue prominence of the superficial veins of the 822 ACUTE INFECTIOUS DISEASES. chest, and at times of the alxlomen and extremities, are sufficient to suggest intrathoracic obstruction to the venous circulation. Tuberculosis of the lung is likely to follow, and may even precede, involvement of the bronchial lymph-nodes; consequently a histor}^ pointing to the existence of the former disease is to be considered. Tubercle bacilli are but rarely detected in the sputum, but their presence strongly supports the diagnosis of tuberculosis of the mediastinal lymph-nodes. Differential Diagnosis. — Aneurism is to be distinguished from enlarged mediastinal lymph-nodes, a distinction that may be made from the following clinical facts: In aneurism there are, in addition to the signs and symptoms resulting from enlarged bronchial lymiah-nodes, ineciuality of the radial pulses, hypertrophy of the heart, pulsation with shock over the area Fio. 299.— Tuberculous Adenitis. Female, aged sixteen years, treated at Philadelphia Hospital. Diagnosis confirmed by section of small gland which showed tubercle bacilli four months before death. Autopsy not permitted. of consolidation, and a bruit, all of which features are unknown to glandular enlargement. Tuberculous Cervical Adenitis. Pathologic Definition. — Chronic enlargement of the cervical lymph-nodes resulting from infection with the tubercle bacillus. Clinical Picture. — In typical cases the submaxillary lymph-node (Fig. 299) is the first to give evidence of disease, but subsequently there is enlargement of the h'mph-nodes in the postcervical, supraclavicular, and scapular .systems, antl enlargement of the bronchial lymph-nodes may also follow. Tuberculous adenitis is, as a rule, a bilateral disease, although generally the hmiph-nodes of one side enlarge in advance of the corresponding structures of the opposite side. All the involved organs en- large slowly, and when such enlargement is first detected, it may vary in size from that of a pea to that of a hazel-nut; after the disease has progressed for months or years, however, it is unusual to see cases in which the lymph- nodes attain the size of a hen's egg. These enlargements, as a rule, occur in SYPHILIS. 823 r K clusters, are smooth, and seldom attach themselves firmly to the skin until just prior to rupture externally. If one or more lymph-nodes break down after undergoing caseation and liquefaction, fluctuation will Ije present. Diagnosis. — Fluid obtained from an enlarged lymph-node may con- tain but few tubercle bacilli, although animals either fed upon cu- inoculated with such fluid are likely to develop tuberculosis. The characteristic growth of the structures, combined with the presence of slight fever, anemia, and pro- gressive loss in weight, strongly favors a diagnosis of tuberculosis. There is also likely to be chronic catarrhal disease of the pharynx and larynx, and enlargement of the tonsils in those suffering from tuberculous adenitis. Suppurative otitis media, keratitis, and chronic conjunctivitis are also com- monly present. Finall}^ chronic eczema of the external auditory' canal and of the lips is not infrequent in connection with tuberculous involvement of the superficial glandular system. (See Special Tuberculin Reactions, pp. 806-809.) Diflferential Diagnosis. — Pseudoleu- kemia, particularly at the onset, is more readUy confused with tulierculous adenitis than is any other disease. Although acute tuberculous ad- enitis may closely smrulate Hodgkin's disease and make a diagnosis l^etween the two almost impossible, more often the lymph-nodes in tu- berculous adenitis enlarge more slowly than they do in Hodgkin's disease. The extension of the lymphatic enlargement of tuberculosis is rare as compared with pseudoleukemia, and, again, tuberculous adenitis is more common in the young, is commonly unilateral in the neck, and attacks the submaxillary lymph-nodes more often than the structures along the sternomas- toid muscle. Periadenitis, adhesion, and sup- puration of the lymph-nodes are seen in tuber- culosis, and tuberculous foci may also be found in other organs. Intermittent attacks of fever favor the presence of Hodgkin's disease. Some one or more of the tuberculin tests (see p. 806) should be employed in making a differentiation between these conditions, and, if necessary, a portion of a diseased organ may be removed for laboratory diagnosis. A hematologic study is necessary in eveiy instance since chronic glandular enlargement may be a feature of true leukemia and the latter condition is recognized only by making a differential count of the leukocytes. The therapeutic test serves as the most practical method for distinguish- ing between tuberculous adenitis and syphilitic adenitis. Fig. 300. — The Two Spiro- chetes IN THE Center are Treponema Pallidum; the Three Others, Spiro- CH.ETA Refringens (Schau- dinii and Hoffmann). SYPHILIS. Pathologic Definition. — A chronic infectious disease, believed to be excited by treponema pallidum. (a) Primary Lesions. — These consist of an infiltration of the connective tissue, chiefly with round-cells, of the same type as those seen in recent granulations. There is sclerosis of the smaller blood-vessels involving the adventitia of the arterioles, and the neighboring lymph-nodes undergo hyper- plasia and induration. 824 ACUTE INFECTIOUS DISEASES. (b) Secondary Lesions. — Macular, maculopapular, papular, and pus- tular lesions are seen on the cutaneous surfaces, and, with the mucous patch, show round-cell infiltration with plasma cells and leukocytes and changes similar to those found in chancre. The favorite sites for the appearance of mucous patches are the mucocutaneous junctions, e. g., the mouth, anus, and vulva (Fig. 301). Other lesions appearing in this stage are general adenopathy, alopecia, and pharyngitis. (c) Tertiary Lesions. — These consist of circumscribed inflammatory masses, known as gummata. They appear in the connective tissue, bones, periosteum, skin, muscles, brain, liver, lungs, kidneys, heart, testes, etc. Although usually sharply circumscril^ed, gummata may he diffuse, and may vary in size from that of a pin-point to a hen's egg. They tend to form ulcers. They are grayish in color, and on section show a caseous, semiopaque center, with a fibrous, translucent periphery. Microscopical! I/, the gumma consists of lymphoid cells, plasma cells, leukocytes, and epithelioid cells, in which fatty degeneration and softening result in the forma- tion of a pasty mass. The mass thus formed may either be ab- sorbed or persist; in most in- stances, however, coagulation nec- rosis, due to local anemia, takes place in the center, with conver- sion of the peripheral zone into fibrous tissue. The central case- ous material may be absorbed, or may remain as a calcareous mass with a cicatrix. Destructive ul- ceration and sloughing may follow. Syphilis shows a special predilec- tion to attack the nasal and frontal bones, the palate, and the tilDise. "Varieties. — (1) Acquired s}T3hilis:^ (2) congenital syphilis; (3) malignant syphilis; (4) vis- "»'^'°^'- ceral syphilis. Predisposing and Bxcit- ing Factors.— Bacteriology.— Schaudinn and Hoffmann have described an organism which is now known as treponema pallidum (Fig. 300) which is found in the lesions of syphilis during all stages of the disease. Acquired syphilis occurs only as the result of inoculation, a break in the cutaneous or mucous surfaces, e. g., a shght abrasion, fissure, or laceration, particularly of the genital mucosa, l^eing essential to infection. The lips and hands may be the seat of the lesions. SiisceptibilUu is universal. Reinjection is exceedina;lv rare, but may occur Contagion of Syphilis.— The blood of a syphilitic during the sec- ondary period and the secretion from the chancre or any of the secondary lesions are contagious, the lesion at the point of inoculation always beintr a chancre. The physiologic secretions— saliva, sweat, milk, and urinfr-^do not convey the virus unless they become contaminated by admixture with Fig. 301. — Mucous P.A.TCHEa on Lip (Schamberg). Lesions are deeper and rather more excavated than SYPHILIS. 825 the discharge from some of the lesions of the primary or the secondary stage. The semen is capable of infecting the embryo. Modes of Infection. — (1) Direct Inoculation. — In approximately 70 per cent, of cases syphilis is transferred by sexual intercourse. (2) Accidental inoculation most frequently results from kissing. " In Russia from 75 to 80 per cent, of cases is acquired in this manner from popular customs" (Anders). The mouth and tonsils may be the site of inoculation, the virus being conveyed during the practices of sexual per^^erts. The wet- nurse may infect the suckling babe, or vice versa. Fournier cites forty instances of chancre of the hand. Humanized vac- cine virus may in rare cases transmit the disease. Unusual Modes. — Acciden- tal infection has, at times, though very rarely , taken place as the result of handling in- fected rags, clothing, drinking- cups, pipes, cigars, and the hke; it has also been known to fol- low tattooing. " Krafft-Ebing found that out of 3455 cases, 15.6 per cent, were of extragenital origin. The lesion was upon the lip in 51 per cent" (Anders). (3) Hereditary Transmis- sion. — Paternal transmission (through the semen) is more common than maternal. Ap- propriate treatment of a syph- ilitic parent greatly lessens the danger of transmission, and in such instances the danger of transmission after the third year of treatment is slight. A syphilitic father or mother may beget healthy offspring, the infants having acquired an immunity that protects them from infection by the mother (Profeta's law). Infected wo- men not uncommonly bear syphilitic children. A woman who has become infected after conception may bear a syphilitic child, although, on the other hand, the infant mav escape infection. Immunity.— Those bom of syphilitic parents may possibly possess a certain degree of natural immunity. A woman that has borne a syphilitic child may enjoy perfect immunity (Colics' law). One attack of syphilis usually bestows immunity. Fig. 302. — PnsTnLAR Syphilid (Welch and Schamberg). During an epidemic of variola this patient was sent into ttie smallpox hospital under erroneous diagnosis. 826 ACUTE INFECTIOUS DISEASES. ACQUIRED SYPHILIS. Clinical Stages.— (1) Primary Stage.— The typical lesion— the chancre — makes its appearance in approximately three weeks after exposure, and within the course of a few days, or at most a fortnight, is foUowed by swelling and induration of the surrounding l}-mph-nodes. The primary lesion appears as a red papule that soon increases in size and shows a tendency to undergo central necrosis with the formation of a small ulcer. The tissue immediately surrounding the ulcer becomes appreciably hard- ened and of cartilage-like consistence— hence the term, "hard chancre." A single lesion is the rule, although two distinct chancres may be present. The chancre may iDe situated within the urethra, near the meatus, but is most likely to occur at or near the junction of the mucous membrane with the skin. " We have seen a number of cases in which the initial chancre made its appearance on the skin, in the mouth, and in one instance upon the cer^-ix uteri. The primary le- sion of syphilis may be so slight as not to attract the attention of the patient, and, as a consequence, we not uncommonly see females in whom no initial lesion was ob- served ( lisplay the secondary mani- festations of the disease. (2) Secondary Stage. — The manifestations of this stage occur within about six weeks after the appeai'ance of the chancre, al- though a much longer interval may iuter^'ene between the ap- pearance of the chancre and that of the secondary stage. The pa- tient complains of languor, a sense of indisposition, aching oj the bones, anore.ria or impaired digestion, and a moderate degree of prostration. Soreness of the throat nnxy be pres- ent, and at times the patient com- plains of pronounced angina. Th ertn ic Features. — ^Moderate fever is the rule, the temperature usually fluctuating between 100° and 101° F., although in exceptional cases it niaj^ run higher. Skin and Lymph-nodes. — The cutaneous manifestations are polymorphous, although an erythematous or roseolar eruption is commonly the earliest cutaneous manifestation of this stage of the disease. The eruption is, as a rule, profuse upon the trunk, chest, back, buttocks, thighs, and forearms. Papules may also appear early, and will be found to vaiy greatly in size. The papular form of the eruption is frequently conspicuous on the face, trunk, and flexor surfaces of the extremities. The lesions are rounded and symmetrically distributed on the two sides of the body. These lesions are, as a rule, symmetric, their outlines being more or less perfectly rounded, and in color they resemble that of a slice of beef, displacing a slight coppery hue. These lesions are usually not accompanied by either itching or pain. Fig. 303. — Seepiginotts Syphilid; only Patches Frf.sext (Schamberg;. ACQUIRED SYPHILIS. 827 _ The lymph-nodes are appreciably enlarged, especially in the cervical and epitrochlear regions. Mucous Membrane. — Mucous patches are seen to occur upon the mucous surfaces, especially at the angles of the mouth, on the tongue, upon the tonsils, pharynx, and vulva, and about the anus. Late m the secondary stage true pustules may be seen (Fig. 302), and the cutaneous lesions show a decided tendency to become agglomerated in certain portions of the body; they are seklom diffuse, and are not so likely to be symmetrically distributed as the earlier secondaries. After the sec- ondary stage of the disease has advanced for a period of weeks or months, the patient maj- complain of certain other symptoms, among which falling of the hair is most common (Fig. 304). Pharyngitis may be annoying, and the patient may state that his fmger-nails are becoming ' ] unusuaUy brittle. Various ocular manifestations, such as iritis, choroiditis, and retin- itis, may develop during this stage. Duration. — Tlris stage usu- ally continues for from two to three months, although it may run a much longer course — from eight months to one 3'ear. The interval between this stage and the onset of the ter- tiary stage varies greatly in different cases, and may be from a few months to many years. The s^-mptoms displayed during the secondary stage vary greatlj^ in severit}^, and no satisfactory cause for such variation can be given. (3) Tertiary Stage.— Oc- casionally tertiaiy symptoms may develop while the late sec- ondaiy lesions of syphilis are still visible. In this stage the cutaneous manifestations are important ; among these are the characteristic rupia, which appears first in the form of pus- tules that later break down with the formation of ulcers that become covered with true, laminated crusts — the so-called "oyster-shell" lesion (Fig. 304). The tubercular variety of lesion is generally seen upon the face, back, and extremities. The cutaneous lesions just described affect only the true skin, and leave distinct scars on healing. These lesions are not believed to be infectious or contagious, and are at times attended liy itching. The detection of treponema pallidum in gummata, however, would seem to throw doubt on the accuracy of this belief. True gummata may be seen to develop in the skin, and may involve the subcutaneous tissue ; these lesions later tend to break down, with the formation of reniform idcers that, in many instances, show a tendency to suppurate. Healing of sj^h- FlG. 30-i.— Syphilis. This case had originally been quarantined as one of smallpox, but was later admitted to the venereal wards of the Philadelphia Hospital. 828 ^ ACUTE INFECTIOUS DISEASES. ilitic ulcers takes place somewhat slowly, and scar formation may be ex- tensive. Mucous Membrane. — Gummata are to be seen upon the mucous mem- branes, where they pass through the successive stages of ulceration and cica- trization. If the gummatous lesion should involve the rectal mucosa, diar- rhea may be present, and, following the healing process, stricture may result. Muscles. — Gummata may appear within the muscle substance in the form of small, hard tumors. Bones. — The osseous structures are not infrequently attacked, and peri- ostitis, followed by necrosis, is occasionally seen. As previously stated, syphilis shows a special predilection to attack the frontal (Fig. 304), the nasal, and the palate bones, and the tibiae, although other bones may be attacked. Bone lesions, as a rule, give rise to pain, this symptom being most marked at night, and increased even upon making slight pressure over the affected organ. Lymph-nodes. — Glandular involvement is common; the affected struc- tures show but slight tendency to go on to suppuration. In certain cases, also, the testicles are attacked. Viscera. — Gummata are occasionally seen in the viscera, a condition that will be discussed further on. Amyloid degeneration of the liver and of the other structures may follow tertiary syphilis. Malig^naut syphilis is a rare but unusually virulent and fatal type of the disease. The successive clinical stages appear early and in rapid suc- cession, a feature that is especially true of the development of tertiary lesions. Malignant syphilis is further characterized by the fact that it resists treatment. A. E. Roussel has described a case that terminated fatally within the course of one year. I/aboratory Diagnosis.— Scrapings from the initial lesions and from the mucous patches, moist papules, and other cutaneous manifestations may show the presence of the treponema pallidum. Recent investigations have shown that syphilis may be diagnosed from the detection of antibodies in the blood by the method of complement binding. Antibodies are as- serted to be present in the blood of syphilitics irrespective of the length of time that has elapsed since the appearance of the initial chancre. (See special works on Laboratory Diagnosis. See a]so Wasserman Reaction, under Locomotor Ataxia, p. 1121.) After the secondary stage is well ad- vanced, marked secondary anemia is generally present, this condition im- proving after the administration of specific treatment. Justus's blood-test consists in a distinct, though transient, reduction in the percentage of hemoglobin following the administration of mercury, given either by inunction or hypodermatically, but it must be remembered that a similar, though possibly less well-marked, reduction may be seen to occur in non-syphilitic individuals. Cobra Venom Reaction (Weil's).— Dr. R. Weil* gives in detail the hemolytic change following his experiments with the blood from various types of disease. An extraordinary degree of resistance to the action of cobra venom is exhibited in blood from syphilitics following the primary stage. In case the cells show a lesser degree of resistance the disease ia question is not syphilis. The possible exception is cancer, where the hemo- lytic changes resemble those of syphilis. Summary of Diagnosis. — Great importance attaches itself to a clear history of the initial chancre in those cases seen after the disappearance * Jour Inf. Diseases, Nov., 1909. HBHEDITAEY SYPHILIS. 829 of the primary lesion. In the absence of a positive history of chancre, fol- lowed by the appearance of secondary symptoms, such as malaise, slight fever, and the characteristic eruption, the diagnosis may be made only with difficulty. When, however, the symptoms of the secondary stage are present, syphilis can scarcely be mistaken for any other disease. During the tertiary stage, if the manifestations of the first and second stages have been un- usually slight, the condition maygive rise to confusion. On the other hand, the presence of the characteristic lesions of the tertiary stage renders the diagnosis clear, but at3T)ical cases are by no means uncommon, and in such the therapeutic test, when followed by improvement in the patient's general condition, confirms the diagnosis. The recovery of treponema pallidum from the lesions is positive evidence of the existence of the disease. Differential Diagnosis. — Numerous affections and conditions, both local and general, are likely to be confounded with syphilis. Only a few of these will be mentioned here : (1) Epithelioma.- — The primary sore of the lip has been repeatedly mistaken for epithelioma. The history and symptoms of syphilis, together with the therapeutic test, will clear up any doubt. In one case coming under our care a chancre of the cervix was diagnosticated as carcinoma by two gynecologists and an operation advised. (2) Skin Eruptions. — Lichen, psoriasis, papular eczema, measles, etc., may be mistaken for the eruption of secondary syphilis, and for their differ- entiation the reader is referred to special works on Diseases of the Skin. (3) The specific eruptive fevers, and particularly the pustular stage of smallpox, have been mistaken for secondary syphilis. (4) Sj^hilitic arthritis, which may develop at the beginning of the second stage, is to be distinguished from rheumatic arthritis. This is best accom- plished by making a careful study of the history of the primary lesion, and the characteristic secondary manifestations of syphilis. (5) The tertiary stage of syphilis may simulate chronic gout or rheu- matism, and unless there is definite evidence of the presence of syphilis, on the one hand, or typical rheumatic symptoms and history on the other, the diagnosis may remain indefinitely uncertain. The therapeutic test, however, may lend assistance. (6) Periosteal nodes, similar to those occurring in syphilis, may foUow acute infections, e. g., smallpox and tj^hus and typhoid fevers, and here again the diagnosis is attained only by making a careful study of the clinical h^tory, and as the result of the therapeutic test (see Justus's Test, p. 828), as well as by the detection of the treponema pallidum in portions of the nodule. (7) Enlargement of the tonsils may result from syphilis, and such en- largements may be confounded with epithelioma of these organs. (8) During the febrile period of syphUis the clinical picture may resemble, in many respects, that seen in tuberculosis. The therapeutic test, a careful examination of the blood, Calmette's ophthalmotuberculin reaction (p. 807), and von Pirquet's needle-track reaction (p. 807) will usually serve as means for differentiating between tuberculosis and syphilis. HEREDITARY SYPHILIS. Clinical Features. — These may, in rare instances, resemble those pre- viously described under Acquired Syphilis; in the hereditary form, however, chancre is absent. In certain cases the characteristic symptoms are present 830 ACUTE INFECTIOUS DISEASES. at birth, although in the vast majority positive symptoms maketheir ai:i- pearance between the first and fourth months of life. " Kassomtz states that one-third of all children procreated of syphilitic parents are bom dead, and of those l:iorn living, 24 per cent, die within the first six months of life" (Anders). Inherited syphilis may further be classified according to the time at which symptoms make their appearance. In the new-born there is a lack of physical development. The child is greatly emaciated, " snuffles" is present, and hiccough occasionally appears 'soon after birth. Cutaneous eruptions are rare, but pemphigus neonatorum may attack the palmar surfaces of the hands and the soles of the feet. Among the rare skin phenomena are gummata around the radiocarpal articulations, palmar psoriasis, and roseola. Ulcers and fissures may be seen about the mouth and the anus. The bony skeleton may show hyperostoses of the long bones. Enlargement of the liver and spleen is common. Pseudo- paralysis has also been olisen^ed. Early Postnatal Symptoms. — Many subjects of hereditarj^ syphilis are well developed at l)irth and exhibit no manifestations of the disease, symptoms appearing, in the majority of cases, not later than the third month. Coryza (syphilitic rhinitis) is often the initial symptom, being accom- panied by a seropurulent and at times a bloody discharge — a peculiar form of obstructed breathing rendering nursing difficult. Coryza may be preceded by suigultus, and ulcers may form in the nose, leading to nea-osis of the bones and ultimate deformity of the organ. Coryza, otitis media, and deajness are the chief symptoms, and the skull may be asymmetric in conformation. The cutaneous symptoms appear early. The skin has a tawny hue; the nates and genitalia are the seats of an erythematous eruption. Onychia is seen at times, and the lips and angles of the mouth may show well-marked fissures. There may be a moderate degree of glandular enlargement, and falling of the hair may occur. Splenic enlargement is a common feature, and when seen before the third month, is of great diagnostic importance. The liver may also be en- larged, but this symptom is of less diagnostic importance than is enlargement of the spleen. Syphilitic infants at times display a marked tendency to develop hemorrhage, and at birth, or within the course of a few days, there may be bleeding from the cord and hemorrhage into the subcutaneous tis- sues and from the mucous surfaces — e. g., the vagina, stomach, and mouth. Syphilitic children are generally restless and sleepless, and may give utter- ance to a peculiar, harsh, shrill cry. Both anemia and cachexia are to be seen. Late Symptoms.— The manifestations of congenital syphilis that develop later m life have been grouped under the foUomng subheadings : (1) Those cases in which the general appearance of the child is a promi- nent feature, and is indicated by a retarded development l)oth of the bony H|^H IH| k$ if* 0:. g^': .■■.^■"- fc fefc-^ l£. "**-'^*'"*^ nia IKk<-'''^ -lI^I m\ *"^^ ■"'' W ' ^ f^^ rii m w^^ h'^'- '-<■' '^T^5^ 1 ^^ W: ^ '■*' **»^ Bp /^.'V-.-'' ■ J2 m Fig. 305. - -Hutchinson's Teeth in a Child with Her- editary Syphilis (Schamberg). VISCEEAL SYPHILIS. 831 structures and of the muscles. This feature may be so pronounced that a child from four to twelve years of age may resemble an infant in size and form. The skin of such children has an earthy tint, and the hair is scanty and poorly nourished. (2) Those cases in which lesions of the skeleton are prominent show the so-called "natiform skull" — a transverse enlargement, lateral bulging, and flattening in the middle. At times the skull may be hydrocephalic or asym- metric, and deformity of the nasal bones, as previously stated, is by no means unusual. Thickening or deformity of the tibiae and of the sternum may also be seen. (3) Cicatrices. — These are seen upon the cutaneous surface, and also about the nose, mouth, soft palate, and genitals. Hutchinson's Teeth. — In some syphilitic children the teeth are erupted late, and often present various irregularities. (See Fig. 305.) The dental arch may be deformed. In rare instances the child may be born with one or more teeth. The incisors, especially the superior median of the second dentition, are notched, and show a thinness of the free edge, atrophy of the summit, and crescent-shaped erosions (Fig. 305). The ab- sence of one, two, or more teeth is an occasional feature of inherited syphilis. Auditory Manifestations. — Otorrhea, previously referred to, is, as a rule, secondary to syphilitic disease of the nasopharynx, and an increasing form of deafness appears at about the time of puberty. Ocular Manifestations. — Interstitial keratitis and iritis are to be seen in inherited syphilis. The testicle may fail to develop at puberty, showing the condition known as "infantile testicle." VISCERAL SYPHILIS. Syphilis of the Nervous System. — See chapter on Diseases of the Nervous System, p. 1118. Syphilis of the Liver. Gummata develop in the substance of the liver, and, following their absorption, the organ becomes distinctly lobulated. The viscus may also be further deformed as the result of chronic inflammation, which appears to affect mainly the capsule of Glisson. True perihepatitis may be present, and serve later to cause lobulation of the organ. (See Perihepatitis, p. 595.) Amyloid degeneration of the liver may be seen to follow syphilitic lesions of the bones and syphilitic ulceration. (See Amyloid Liver, p. 593.) Symptomatology. — ^The clinical picture may be that of hepatic cir- rhosis, with ascites, gastro-intestinal disturbances, and slight jaundice. In certain cases the liver may be appreciably enlarged, and there may be en- largement of the spleen even in those cases in which sclerotic changes are present in the liver. Distinct gummatous tumors may be responsible for enlargement of any portion of the liver, although the left lobe is more commonly involved. The symptoms may arise both as the result of contractions from the forma- tion of cicatricial tissue and from pressure by gummata upon the portal circulation. Summary of Diagnosis. — Unless there be a clear history of sj^Dhilitic infection, the diagnosis is made with difflculty. In those cases in which ascites is present, the actual size of the liver can be ascertained only by re- 832 ACUTE INFECTIOUS DISEASES. moving the ascitic fluid. Well-marked indentations along the edge of the liver are highly suggestive of syphilis of the organ. In obscure cases the administration of antisyphilitic remedies may be necessary in order to for- mulate a diagnosis. Syphilis of the Lung. Syphilitic changes occasionally attack the pulmonary structure, in which case the general clinical picture is that of chronic pulmonary tuberculosis. (See Pulmonary Tuberculosis, p. 796.) The symptoms of chronic bronchitis are present. In doubtful cases of fibroid tuberculosis of the lung accompanied by slight fever, in which the sputum does not contain tubercle bacilli, a therapeutic test must be made in order to arrive at a diagnosis. Diagnosis. — The features that point strongly to syphilitic infection of the lung are extensive amyloid disease involving the viscera, the presence of a well-marked secondary anemia, and arteriosclerosis. Syphilis of the Rectum. When syphilis appears in the form of more or less diffuse, submucous gummata located within the external sphincter, the most characteristic symptoms are those pointing to progressive stricture of the rectum. The patient may complain of a more or less constant dysentery, which is chronic in nature and not accompanied by pain or tenesmus. An examination of the rectum is necessary, and usually reveals the presence of a firm fibrous ring. Ulceration of the mucous surface may also be present. Syphilis of the Testicles. There are two clinical forms of syphilis of the testicle: (1) Atrophy of the gland, which may be either irregular or uniform in outline, is not ac- companied by pain, and commonly involves one organ more than the other; (2) gummata of the testicle. Differential Diagnosis. — Syphilis produces an irregularity m the body of the testicle, which serves to distinguish it from tvberculosis of this organ, which attacks the epididymis. Malignant disease of the testicle de- velops more rapidly than does syphilitic tumor, and is, as a rule, painful, a feature which is uncommon in syphilis. Syphilis of the Kidney. Syphilis of the kidney is sometimes found at autopsy, but concerns us but little with reference to antemortem diagnosis. The changes are chronic in nature, the most common being amyloid degeneration. Syphilis of the Heart. Gummata may develop in the wall of the left ventricle. Fibroid sclerotic myocarditis is also seen, this process beginning in the perivascular tissue, and proceeding outward from the vessel-walls. These changes are more or less diffuse, and in time cause narrowing of the lumen of the coronary arteries and their branches, although in some cases aneurismal expansion of the arteries has been observed. Syphilitic endocarditis is also of the fibroid sclerotic type. The diagnostic clinical features of syphilis of the heart are the same as those described under Chronic Myocardial and Endocardial Changes. (See Diseases of the Heart, pp. 261 and 297.) LEPROSY. 833 Syphilis of the Arteries. Clinical Forms. — Two varieties are recognized: (1) Obliterating endarteritis, in whiclr tlrere is a proliferation of the sulsendothelial tissue, which in time encroaches upon the lumen of the artery. (2) Gummatous peri- arteritis is the name given to a condition in which the arteries at the base of the brain are most often attacked. (8ee Syphilis of the Brain, p. 1118.) During the course of sj'philis a varial^le degree of arteriosclerosis is likely to develop, and following such atheromatous changes aneurism (p. 311) is common. LEPROSY. Pathologic Definition. — A chi-onic disease, due to infection by the lepra bacillus, and characterized by the presence of clusters of bacilli in Patient, airerl fifteen. Fi*;. 30b. — Tubercular Leprosy. Disease of three years' duration. Began as pinhead-sizecl nodules on faee (S;uid\\-ich Island ejise). the skin, these being surroimded Ijy a tuljerculous nodule. There may also be areas of cutaneous pigmentation, with the deposition of bacilli in the epithelial cells and leukocytes. Each granulomatous mass is surrounded by a layer of connective tissue; certain of the lymph-noclcf^ l)ecome en- larged, and baciUi are deposited within them. The.se l)acilh are also pre.sent 53 834 ACUTE INFECTIOUS DISEASES. in the liver, spleen, and blood drawn from the lesions, and rarely in the cir- culating blood. Secondary infection with pus-producing organisms may hasten destructive changes in the lesions. When the lepra bacilli are de- posited around the ner\'e-sheaths, irritation and hyperplasia are set up, leading to atrophy and degenerati^'e changes in such ner\'es. Varieties. — (a) Tubercular leprosy is characterized by cutaneous manifestations, such as er}i:hema, macules, tuberculous nodules, and cutane- ous pigmentation, (b) The anesthetic form is marked by local symptoms, such as pain, hyperesthesia, and anesthesia. Exciting and Predisposing Factors. — Bacteriology. — The bacillus leprce, which was first described by Haynes, resembles in certain respects the bacillus of tuberculosis. Upon sectioning the lesions, the bacilli are found mthin the tissue. Age figures prominently as a predisposing factor, the majority of cases being seen between the twentieth and fortieth years; the disease is extremely uncommon among children. The influence of heredity, although questionable, is a conspicuous factor in approximate!}' 25 per cent, of cases; there are many in- vestigators, however, who be- lieve that the disease is not in- herited. Immediate surroundings and environment are promi- nent influences in certain lo- calities in which the disease prevails, lepers being seen, as a iiile, more commonlj' in the rural districts than in the large cities. Latitude is usually recog- nized as a predisposing fac- tor, although the disease may be found in different, more or less isolated localities, extend- ing from the equator to Nor- way and Iceland. From re- cent oliservations we learn that leprosy is extremely com- mon among the natives of Peru and P^cuador. The na- tives of the Hawaiian and other of the Pacific Islands are also frequently victims of the disease. There are iso- lated regions in the United center, in which cases of leprosy Fig. 307. — Macular Lesions in Leprosy. of which New Orleans is the State, occur Modes of Infection. — Different investigators hold mdely divergent views as to the modes of infection, although practically all agree that the disease is proljably transmitted Ijy contact. IMorrow siiggests'that leprosy, like syphUis, is generally transmitted by sexual intercourse, whereas other observers hold that the disease is propagated l\v insects. As a matter of fact, CEREBROSPINAL MENINGITIS. 835 the exact mode of infection is unknown. Sticker believes the primary site of infection to be the nasal mucous membrane. Incubation Period. — This, according to Hansen, is from three to five years. Some writers believe this stage to occupy a much shorter period, but there is evidence to show that, in certain cases at least, incuba- tion may occupy several years. Such prodromes as chilliness, recurrent at- tacks of fever, excessive sweating, mental dullness, drowsiness, and debility may be experienced for years before the characteristic symptoms become manifest. Clinical Picture. — Tubercular Leprosy. — In the first stage there are areas of cutaneous erythema, with a slight hyperesthetic elevation of the affected skin, seen on the face or upon the extensor surfaces of the arms, hands, legs, back, buttocks, abdomen, and chest. These may vanish after a time, leaving the skin pigmented and anesthetic; later the pigmented areas may disappear, leaving in their stead white spots of corresponding size (lepra alba). Such areas lose the hair that is normally present — a characteristic feature. Tubercular nodules that tend to fuse and form irregular masses, dusky red or almost brown in color, develop in addition to the anesthetic patches. These tubercles may soften and become absorbed, or they may ulcerate. The skin is greatly thickened, presents a scaly surface, and there is loss of substance in certain parts, whereas other portions are markedly enlarged (eyebrows, nostrils, hps). Ozena, hoarseness, and aphonia are present as the result of involvement of the respiratory mucosa, and there may be ex- tensive ulceration of the larynx, pharynx, and nose. Anesthetic Form. — Here the local symptoms are referable to implica- tion of the nerves, and as a consequence pain and areas of hyperesthesia con- stitute the prominent early symptoms. As the disease progresses minute bullae may be seen, and evidences of trophic changes, with wasting of mus- cles that are supplied by the involved nerve-trunks, appear. Distinct no- dules along the course of the nerves may also be present. Anesthesia is a characteristic feature of this type of the disease, and areas of vasomotor congestion usually precede the anesthetic stage. Yellowish-white patches, which are dry and scaly and may at any time become anesthetic, are distri- buted over the body. Extensive ulceration of the skin is most likely to occur upon the extremities, and, depending upon the degree of ulceration, wasting and necrosis, with extensive deformity, will result. An example of such deformity is the so-called " claw hand." I^aboratory Diagnosis. — Blood withdrawn through an incision into a tubercle may contain lepra bacilli. We have found bacilli free in the circulating blood in one case, but other instances of such finding are recorded. Lepra bacilli may be present in the exudate collected from ulcer- ated surfaces, and where the nasal mucous membrane is involved, they are commonly present in the nasal secretion. The sputum of cases suffering from ulceration of the pharynx and larynx will also be found to contain the baciUi. CEREBROSPINAL MENINGITIS (Spotted Fever t Cerebrospinal Fever). Pathologic Definition. — An acute infectious disease, caused by the micrococcus (diplococcus) intracellularis, and characterized by an acute inflammation of the cerebrospinal meninges, with the formation of pus and of an excessive quantity of seropurulent cerebrospinal fluid. 836 ACUTE INFECTIOUS DISEASES. The entire meninges of both the brain and the spinal cord are cov- ered with a somewhat thick, cream-like or yellowish exudate, which is com- posed principally of pus-cells. The meningeal arteries are engorged with blood. Predisposing and Bxciting Factors.— Bacteriology.— The ex- citing cause is the diplococcus intracellularis, which may be _ found in microscopic examinations of the cerebrospinal fluid. The meningococcus may also be recovered from the synovial fluid of the larger joints, from the nose, and we have obtained a pure culture from a myocardial abscess. Age. — ^Most cases occur during childhood and early adult life, although the disease may be seen at practically any age. Climate is an important predisposing factor, epidemic meningitis being unknown in the tropics, whereas both epidemic outbreaks and sporadic cases have developed in practically all parts of the temperate zone. Season. — ^The disease is said to prevail more commonly during cold weather, but a statistical study of its epidemiology shows that epidemics are likely to develop at any season. Boston* showed, in an analysis of the post- mortem findings in 80 cases of sporadic meningitis that came to autopsy at the Philadelphia Hospital from April 4, 1894, to October 26, 1898, that 13 of these were due to infection with the diplococcus intracellularis. The accompanying table shows the influence of season, sex, age, race, and nativity as predisposing factors in sporadic purulent meningitis : Month. Sex. Age. Color. i Nationality. April June October Male K ({ (I Female Male It Female 6 months 1 week 13 months 26 years 64 " 26 " 31 " 7 months 37 years 52 " 26 " 26 " 13 " White Black White Black White Black White American April June March May August October January July September Irish German American u German American i( u Environment appears to exercise a prominent influence, since epidemics are common in homes, schools, barracks, etc., where the inmates are over- crowded in Ul-ventilated apartments. Extensive epidemics may be seen in country districts, but are somewhat more common in towns and cities, and, indeed, they are often limited to a small section of a town. The mode by which the specific infection is conveyed from one patient to another is not definitely understood, and although several theories have been advanced, none of these have proved their claims conclusively. Clinical Varieties. — (a) The Malignant or Apoplectic Form. — The symptoms characterizing this fulminating type of meningitis are not constant. There may be a severe chUl, followed almost immediately by headache, loss of consciousness, and death — the entire clinical course occupy- * "Etiology of Sporadic Purulent Meningitis," Med. News, May 20, 1899. CEREBROSPINAL MENINGITIS. 837 ing a period of but a few hours. As a rule, however, the disease is not so rapid in its course, but continues for two or more days following the initial symp- tom, which is an intense rigor. Headache, vertigo, obstinate vomiting, extreme prostration, rigidity of the muscles of the neck, stupor, and coma develop in rapid succession. The fever may not be high, and the pulse-beats may not exceed 40 to 60 beats a minute; as the disease progi-esses all the symptoms become intensified, and coma ends the scene. The fulminating type of meningitis is a characteristic of certain epidemics, whereas in others such cases are not observed. (6) The Mild Form. — The disease may be so mild that the patient may be able to walk about or even to follow his usual occupation, complaint being made merely of headache, languor, nausea, occasional vomiting, and pain in the muscles at the back of the neck. In this type of meningitis, fever is not an essential symptom, but a mild febrile movement is the rule. (c) Intermittent Form. — In this variety of the disease the symptoms intermit or remit eveiy two or more days, the fever bemg decidedly inter- mittent, and resembling somewhat that of chronic sepsis. (d) Abortive Form. — Here the initial attack is quite as intense as in the ordinary type of the disease described further on, but a decided ameliora- tion occurs in the course of two or three days, and the patient goes on to convalescence without interruption. (e) Ordinary Type. — During the course of an epidemic there appears to be no accurate means of ascertain- ing the incubation period. Cer- tain prodromal symptoms, however, will be found to be present, and to vary widely in different epidem- ics, although even in severe types of the chsease these may be want- ing. A patient previously in vig- orous health may be suddenly stricken down as though he had received a blow upon the head. In those cases that tend to be rapidly fatal there are lassitude, headache, muscular pains, joint pains, nau- sea, and obstinate vomiting. The prodromal symptoms are at times present for but a few hours, where- as in other, milder cases they may persist for from three to six or more days, during which time occipital pain serves as the most conspicu- ous feature. Irrespective of the character of the prodromal symp- toms, the disease may follow these without an initial chill; mild cases are hkely to complain only of languor, debility, headache, pain in the loins, vomiting, and possibly fliarrhea prior to the development of typical symp- toms. In those cases in which the disease begins abruptly there is likely to be a severe chill. In children convulsions are common, and are usually followed by intense pain in the back and cervical regions. Movements of the head increase the pain in the neck, and bending the back intensifies the spinal ■ Fig. 308. — Diplococcus Intracellularis (Boston). Meningeal pus obtained by lumbar puncture from case of epidemic cerebrospinal fever observed at Philadelphia Hospital (obj. Spencer one-twelfth oil-iminersion). 838 ACUTE INFECTIOUS DISEASES. pain. Early during the disease the patient may refuse to swallow because of the extreme pain excited by deglutition. There may be cough and difficulty in breathing, although in uncompli- cated cases the respirations may be free and not greatly increased. Owing to exhaustion of the respiratory center the respirations become frequent and irregular and there may be marked dyspnea. In unfavorable cases Cheyne- Stokes breathing may develop. Myalgic pains are often intense, involving both the extremities and the abdominal region. Gastrointestinal Phenomena. — As previously stated, vomiting is the most common among this particular group of symptoms, and is present in 75 per cent, of cases, and, from its character, appears to be of cerebral origin. The appetite may be normal until the initial chill appears, or it may be impaired during prodromal symptoms. After the disease has become well estabhshed, anorexia obtains. Constipation usually exists throughout the entire course of the disease, although diarrhea may occasionally be present. The patient complains continually of intolerance to light (photophobia), and intolerance to sound is also present during the early stage of the disease; later, however, a variable degree of deafness is prone to occur, which may continue even after convalescence is well established. Tinnitus aurium may be an early and annoying symptom, and abscess of the middle ear is often an alarming complication. Nervous Symptoms. — In addition to the nervous s5Tnptoms already de- tailed there are often active delirium and hallucinations, during which the patient may shout loudly, and restraint may be necessary to keep him in bed. Paroxysmal outbreaks of delirium are by no means uncommon, and occur most often during the night; in young females the nervous symptoms are hysteric in character. The maudlin delirium of alcoholics is occasionally seen, but sooner or later the patient becomes somnolent, and eventually passes into a state of coma, which may continue from the time the disease develops, although it is occasionally a temporary condition. In those cases displaying a high grade of hypersensitiveness of the cutaneous surface, priapism may be an annoying symptom. Catalepsy is rarely present. Holmes* believes that his sign — analgesia or partial or complete anesthesia of the conjunctivae and cornea — is present in a large proportion of aU cases. Thermic Features. — The fever of epidemic meningitis is not characteristic, and may be found to vary between 100° and 105° F.; in the average case it will be found to fluctuate between 100° and 103° F. The fever continues to run an irregular course until defervescence, which takes place gradually by lysis, occurs. We have seen cases in which the temperature rose to 106° and even to 108° F. during the last few hours of life. Under ordinary conditions the fever is lower in children than in adults, although we have seen cases of epidemic meningitis in persons after the age of fifty in whom the temperature did not exceed 102° F., and in whom the range was from 99° to 101° F. Physical Signs. — Inspection. — Immediately following the onset of active symptoms the cheeks are flushed, although pallor and lividity are equally common; pallor of the lips is regarded as a fairly constant sign in this disease. In children conjunctivitis may be present. Keratosis, corneal ulcer, strabismus, ptosis, inequality of the pupils (see p. 1104), iridochoroid- itis, and temporary, as well as permanent, blindness are among the ocular manifestations of epidemic meningitis. Coma-vigil is not uncommon, and the patient may lie for hours, and even for days, without moving the eye- lids. As the disease progresses there may develop, at any time during * Jour. Amer. Med. Assoc, January 25, 1908. CEREBROSPINAL MENINGITIS. 839 its course, an eruption which is not characteristic, and which may be a rather generalized subcuticular mottling (10 per cent, of cases) which disap- pears within a few hours. The eruption may be erythematous, macular, maculqpapular, or petechial. In the case of blondes the eruption is cherry red. In brunettes a brownish-red or raw-ham color. In negroes it is slightly darker than the surrounding skin. A bullous eruption is rarely seen. A fact ever to be borne in mind is that in some cases the eruption is absent. Herpes facialis is also quite common and was present in 58 per cent, of cases in a 1911 to 1912 epidemic, and it should be remembered that this condition is frequent in but two other infections — lobar pneumo- nia and malaria. Among the unusual cutaneous manifestations seen in meningitis are sudamina, ecthyma, erysipelatous reddening, urticaria, and gangrene, although none of these is of diagnostic importance. Bed-sores may develop, and the abdomen is usually scaphoid. The tongue is sHghtly coated at first, but as the disease progresses, this coating becomes heavier and heavier, and in those cases that go on to the so- called "typhoid state" the tongue becomes dry, brown, and fissured; the teeth and lips being covered with sordes. In the course of one or more days localized paralyses may develop; these are the result of motor irritation, and consist of strabismus or paralyses of the face or of the extremities. Muscular contractions, particularly of the lower extremities, may develop. Twitching of a group of muscles is by no means uncommon. Later during the course of the disease tonic spasm of certain groups of muscles holds the patient in a fixed position; thus we have fre- quently seen the forearm flexed upon the arm, and the arm fixed firmly against the side of the chest. (See Fig. 418.) In another frequent form of contracture the thumb is coiled tightly within the palm of the hand. The illustration (Fig. 418, on page 1126) is taken from the photograph of a patient seen in our service at the Philadelphia Hospital. The position of the lower extremities and of the left hand and arm was permanent and the result of spasm. Spasmodic contraction of the muscles at the back of the neck causes the occiput to be drawn backward, and the child is unable to bring the chin forward upon the chest. The patient usually assumes the dorsal posture, and complains when he is turned from side to side. Contraction of the muscles of the back, Hmbs, and neck may be sufiiciently weU marked to produce opisthotonos, a condition in which the patient rests only upon his occiput and his heels, the entire body being arched — a feature characteristic of but one other disease, namely, tetanus. Palpation. — Tenderness is usually present over the muscles of the back of the neck and along the course of the spine. Areas of h3rperesthesia are common, and hypersensitiveness of the skin may be general. Localized areas of anesthesia also constitute one of the valuable signs of meningeal involvement. The joints, especially the larger of these, may be swollen and tender, and movement of parts controlled by certain groups of muscles often excites great pain. The jndse is at first moderately accelerated, but in those cases that pro- gress from bad to worse the pulse finally becomes weak, rapid, thready, and irregular. According to Head, Kemig's sign is present in 84 per cent, of all cases of spinal meningitis, but it may be confined absolutely to epidemic types of the disease. It may be absent during the early stages of the disease, and, in our opinion, if the sign is not present as an early feature of the disease, the patient should be examined for it daily throughout the entire course of the 840 ACUTE INFECTIOUS DISEASES. illness. Kernig first pointed out the impossibility of obtaining cooiplete extension of the leg on the thigh when the patient is sitting and the thigh is flexed at a right angle to the trunk. The sign is produced as the result of irritation of the meninges of the lower portion of the spinal cordand of the nerve-roots that constitute the cauda equina, although it is no indication of a distinct lesion of these structures. This irritation, which is augmented by the stretching effect of the sitting posture, increases the tonicity of the flexor muscles of the leg, and, as a consequence, complete extension of the leg be- comes impossible. If the patient is lying in bed. the thigh may be flexed Fig. ;iU9. — Kernig's Sign, Showing the Strong Contraction of the Flexors on Attempting to Extend the Leg (Ruhrah, from Osier). upon the abdomen (Fig. 309), when, if meningitis is present, complete extension of the leg will be prevented by contraction of the flexor muscles (Fig. .309). Should Kernig's sign be doubtful, force the chin forward on the chest and then try for Kernig's sign. This procedure often makes a ques- tionable Kernig's sign positive. Whenever Kernig's sign is typical, its pro- duction excites spasm and pain. Kernig's sign may rarely be present in one leg and absent in its fellow. Brudzendski' s Sign. — By flexing the head on the chest there is some bending at the joints of the lower extremities (knees and hips). Flexion of one leg on the abdomen is accompanied by a lesser degree of flexion of the opposite leg. MacEwen's sign is designed to indicate increased pressure of the fluid present in the ventricles by giving an increased resonance. Place the belj, of the stethoscope against the forehead, and at the same time tap- with the finger over the squamous portion of the opposite temporal bone. I^aboratory Diagnosis. — Blood. — The percentage of' hemoglobin and the number of red blood-cells are but slightly altered during the active stage of the disease, except -when well-marked cj-anosis is present, in which case both the hemoglobin and the red cells give unusually high readings. Leukocytosis is present early, and continues throughout the febrile period. A differential leukocyte count shows an increase in the polymorphonuclear elements. CEREBROSPINAL MENINGITIS. 841 The quantity of urine voided during the twenty-four hours is approxi- . mately normal, although it may fluctuate as the result of cerebral irritation. A trace of albumin may be present, and, rarely, the urine contains a trace of glucose. It is frequently necessary to obtain the urine by catheterization, as both retention and incontinence are symptoms of meningitis. Spinal Puncture. — Aspiration of the subarachnoid space results in the recovery of a turbid exudate, which, when smeared and stained, will be found to contain many diplococci that resemble the gonococcus in appearance. The diplococcus intracellularis is found within the pus-cells, although it is cus- tomary to find many extracellular cocci also present. Another characteristic feature of the meningococcus is that it does not stain by Gram's method. Cultures on Loffler's blood-serum made from the cerebrospinal fluid will, when kept at body-temperature, develop colonies of the meningococcus in from twenty-four to forty-eight hours. The Bacillus proteus, the bacillus of influenza, Bacillus typhosus, and Bacillus coli are at times present. The pneumococcus and pyogenic cocci may be found. The nasal secretion is increased, and both cultural studies and stained specimens will show the presence of the diplococcus intracellularis. Slata- per's analysis of 210 cases gave coryza as an early feature in 97 per cent, of his series. In a case studied by us at the Philadelphia Hospital, in which there was an associated purulent ophthalmia, the Diplococcus intracellularis was recovered from the conjunctivae. Illustrative Case of Epidemic Meningitis. — C. C. D., female, colored, aged nine years. Family History. — Mother died of pneumonia at the age of twenty-seven. Father died as the result of an injury sustained by falling a distance of 20 feet. Previous History. — No further evidence could be obtained than that the child had enjoyed good health during the past year. Social History. — Admitted to a children's home in Philadelphia one year ago, and has remained in the institution ever since. Performed the usual school work given to the children of the home, the attendant stating that, until the present illness, she has been in excellent health. Two weeks ago a child suffering from epidemic meningitis was removed from this institution. Twelve years ago there was an outbreak of epidemic meningitis in the same home, 16 children being afflicted with the disease; since this epidemic there was no return of the disease in the institution, the case here narrated being the first to occur since that time. Following the removal of the child suffering from meningitis no other cases have developed until the present one appeared. Present Illness. — During the past three days the child has shown an indisposition to play. Anorexia is present, and the child complains when compelled to move her head. There is obstinate constipation. She awoke during the night and complained of feeling chiUy, and a few hours later, after an apparently sound sleep, she awoke, utter- ing a harsh, shrieking cry. There is pain in the muscles of the neck, back, and limbs. Pain is aggravated by lifting of the head, and becomes intense when an attempt is made to tip the chin forward on the sternum. There is slight cough. Pain is increased upon swallowing, and becomes severe when the child attempts to move her head. Late during the disease she would shriek with pain whenever moved about the bed. She also exhibited an intolerance for sound, and would often cry out whenever any harsh noise was made. Photophobia developed early, and strabismus, ptosis, inequality of the pupils, and paralysis of the extremities were observed during the fourth to the eighth days of the disease. Distinct convulsions did not occur, al- though muscular twitching was frequently seen. Spasmodic contraction of the muscles frequently followed when a draft of cool air was permitted to come in contact with the patient. During the first day the temperature rose to 101° F., and subsequently pur- sued an irregular type, ranging between 99° and 102.5° F. Physical Examination. — General. — When seen during the second day of the illness, the child was resting in bed, and when lying upon tne back, the chin was well elevated and the back slightly arched. When turned upon the side, it immediately became apparent that the head was markedly retracted, and that there was some curv- 842 ACUTE INFECTIOUS DISEASES. ing of the spine. The Ihnbs remained in one position when the child was turned from her side to the supine position. The expression was anxious, the mental condition was markedly dulled, the muscles of the nape of the neck were spastic, and paresis of the right arm and strabismus were also present. There was a petechial eruption on the extremities and over portions of the body, but these petechias were not numerous. By the fourth day of the disease distinct arching of the body was seen when the chUd was resting upon her back. Local Examination. — Palpation. — ^The head could not be brought forward so that the chin would touch the sternum unless force were used, and the mere act of pushing the head forward elicited an expression of pain. The lower hmbs and the arms were more or less spastic. Auscultation. — At first the heart-sounds were strong and shghtly increased in fre- quency; as the disease advanced, the first sound lost its muscular, booming quaUty, and the heart became rapid — 120 to 140 beats a minute being recorded. Laboratory Findings. — ^The urine was scanty, and by the third day was voided in- voluntarily. A specimen obtained by catheterization on the fourth day of the disease contained a trace of albimiin, and gave a feeble reaction for glucose. The spine was punctured, and about three drams of turbid fluid were recovered from the canal. Microscopically, the fluid contained pus; and in many of these cells diplo- cooci were seen. Extracellular diplococci were also present. Cultural studies of the meningeal fluid showed the presence of the diplococcus intracellularis. Cultures made from the nasal mucous membrane also revealed the presence of the Diplococcus intra- cellularis, as well as of other bacteria. Diagnosis by Induction from Clinical Data. — ^Two weeks ago a child found later to be suffering from epidemic meningitis was removed from the institution; hence suspicion was at once aroused as to the nature of the condition in question. The early development of rigidity of the muscles of the neck, together with an expression of pain upon moving the head from side to side and upon swallowing, further increased the probabiUties of meningeal inflammation. At the onset photophobia was present, and as the disease progressed, strabismus, inequality of the pupils, ptosis, and paralysis of the extremities followed — features that are all practically characteristic of meningitis. The detection of the Diplococcus intracellularis in the spinal fluid left no room for doubt as to the true nature of the disease. Course of the Disease. — The rigidity of the muscles progressed until distinct opisthotonos existed. By the fourth day of the disease respirations became hurried, and continued to increase in rapidity and to become more and more shallow. The nervous symptoms subsided slightly after lumbar puncture, but within the course of twenty- four hours they were again severe, and the general condition became decidedly unfavor- able about the fifth day, and continued so until the twelfth day, when death terminated the scene. Summary of Diag^uosis. — In typical cases the diagnosis is made with extreme ease, as has been outlined by the clinical picture in our de- scription of the ordinary type of the disease. We would call special atten- tion to headache, rigidity of the muscles of the neck, and to hysteric and maniacal outbreaks, as features that are common in even atypical forms of the disease. The eruption, unless it should be petechial in character, carries with it but little diagnostic significance. Kemig's sign, when present, is positive evidence of meningeal irritation only. Lumbar puncture serves as the only positive means of diagnosis, and in certain cases this method alone enables us to obtain an accurate knowledge of the character of the disease in question. Inequality of pupils, strabismus, ptosis, and rigidity of certain groups of muscles are valuable clinical factors in formulating a diagnosis. While the typical cases of meningitis are always referred to, in our experi- ence the so-called "text-book cases" do not include the majority. Differential Diagnosis.— In the light of our present knowledge of laboratory naethods meningitis is to be regarded as one of the few diseases in which this means of diagnosis is the only reliable one. A microscopic study of the cerebrospinal fluid obtained by lumbar puncture is a positive means of diagnosis and of differential diagnosis; consequently other tedious methods are unnecessary. The Widal reaction is also valuable in distin- ACUTE ANTERIOR POLIOMYELITIS. 843 guishing between typhoid fever and meningitis, being negative in the latter condition. Clinical Course. — The fulminating type of the disease usually ter- minates in death during the first few days. Mild and other atypical forms may continue over a period of one or more weeks before convalescence is established, whereas in the usual type favorable cases show improvement in two or three weeks, although convalescence is generally protracted. Complications. — Eye and ear complications are quite common, and always cause an aggravation of the existing symptoms. Bronchopneu- monia and arthritis are probably the most frequent comphcations. ACUTE ANTERIOR POLIOMYELITIS. (Infantile Spinal Palsy.) Pathologic Definition. — In the acute stages there is usually found an acute congestion of the blood-vessels, especially in the gray matter of the anterior horns, with roimd-cell infiltration and hemorrhages, some of which are quite large, destroying the cells of the anterior horns. Occa- sionally the hemorrhages or areas of inflammation involve the surrounding white inatter, especially of the motor columns. Rarely a slight round-cell infiltration is found in the meninges. Early in the disease lumbar puncture may sometimes detect an increased amount of fluid. In most cases the acute congestion with hemorrhages disappears, but in those cases in which the cells in the anterior horns have been fully destroyed the paralysis is permanent — the so-called residual palsy. Contributing and Bxciting Factors. — The disease usually ap- pears in a child previously healthy, and rarely in the course of or following infectious diseases. It occurs singly, although several members of the same family may become diseased. Season. — The greatest number of cases are seen during the summer months, although the disease is not unusual throughout the year. Rosenau* gives a preliminary report upon the transmission of poliomyelitis by the common stable fly (stomoxys calcitrans), and Anderson and Frost f report having confirmed Rosenau's work. These investigators find that where stomoxys were permitted to bite monkeys that had been previously infected with poliomyelitis by intercerebral inoculation, these same flies were capable of transmitting the disease to uninfected monkeys. LanghorstJ cites 2 interesting cases, 1 following the bite of a dog, and the other developed after a dog (suffering from paralysis of the hind legs) had been permitted to lap his master's hand upon which there were a few slight wounds. Haywood (1913) reports a case where fourteen days after receiving a bite from a rabid dog a boy of fourteen developed the disease. Flexner has called attention to the probability of the infection being carried through the mucous secretion from the nose, while Langhorst's unique experience emphasizes the danger of infection through the secretion of the buccal cavity. * Congress on Hygiene and Dermography, Oct 5, 1912. The Jour. Amer. Med. Assoc, Nov. 2, 1912, p. 1627. t PubUc Health Report, Oct. 25, 1912, p. 1733. t Jour. Amer. Med. Assoc, Dec. 28. 1912, p. 2312. 844 ACUTE INFECTIOUS DISEASES. Manning* has emphasized the probability of the disease being at times transmitted through the bites of the bedbug (cimex lectularis), while other writers have reported instances where acute myelitis has developed follow- ing the bite of this parasite. The habits of the cimex, as is well known, are such as would explain the outbreak of epidemics in man during the winter months. Townsendt, of Rutland, Vt., has examined the spinal cord of a horse dead from paralysis, during an epidemic of poliomyelitis. Townsend's findings were as follows: "Section of the lumbar portion of the cord showed a granular degeneration and pigmentation of the ganglion cells of the anterior cornua, and atrophy of the nerve-roots." During an epidemic of 1000 cases in Minnesota in 1909 several members of the equine family were attacked. There are at least four recorded epidemics throughout the United States, where domestic animals and man were at the same time afflicted with acute epidemic paralysis. Among the animals and fowl thus afflicted were horses, hogs, sheep, dogs, cats, chickens, and ducks. Manning cites the epidemic of 1911 in Brazil, J where a heretofore un- known disease of this country caused the death of approximately 4000 cattle and 1000 horses. During the past summer there have been 13 cases of acute poliomyelitis in man reported from this district. Extensive epi- demics have prevailed in Scotland and various sections of England, and there was in these locaUties at the same time an epidemic among the sheep, goats, and other domestic animals. ACUTE PARALYTIC DISEASE AND DEATH AMONG DOMESTIC ANIMALS OCCURRING COINCIDENTALLY WITH EPIDEMIC POLIOMYELITIS IN MAN (Manning). Reported BY Locality Yeab HOBSE Sheep DOG Cat HOQ Fowls Total Caverly Vermont 1894 Horse Dogs Chickens Many. Wiokman Sweden 1905 Dogs And other animals. Free Dubois, Pa. 1907 Pigs Chickens Manning Wisconsin 1907-08 Colts Sheep Cats Ducks Many. Lovett Massachusetts 1911 Dog Cats Hens 39 in all. Hill Minnesota 1909 Colts Three. Snow California 1910 Colts Dog Cat Chickens Many. Kelly Washington 1910* Williams Wash., D. C. 1910 Chickens Many. Bierring Iowa 1910 Cat Hog Chickens Many. King Indiana 1911t Batte Ohio-Ky. 1911 Chickens Krause Gregor & Westphalia Cornwall, 1910 Chickens Many. Hopper England 1911t Carina Sao Paulo, Brazil 1910-11? * Dog paralyzed one week before onset in child. t Eighteen animals (1 cow) paralyzed among 102 cases of poliomyelitis. I Horse, one week before onset of paralysis in boy. § One thousa,nd horses and 4000 cattle dead with "symptoms of rabies," coincidental with 13 cases of human poliomyelitis at Sao Paulo. From the evidences furnished by the various reporters it is only fair to suppose that probably more than one biting insect is capable of trans- mitting epidemic myelitis from man to man as well as from man to domes- tic animals, and vice versd. Thus far we are cognizant of proof of the trans- mission of the disease by the ordinary stable fly, yet there are recorded * Medical Times, April, 1912, p. 112 t Jour. Amer. Med Assoc, Jan 4, 1896. t Annates de Institute Pasteur, Paris, Nov., 1911. ACUTE ANTERIOR POLIOMYELITIS. 845 several instances where bites from the ordinary bedbug and the saliva of the dog appear to have been the source of the infection. Proescher* has detailed a method for the staining of the organisms in pohomyelitis virus, as well as in smears, from the diseased portions of the nervous system. This writer described spirilli coccus and bacillus forms as being present in poliomyelitis. Varieties and Symptoms. — The disease usually appears in the in- fantile period, generally between the ages of one and three, although it may occur later in life, especially in epidemics. Rarely it may be seen in adults. It is ushered in by fever, with its accompanying symptoms of malaise and chilliness, or the child may feel sick for a day or so with at times an indefinite eruption, when the weakness or paralysis is discovered. At Fig. 310. — Paralyhi.s of the Left Upper and to A Le.ss Extent of the Lept T^ower Limb, SHOWING -\trophy, in Acute .\nterior Polio- mteliti.s. Fig. 311. — Paralysis of the Left Upper and to A Less Extent of the Left Lower T^imb, showing .\trophy in Acute Anterior Polio- myelitis (Posterior Position). first it is quite extensive and may affect all of the limbs, but, as a rule, it involves by preference one or both lower limbs. Within a few days to four or five weeks the extent of the paralj^sis graduallj' lessens, and there remains what is called a residual palsy. All the muscles of the limb are never paralyzed, but there seems to be a predilection for certain groups, as, for instance, in the leg, the anterior tibial, and peroneal. Because of this unequal paralysis contractures of various types result. The paralysis is always flaccid in type and it is possible to passively move the limbs freely. Rarely the cells of the anterior horn in the thoracic part of the cord are diseased, this causing weakness or paralysis in the abdominal, lumbar, and thoracic muscles. This sometimes produces inability to sit up or to stand properly. Following the lo.ss of power atrophy develops, the degree de- pending upon the extent of the destruction of the cells in the anterior horn. * New York Med. Jour., April 12, 1913- 846 ACUTE INFECTIOUS DISEASES. The tendon reflexes, as well as the normal electric reactions, will be lost in those parts in which the reflex arcs have been destroyed or interfered with (Figs. 310 and 312). Not only will there be an atrophy of the muscles, but there also will be an atrophy of the bones of the involved limb. Because of the fact that the cells in the anterior horn are trophic in frmction there will also be lessened nutrition of the skin, which sometimes becomes dry, and the hair may not grow. It is not at all uncommon in the onset of the disease to have a rigidity of the head, neck, and limbs, with pain in the back and neck and consider- able tenderness in the limbs. This is due to an early meningeal involve- ment, which usually does not last very long and subsides within two or three days or a week. In rare instances, however, the pains may persist for a month or longer. There are never disturbances of sensation or of the l)ladder and rectal functions. When the disease appears in adults, the onset and clinical symptoms do not difi^er from those already described. This, however, is rare. Summary of Diagnosis. — A previously healthy infant of from one to three years of age, with or^ without fever and its accompanying symptoms, sudden paralysis of one or both upper or lower limbs, flaccid in type. There is gradual diminu- tion of the paralysis in the course of from one to seven weeks, followed by atrophy with contractures, loss of tendon reflexes, and electric reac- tions of degeneration. Bladder and rectal functions normal. Differential Diagnosis. — The disease must be distinguished from acute myelitis and multiple neuritis. In acute mj-elitis the onset and the early clinical picture may be the same, but in acute myelitis there are always sensory symptoms with involvement of the bladder and rectum and greater and more general paralj'sis. From multiple neu- ritis the disease can be distinguished by the absence of sensory disturbances and persistent pain on pressure over the nerve-trunks, and the paralysis in multiple neuritis is limited to the distribution of certain peripheral nerves. Again, multiple neuritis in children is very rare. Acute anterior poliomyelitis is sometimes difficult to differentiate from the symptom-complex, known as Landry's paralysis. In the latter, how- ever, the paralysis is rapid, death usually resulting in a few days. Clinical Course and Complications. — The course of the disease is chronic, and, with exception of the improvement of the paralysis in the first few weeks, there is no recovery of function. Fig. 312. — Acute Anterior PoLiDMnrLms, show- ing Atrophy of the Muscles of the Back Shoulders, and Upper Limbs. SCARLET FEVER. 847 Sometimes the pathologic process involves not only the spinal cord, but also different parts of the brain, and we may have, in addition to the symptoms already described, those resulting from involvement of the me- dulla, pons, or cerebrum. These have been previously discussed. Sometimes in adults in whom there is an old acute ante^-ior poliomyelitis there may develop a chronic degenera- tion of those anterior horn-cells which were at one time involved by the pathologic process, but in which recov- ery ensued. This degeneration caused gradual wasting with fibrillary tremors, and loss of power. SCARLET FEVER. Pathologic Definition. — An acute infectious disease, characterized by high fever, marked angina, and a diffuse erythematous dermatitis. Varieties. — Clinically, three types of scarlet fever are seen: (1) The aver- age type, in which all the symptoms are active; (2) the mild type, in which all the symptoms are mild; and (3) the malignant type, in which all the symp- toms are severe, and which may termi- nate fatally within the first twenty- four hours, before the appearance of the eruption. Usually, however, death does not take place until several days have passed. Predisposing and Bxciting Factors. — The presence of an epi- demic or exposure to the contagium serves as the most important predis- posing factor. Age figures prominently in the pre- disposition to scarlatina, the disease being most prevalent between the first and sixth years, and practically un- known during the first six months of life. It is rare between the sixth and twelfth months, and the tendency di- minishes after the tenth year, although an occasional case of scarlet fever is encountered after the thirtieth year. Women are particularly liable to contract scarlet fever during the puer- perium, and the infection may be conveyed to them by the physician or nurse. During the winter of 1878 an epidemic of scarlet fever occurred in the maternity wards of the Philadelphia Hospital. Climate. — The disease is more common in temperate than in tropical districts. jfliiFta MnR WR MAY JL H JOL AUG SEP oci|nov Dec ^ TflS ~ iqi 710 nn IK • m 280 ITS /[ n« / m 210 II 7T0 Its 2fcO ^ l\ 7t5 1 1 \i 2to 75S \l • 2SI1 / ^ ;so 345 u ¥ 2« 74fl I'm / n'i / 23', 7W 1 ne ?2S 1 225 220 220 ;is 1 21 ■; jyi / 210 20S / 20,'i ^0 i MO iV. J NS m 1 IPO Iff. 1 ISS |«0 ISO n.i I7.S 17D 1 170 l(,S 1 16,! ItO 1 IfO ISS 1 155 150 r 15} mi; f 145 KO J I4G TO ' |J M 135 no 130 125 125 i?n 120 U-i 115 HO 110 IM 105 llW — — — — 100 Fig. 313.^ — Average Number of Cases OF Scarlet Fever Occurring Dur- ing Each Month of the Year. Sta- tistical Analysis of 32,317 Cases (A. K. Sallom, in " Medical Record "). 848 ACUTE INFECTIOUS DISEASES. , Season.— Statistics show that the greatest number of cases develop during the winter, fall, and spring months. Cold weather, therefore, ap- pears to exercise some influence on the spread of scarlet fever, but, as in diphtheria, it is possible that the fact that children are congregated in schools and homes during the cold weather may account for the increased number of cases seen during the winter months. Caigere, in his analysis of 1008 cases of scarlatina, gives October as the month in which the highest mortality of cases developed, and Whiteleege's analysis of 6000 cases con- firms Caigere's observation. The result of A. K. Sallom's analysis of 32,317 cases reported in Philadelphia is shown by Figs. 313 and 314. Bacteriology.— Many varieties of bacteria have been recovered from the skin, mucous membranes, urine, and blood of persons suffering from scarlet fever, but thus far the exciting microorganism has not been dis- FiG. 314. — Chart Showing Number of Cases and Mortat.itt of Sgarlkt Fever by Months. Sta- tistical Analysis of 32,317 Casks (A K. Sallnm, in " Medical Record "), covered. Streptococci, cliplococci, atypical pneumococci, and streptoba- cilli have all been isolated from the throat of scarlatinal ]Datients. In 1899 Class isolated a special diplococcus (diplococcus scarlatinae) from the mucous membrane of the throat, from the blood, and from the urine of scarlet fever patients. Bodies have been described by Mallory and by Duval which were found in the epithelial cells and in the lymphatic ves- sels of the skin in cases of scarlet fever, and which they believed were protozoa; these they considered might l)ear some etiologic relation to the disease. Scarlet Fever in Hogs. — Behele reported an epidemic of scarlet fever in swine. There are at jnesent a few complete records of epidemics of scarlet fever following a peculiar sickness affecting the hogs of the district in which the epidemic prevailed. Both streptococci and cliplococci isolated from scarlatinal patients will be found highly toxic for swine. Modes of Infection. — Scarlet fever is a highly contagious and in- fectious disease, although not so markedly so as smallpox and measles. The infection is generally believed to be conveyed from the sick to the well by means of the fine epithelial scales that are given off during convalescence, and this probably explains why the virus of scarlatina is so often conveyed SCABLET FEVER. 849 by clothing, carpets, furniture, toys, and the like. Examples are recorded in which the disease has unquestionably been conveyed by the nurse or by the physician. The secretion from the throat and nose are infectious, as is also the urine. Billington's observations, made among 26 families residing in the tene- ments of New York city, where there was practically no attempt at isolation, showed 43 cases of scarlet fever, and, further, that 47 other children, who resided in the same tenements at the same time, and who were unprotected by previous attacks, did not contract the disease. Johannessen reported that of 158 children who were exposed to scarlet fever, 28 per cent, con- tracted the disease. Johannessen also observed that of 314 adults exposed, 5 per cent, developed scarlet fever. Domestic animals, particularly cats and dogs, are likely to spread the dis- ease, and, as previously stated, there is authentic evidence to show that hogs may suffer from scarlet fever. The fact that several investigators, as well as one of the present writers, have been able to produce scarlatinal symptoms in rats and other laboratory animals would seem to indicate that rodents may be instrumental in spreading the infection of scarlet fever. Persons afficted with open wounds are especial^ likely to become infected. As a result of the careful investigations recently made by the various boards of health throughout the United States, a number of epidemics of scarlet fever would appear to have had their origin in the milk-supply, and were traceable to cases of mild scarlatina occurring in some one who handled the milk supplied to a certain district. Immunity. — One attack protects against subsequent attacks of the disease. Incubation Period. — Holt, in his tabulation of 113 cases in which the period of incubation could be accurately determined, gives the following figures: 24 hours or less 6 cases 8 days 2 cases 2 days 15 3 " 28 4 " 25 5 " 6 6 " 15 7 " 8 9 " 5 11 " 1 case 14 " 1 " 21 " 1 " Clinical Varieties of Scarlet Fever. Ordinary Type. — As a rule, the initial symptoms of scarlet fever are pronounced, and, generally speaking, may be said to appear suddenly. At first a variable degree of lassitude is present for a few hours, during which period the child feels uncomfortable, is drowsy, and may complain of some soreness in the throat. These prodromata are followed by an abrupt chill, with anorexia, nausea, vomiting, and, in small children, there may be a convulsion or a series of convulsions. By the time the physician is summoned the child complains of intense headache and nausea, and the vomiting may be obstinate. Marked angina and sharp pains over the muscles of the back and limbs are also present. At this time the pvlse is found to be between 110 and 160 a minute, and is full and bounding, of high tension, and out of all proportion to the amount of fever present. Thermic Features. — Within a few hours after the chill the temperature rises to 102° to 104° F., and continues to rise steadily until the eruption is completely developed, when it may reach a maximum of 104° to 106° F. 54 850 ACUTE INFECTIOUS DISEASES. With the fading of the eruption there is a remission m the fever toward the close of the first week, and in uncomplicated cases the temperature may then fall to near the normal line. With the onset of such complications as nephri- tis, otitis media, and bronchopneumonia the temperature may be present for an indefinite period, and whenever the fever continues for more than seven days, complications are to be suspected. Cutaneous Manifestations.— A diffuse rose-red or scarlet punctiform erythema ordinarily develops within the first twenty-four hours, and never appears later than "the thirtv-sixth hour. It is seen first about the clavicles and neck, but rapidly spreads over the chest, back, and extremities, so that within four or five hours the entire surface of the skin is of a scarlet hue. Exception. — The face is the last part to become involved in the dermatitis; the forehead, nose, chin, and lips are pale, being in striking contrast to the M t Tm E M E M E M E M E M E [m E M E M E M E M E M E M E aOWBL3 / / / / / / / / / / / / Vrine VaUy Am't 104" 103" 102° 101° 100° 99° 98° Daijo/IHs Pube. Besp. Dale. -40° A K \y \\ A 1 ) 1 A ;v 1 1 V > / \i > Y \ \ 1 A -39° y V /l I \ i y I A 1 y A '' \/ V ^ A V,' \ -ZT \ / V / z 3 ^ 5 6 y 8 f /o // /z /3 1^ -36" ■ly o'm "k '% %^ %^ '^0 'm "^0 % m^ ^Mfl m efv y ^^ y y ,'■' y' Fig. 315. — Temperature-curve of a Case of Scarlatina "with Favorable Course. Patient Aged Seven Years (.IndersJ. cheeks, which are an intense scarlet. Filatoff has called special attention to the unusual pallor of the chin, which is in striking contrast with the degree of redness of the cheeks. Pastia has likewise called attention to a some- what distinctive eruption that occurs at the bend of the elbows, but which is by no means a constant feature of scarlatina. Pressure over the skin of the chest or of any other portion of the body causes a decided pallor, the scarlet hue reappearing as soon as the pressure is removed. So marked is this pallor of the skin that one may write upon the child's chest or back. The rash of scarlet fever is particularlj' fine, and can scarcely be confounded with the eruption of any other disease, although SCARLET FEVER. 851 a not dissimilar reddening of the skin is occasionally seen to occur in some persons after the ingestion of shell-fish or of certain vegetables. In the ordi- nary type of scarlet fever the eruption is manifest for from thirty-six to forty-eight hours, being present, as a rule, during the greater portion of the second day; in mild cases, however, to be described later, the eruption dis- appears after the first twenty-four to thirtiy-six hours. A close inspection of the skin shows that the eruption is made up of innumerable fine red points (puncta), each of which surrounds a hair- follicle. At the margin of these spots there is a zone of intense redness, which blends with adjacent red areas, thus producing the general erythema. In atj^jical forms of eruption the reddened areas surrounding the hair- follicles are not surrounded by the erythematous blush. Blotches of scarlatinal eruption interspersed with healthy skin are oc- casionally seen, but are by no means common; these are more characteristic of malignant scarlet fever. We have seen cases in which the eruption was distributed in blotches and developed after death, and at this time there maj' also be detected fine hemorrhages into the skin. Fig. 316. -ScARLATiNiFORM Erythema: DESQUAMATION UPON THE Hands (Wclch and Schamberg). Patient, ix man of twentj'-nine years, has had two attacks every year of his life. Rumpell-Leede Phenomenon. — By the application of a bandage im- mediately above the elbow, pressure excreted between 45 and 60 mm. of mercury, for a period of from five to twenty minutes, minute hemorrhage will be seen to form on the anterior surface of the elbow. This same result is obtained by lifting a portion of the skin of the chest and pressing it rather firmly between the thumb and index-finger. This cutaneous sign is of some value in distinguishing scarlatina from other eruptive fevers. It is to be remembered that in measles, and at times in small-pox, a slight irrita- tion of the skin is followed by a tendency to hemorrhages. Desquamation. — In cases of scarlet fever of average severity desquama- 852 ACUTE INFECTIOUS DISEASES. tion begins within a few days after the eruption has fully developed; the severity of the exfoliation is in direct relation to the degree of eruptioii, and likewise to the height of the fever. The entire integument is involved in the desquamation and the epithelium is thrown off in large and small flakes. A similar desquamation takes place in the throat and in the mucous mem- brane of the soft palate, uvula, pharynx, and tonsils. The tongue, the entire mucous surface of the mouth, and the nasal fossffi may exfoliate. Followin, the desquamation of the tongue its dorsal surface becomes a bright red, and its papilliE become prominent, thus giving rise to the so-called strawberry tongue, which is said to be characteristic of scarlet fever. The duration of the desquamation is varialjle, the palms of the hands (Fig. 316) and the soles of the feet being the last parts to be involved. Health l;)oards maintain that so long as there is any evidence of this process the child is capable of transmitting the disease to unprotected individuals. We have repeatedly seen cases of the ordinaiy type of scarlet fever in which desqua- mation continued for from six to eight weeks after the fever lind subsided, b I'iG. 317. — Epit>f.rmat, Carts of the Hands Shed from a Fatal Care of Scarlet Fever (Welch and Sehamberg). and our experience has been that, in the majority of cases, the process requires alDout three weeks for its completion. Ocular Manifestations. — In scarlet fever the conjunctiva^ ai-e markedly congested early and the eyelids are often swollen. Nasal Symptoms. — Coiyza develops together ^'i'ith the eruption, and may even precede it !))• a few hours, although the nasal secretion is Ijut slightly increased after the first thirty-six hours. In some cases, however, a dimin- ished secretion is present throughout the course of scarlet fever. Gastro-intestinal Symptoms. — ^'omiting is an early symptom in the majority of cases. During the first forty-eight hours anorexia occurs, but after this time, in uncomplicated cases, the appetite improves, as a rule, and by the end of the first week the child relishes its food. Constipation is the rule, and unless treated, usually obtains during the first week. Local Symptoms.— With the onset of the disease the entire mucous membrane of the throat becomes reddened, and at times covered with a SCARLET FEVER. 853 thick, yellowish, tenacious mucus that serves to make a differential diagnosis between tonsillitis, measles, and scarlet fever difficult. The child complains of intense pain in the throat on swallowing or even on tallcing, and of lancinat- ing pains shooting to the ears. He holds his head in one position, as though it were fixed, and utters a cry of pain on being compelled to move his chin. Nervous S3miptoms. — As previously stated, convulsions may occur early in scarlet fever, and mild delirium is not unknown, even in uncompli- cated cases. It must be remembered that scarlet fever is one of the few diseases that show a predilection to attack the serous surfaces; consequently the physician should be ever alert for meningeal, joint, pericardial, endo- cardial, and pleural symptoms. Illustrative Case of Scarlet Fever. — C. K. C, male, aged nine years. Family History. — Parents and three sisters living and in apparent good health. Previous History. — Developed measles at the age of four years and later had whooping-cough and mumps. Has enjoyed good health during the past two years. Social History. — Breast-fed until one year of age. Began to go to school three months ago. Present Illness. — ^While at school he complained of chilliness and of headache and was dismissed for the day. Upon reaching home he vomited, the headache became more severe, and he complained of intense pain in the throat. The child appeared to be feverish, and refused to take nourishment. When seen, the child rested quietly in bed, with the chin slightly elevated. He complained of pain in the throat and neck whenever disturbed. Angina was increased by swallowing and by turning the head from side to side. He would complain occasion- ally of a shooting pain in the right ear. When seen four hours later, the temperature was 102° F. ; it continued to rise during the night, reaching 104° F. the following morning. The temperature continued high for a period of four days, when it fell gradually, reaching the normal by the ninth day. The mother stated that, soon after returning from school, the child appeared to be greatly exhausted, showed some nervous twitchings of the hands and face, which were followed by a distinct convulsion. Mild delirium was present during the night for a period of three days, and at the time when the temperature was highest. Physical Examination. — General Examination. — ^Twenty-four hours after the first symptoms were noticed the entire body was covered with a rose-red erythematous eruption. There was paUng of the skin at those parts where pressure was made, and dermographia was well marked. The head was somewhat fixed, and the chin elevated. Local Examination. — Inspection. — There was distinct swelling at the angles of the jaw, and by the end of the second day this was so prominent that the neck was greatly distorted. After the fifth week there was puffiness beneath the eyes, and swelling of the backs of the hands and of the feet and ankles. The erythematous eruption, which appeared at the end of the first twenty-four hours, faded by the end of the third day, and about one week later there was a distinct, scale-like desquamation, which continued imtil the beginning of the eighth week; the palms of the hands and the soles of the feet were the last to show desquamation. The mucous membrane of the tonsils and pharynx was intensely congested, and the tonsils were moderately swollen. The tongue was heavily coated at the beginning of the iUness, and by the third day the typical straw- berry appearance was present. Palpation. — ^There were distinct enlargement and hardening of the lymph-nodes of the neck, and pressure upon them and in the vicinity of the angles of the jaw elicited pain. The pulse was rapid — 130 beats a minute — and of high tension. Auscultation. — ^The heart action was rapid, and the sounds were loud and clear. A few moist rdles were present at the bases of both lungs posteriorly from the third to the fifth days of the disease. Laboratory Findings. — Cultures from the throat showed the presence of strepto- cocci and of diplococci. By the end of the second day the urine was scanty, not more than eight ounces being excreted during the twenty-four hours. The urine showed the presence of albumin, granular casts, leukocytes, and a few red cells until the tenth day of the disease, when the quantity of urine excreted was increased to from 20 to 30 ounces a day. Albuminuria continued, however, until the end of the fifth week, when epitheUal casts and few granular and hyaline casts were present. From the fifth to the tenth weeks the amount of albumin gradually diminished, and the quantity of urine excreted became slowly greater until, by the twelfth week, the evidence of renal involvement 854 ACUTE INFECTIOUS DISEASES. had disappeared. Early during the disease the only conspicuous blood change was a mild leukocytosis. A blood examination made during the fourth week showed: red cells, 3,150,000; hemoglobin, 70 per cent. The general characteristics of the stained blood were those known to secondary anemia. Diagnosis by Induction from Clinical Data. — The sudden onset, developing with a chill follctived by nausea, vomiting, angina, and a somewhat rapid rise in the tempera- ture to 104° F., all strongly suggested the existence of scarlet fever. By the end of the first twenty-four hours the characteristic eruption appeared and confirmed the diagnosis. The later development of albuminuria, together witn the characteristic desquamation, further supported the diagnosis. Differential Diagnosis. — The sudden onset, headache, nausea, and vomiting somewhat resembled an attack of acute gastritis, from which scarlet fever was dis- tinguished by: (1) Soreness of the throat; (2) the characteristic eruption by the end of the first thirty-six hours; (3) the fact that the high temperature continued for a longer period than is characteristic of gastritis; (4) the presence of albimainuria; (5) the ap- pearance of a scaly desquamation at the end of the second week, which continued in a manner characteristic of scarlet fever. Course of the Disease. — By the end of the third week the glandular enlargement of the neck had nearly disappeared, and desquamation was now taking place, and con- tinued until the eighth week, when there was still some scaling of the palms of the hands and the soles of the feet. Albuminuria continued from the first to the tenth weeks of the disease, and from the fifth to the eighth weeks of the illness edema of the feet, ankles, and backs of the hands and puffiness beneath the eyes were conspicuous. The child was unable to leave his bed until the twelfth week following the initial symptoms, after which time convalescence progressed somewhat slowly. Laboratory Diagnosis. — Urinary Phenomena. — Even in uncomplicated cases the urine is high colored, of high specific gravity, — 1.020 to 1.030, — and diminished in quantity, from 15 to 30 fluidounces being excreted in a day; it contains a trace of albumia and is rich in solids. Casts, renal epithelium, and red blood-cells are by no means uncommon. During the first week of the disease the diazo-reaction is positive in from 15 to 20 per cent, of all cases. The Blood. — Early during the course of scarlet fever the number of leuko- cytes is decidedly increased, ranging between 12,000 and 20,000 per c.mm. In imcomplicated cases the hemoglobin and red blood-cells are relatively decreased in number at the beginning of convalescence. NicoU and Williams* have reviewed the work done in reference to the inclusion bodies of Dohle, and at present there appears to be sufficient observations confirming the work of Dohle to regard the presence of these bodies in the blood of those suffering from scarlatina as a point of diagnos- tic value. These bodies are usually present in the blood of scarlatinal patients dxiring the first week of the disease; they have been detected before the appearance of the eruption, and may persist after the sixth day of the disease, but in such event they are not present in great numbers. Method. — Blood-smears are made after the usual method (see page 327), fixed and stained with LofHer's methylene-blue solution, or Manson's stain (borax methyl-blue), for a period of several hours. Inclusion bodies are chiefly located in the polymorphonuclear leukocytes. These bodies vary greatly in size and form, from that of a small coccus to irregular masses, approximating one-fifth the size of the normal red blood- corpuscle. Certain of the bodies are elongated (so-called bacillary forms) . Manson's stain gives to the nuclei a deep blue cloor; the cytoplasm a very faint blue, and the inclusion bodies a tint varjdng between these two shades. Caution. — Inclusion bodies have been found in the blood of patients suffering from measles, erysipelas, and syphilis. * Archives of Pediatrics, May, 1912. SCARLET FEVER. 855 Cultures from the throat show streptococci, staphylococci, and bacilli, but no diphtheria bacilli, unless both diseases are present at the same time. Malig^nant Scarlet Fever. — In this type of the disease there may be no prodromal symptoms; the attack is usually ushered in by a decided rigor or a convulsion. Angina is intense, and vomiting is, as a rule, un- controllable. The temperature rises abruptly to 105° or 107° F., and, as a rule, remains high until death occurs. Indeed, the temperature may reach its highest point one hour after death. In cases that tend to go on toward recovery the temperature becomes remittent after the first twenty-four hours, but may continue at a high point for several days, and, if the patient survive the first forty-eight to seventy-two hours, the fever-curve generally becomes septic in character. Physical Signs. — Inspection. — In malignant cases the throat and, more particularly the tonsils, are usually covered with a thick, tenacious mem- brane that resembles in a measure the pseudomembrane of diphtheria. Within the first twelve hours following the chill the child either becomes stupid or, in some instances, at least, restless, and there may be evidence of cyanosis, which often increases rapidly. The accumulation of mucus in the throat and mouth is very annoying, and the discharge from the nose is profuse. Before the end of the first day the glands of the neck are greatly enlarged, and a true acute cellulitis may exist. Following the chill the skin may become very hot to the touch, although it may be livid in color; if the child survive until the end of the first twenty- four to thirty-six hours, a profuse scarlatinal eruption will appear. In the most severe types of scarlet fever the child succumbs to the disease before the appearance of the eruption,- which is first detected after death. In the hemorrhagic type of malignant scarlet fever the eruption is petechial, and these minute hemorrhages frequently coalesce to form large ecchymoses. The hands and feet become pale and cold, and there is evidence of embar- rassed circulation. Indeed, many of these cases fall into a state of circulatory collapse during the first twenty-four hours, and death soon follows. Cases tending to go on toward recovery show, after the third day, a septic temperature, extensive necrosis and sloughing of the tonsils, ulcera- tions of the face, glandular enlargement, purulent rhinitis, and purulent otitis media. If the case have assumed the hemorrhagic type of malignant scarlet fever, hemorrhages from any of the mucous surfaces may occur; the com- monest of these is hematuria, although epistaxis and melena may appear. Complications are far more common in the malignant types of scarlet fever that go on to convalescence than in the milder or ordinary forms of this disease. Desquamation begins by the end of the first week, and is similar to that seen in other types of scarlet fever, except that the scales given off are larger, and may measure one, two, or even three inches in length. A complete cast of the finger or of the hand may be exfoliated. Following a profuse eruption, the hair and nails may fall out. Nephritis is common. Mild Scarlet Fever. — ^When the disease is not marked by any de- cided symptoms, the invasion is of short duration and the child is, compara- tively speaking, ill but a few hours. Among the symptoms are nausea, •vomiting, headache, and fever, the temperature reaching 101° to 103° F. If examined carefully at this time, congestion and reddening of the pharynx, tonsils, uvula, and soft palate will be seen. The eruption is not profuse, and may occur only about the neck and chest, all evidence of it disappearing by 856 ACUTE INFECTIOUS DISEASES. the third day. We have seen many cases of this type of scarlet fever in which the child played throughout the entire course of the illness. In one epidemic occurring in Pennsylvania the eruption faded by the second day, and nearly aU the cases seen were extremely nuld and free from complications. The following year an epidemic broke out in the same vi- cinity, and one case of malignant scarlet fever was seen among every six chil- dren suffering from the disease. It must be remembered that a child may contract mahgnant scarlet fever from one who is suffering from a mild case. Holt states that in his dispensary service in New York city he has repeatedly seen children in the desquamation stage of scarlet fever who had never re- mained from school a day during the entire attack. The nuld cases of scarlet fever are doubtless responsible for the majority of epidemic outbreaks. Relapses. — Relapses are rare in scarlet fever; they occur most frequently during the stage of desquamation — seldom earlier than the tenth and not later than the twenty-fifth days. A relapse may be accompanied by most of the symptoms characteristic of scarlet fever, but, as a rule, they are all milder than those of the initial infection. In rare cases the relapse may assume a severe type and terminate fatally. Stunmary of Diagnosis. — The characteristic sjmaptoms and signs of scarlet fever are: The presence of an erythematous eruption; rapid, wiry pulse; vomiting; angina; strawberry tongue; and a characteristic, scale-like desquamation. Among the symptoms suggestive of scarlet fever should be mentioned an abrupt onset with a chill, possibly convulsions and fever, and the occurrence of certain serious complications. Diflferential Diagnosis. — ^The various clinical forms of scarlet fever mus^ be distinguished from acute follicular tonsillitis, the charac- teristic features of which have been tabulated below. The eruption of scar- let fever is to be distinguished from those rashes that follow the ingestion of large doses or the prolonged use of such drugs as quinin, belladonna, and the like. The characteristic pulse of scarlet fever and the angina are absent in drug rashes, and the eruption is rarely so diffuse as is that of scarlet fever. Lastly, the eruption of scarlet fever is to be distinguished from that as- sociated with acute gastro-intestinal irritation, such as that following the ingestion of certain vegetables, strawberries, and shell-fish. In the latter condition urticaria and intense itching are usually present, two features unknown to scarlet fever during the first twenty-four hours. The following table sets forth the distinctive features of scarlet fever and of acute follicular tonsillitis: Scarlet Fever. Acute Follictjlak Tonsillitis. 1. There may be a history of exposure to 1. Exposure to cold and wet common. the disease. 2. Entire mucous membrane of the throat 2. Membrane of tonsils congested; small is intensely red. yellowish patches distributed over its surface. Often unilateral. 3. Nausea and vomiting follow the chill. 3. Vomiting rare. 4. Extensive scarlatinal eruption appears 4. Eruption uncommon and never exten- during the first thirty-six hours. sive. 5. Albuminuria develops by the end of the 5. Albuminuria seldom present. first week. 6. Characteristic desquamation begins by 6. Desquamation not characteristic. the end of the first week. Acute Pharyngitis. — In this condition the initial symptoms are less severe, the eruption is absent, and there is but little likelihood of the occur- rence of grave compHcations. (See table, p. 857.) SCARLET FEVEB. 857 Measles. — Since both measles and scarlet fever are common among the diseases of childhood, a careful discrimination between the symptoms pre- sented by each individual case must be made. Many workers among con- tagious diseases assert that scarlet fever and measles frequently develop in the same individual at or about the same time — an unfortunate condition . that would render the making of an accurate diagnosis very difficult. For convenience of study we have tabulated the distinctive differential features of acute pharyngitis, scarlet fever, and measles. Acute Pharyngitis. 1. Usually follows a cold affecting the head ajid throat. 2. May be ushered in with a slight chill or a series of chilly sensations. 3. Temperature usually ranges between 99.3° and 101° F., although a high temperature is not impossible. 4. Vomiting unusual. 5. No eruption. 6. Koplik's spots absent. 7. No desquamation. 8. There is scratching of the throat, with some pain upon talking, and swallowing. 9. There is a continuous desire to relieve the throat of mucus, but cough is seldom present unless the inflamma- tion extends to the larynx. 10. Photophobia and con- junctivitis absent. 11. Albuminuria absent. 12. Examination for Plas- modium negative. Scarlet Fever. 1. Follows exposure to the disease. Child healthy prior to the initial symptom. 2. Decided rigor may be the initial symptom. 3. Temperature reaches 102° to 105° F., im- mediately following the chiU. 4. Vomiting an early symptom and may be persistent. 6. A diffuse, erythematous rash, with red points. Appears within the first thirty-six hours. 6. Koplik's spots absent. 7. Scale-like desquamation begins at end of a week. 8. Angina a most annoying symptom. 9. The child makes no ef- fort to clear the throat, but often places the hand to the throat when attempting to swallow. 10. Photophobia absent. Conjunctivitis may de- velop late. 11. Albuminuria appears early and may con- tinue throughout con- valescence. 12. Examination for Plas- modium negative. Measles. 1. Follows within ten to fourteen days after ex- posure. 2. Chill is less decided than in scarlet fever. 3. Temperature rises steadily until the sec- ond day, and then re- mits until the fourth day, when with the appearance of the erup- tion, it again rises. Fever declines after the eruption has de- veloped. 4. Vomiting not common. 5. Eruption does not ap- pear until the fourth day. It appears in the form of blotches, first upon the neck and cheeks, and then spreads over the en- tire body. 6. Koplik's spots present. 7. Branny desquamation. 8. Moderate soreness of the throat. 9. There is a marked acute bronchitis, which be- gins early and contin- ues throughout the course of the disease. 10. Photophobia is an early symptom, and conjunctivitis is also common. 11. Albuminuria uncom- mon except in compli- cated cases. 12. Rosenberger's plas- modiuni may be recov- ered from the blood and from the secre- tions of the throat. 858 ACUTE INFECTIOUS DISEASES. Clinical Course and Duration. — In moderately severe types of infection convalescence is well established during the third week, and if no complications set in, the child is able to leave the house as soon as desqua- mation is completed. In malignant scarlet fever death ensues, as a rule, by the fourth or fifth day, and many cases die during the first forty-eight hours. Complications of whatever nature increase the severity of the disease, and render the prognosis more unfavorable. Complications and Sequelae. — Pseudomembranous Angina. — This throat condition may be mistaken for diphtheria, which it greatly resembles; the only distinctive feature is obtained by making a bacteriologic study. Pseudomembranous angina is due to infection with a virulent strep- tococcus. It is possible, however, to have a mixed infection, both strepto- coccus and Bacillus diphtherise being present. Pseudomembranous angina develops either early during the course of scarlet fever or at the height of the disease. The membrane usually covers the tonsils, may extend to the soft palate, pharynx, nose, mouth and Eustachian tube, and may even invade the middle ear. The color of the membrane resembles that of diphtheria, and may be of a grayish-black or a grayish-brown hue. Pseudomembranous angina is also characterized by marked infiltration of the cellular tissue of the neck, swelling of the lymph-nodes, general edema of the throat, and difficulty in swallowing. After the condition has persisted for two or more days the expectoration and the discharge from the nose and mouth emit a fetid odor. There is some evidence of nasal obstruction, and occasionally laryngeal obstruction with associated croup ensues. In practically all cases of membranous angina the constitutional symp- toms are severe, and the general condition of the patient is of the nature of a profound streptococcus infection. The lymph-nodes may sup- purate. Gangrenous angina is known to complicate only the severest types of scarlet fever. The gangrenous process may be seen to involve the throat during the first forty-eight hours of the disease, and in rare instances it may be detected almost with the development of the infection. The tonsils and other affected mucous surfaces are grajdsh-black in color, and masses of necrotic tissue may be seen hanging from the involved areas. The gangrenous process may extend to the cellular tissue of the cheeks or neck. The odor of the breath is characteristic of gangrene. The blood-vessels of the throat, and particularly those of the tonsils, are likely to be encroached upon by the gangrenous process, and death may result from hemorrhage. There is a rapidly progressing anemia, septic in nature, which is accompanied by the general symptoms of asthenia. Most cases of gangrenous angina terminate fatally between the third and seventh days. Cellulitis. — Involvement of the cellular tissue of the neck may complicate severe cases of scarlet fever, but does not develop, as a rule, until the end of the first week. There is a somewhat rapid infiltration of the tissue, the head is held in a fixed position, respirations are often labored, and the skin of the neck becomes tense and presents a brawny appearance. The infiltration may be localized to the lymph-nodes, or, less often, it may be diffuse. Death usually results from septicemia, thrombosis of the jugular veins or of the lateral sinuses, meningitis, or pyemia. Pulmonary Complications. — Bronchitis occurs less frequently during the course of scarlet fever than in either measles or diphtheria. Broncko- pneuTnonia is the commonest pulmonary complication, and is most likely to SCARLET FEVER. 859 develop in those cases in which there are laryngeal stenosis, high fever, and delirium. Bronchopneumonia seldom develops until after the third day of the disease, and in many instances gives rise to no definite symptoms or signs by which it may be recognized until the condition is well advanced. Empyema may occur as a sequel of scarlet fever, and if permitted to run its course without treatment, is likely to result in general pyemia. Edema of the lurigs is seldom seen unless scarlatinal nephritis, of which pulmonary edema may be the terminal stage, is present at the same time. Cardiac Complications. — Endocarditis and pericarditis are said to be uncommon iu the scarlet fever of children, although they may appear during convalescence. Endocarditis is sometimes seen after cases of scarlet fever in which sepsis has been a complication, and it is fairly common as a sequel of scarlatinal nephritis. During convalescence a systolic murmur is frequently heard over the base of the heart (hemic), but with general improvement in the condition of the blood, the murmur disappears. Malignant endocarditis is seen only in those cases in which extensive suppuration is present. Associated with endocarditis there may be embolism of the brain, hemiplegia, and other par- alyses, all of which are to be differentiated from post-diphtheritic paralysis. In the more severe forms of scarlet fever there is a variable degree of myo- cardial degeneration, manifested by diminished volume and force of the pulse, irregularity, and a tendency toward dicrotism. It is exceptional to find acute dilatation following the myocardial changes. Involvement of the Serous Membranes. — As has previously been stated, the pleura, pericardium, and endocardium may become involved during the course of scarlet fever, and in particular is this true of the serous sacs of the joints, those of the wrists and hands suffering most frequently, although any of the other joints may be attacked. Carslaw collected the reports of 533 cases of scarlet fever, and found involvement of the articulations in 60 of them. Synovitis develops at the end of the first or the beginning of the second week of the disease. It is characterized by redness, swelling, tenderness of the joints, and a moderate elevation of temperature. Involvement of the serous surface of the joints closely resembles that seen in acute articular rheumatism, except that it does not pass from joint to joint and seldom, if ever, causes a fatal termination. Septic arthritis, often associated with extensive throat involvement and pyemic symptoms, is rarely met in severe and fatal cases. Occasionally tuberculous invasion of the joints occurs as a sequel. Auditory Complications. — Of these, the most common, and by far the most serious, is otitis media, which results from the direct extension of the infection from the pharynx through the Eustachian tube to the middle ear. Some writers assert that otitis media is the most frequent complication of scarlet fever, and that the younger the patient, the more likely is he to de- velop this disease. Season is not without its influence, the greater number of ear complica- tions occurring during the winter months. The type of the infection in a given epidemic also influences the number of ear complications during such an epidemic. Holt cites as an instance an epidemic occurring during the spring and summer of 1889, in which, in 73 cases, not one developed ear com- plications. In another epidemic in the same locality occurring during the winter months, of 43 cases of scarlet fever, one in every five developed ear complications. Finlayson collected 4339 cases from the literature, and found that otitis media occurred as a complication in 10 per cent, of them. Craig, 860 ACUTE INFECTIOUS DISEASES in an analysis of 1008 cases, found otitis media present ia 13 per cent. When severe throat symptoms are present, ear involvement will be found to follow in from 20 to 70 per cent, of the cases. Otitis media manifests itself by extreme pain in the ear and by an abrupt rise in temperature. Within a few hours rupture of the tympanum occurs, and purulent or bloody material is discharged from the ear. The time at which involvement of the ear takes place may vary con- siderably in different cases and in different epidemics. Both ears are seldom attacked at the same time, and in the majority of cases the first evidence of otitis media is detected after the disease has reached its height. Ear com- plications seldom develop after convalescence is well established. Deajness. — The pathologic changes present in the ear are usually of a suppurative nature. The hearing is generally markedly impaired, even if the attack of otitis media has been comparatively mild. The number of patients that become permanently deaf as a result of this complication is very high, and varies with different epidemics. May, in the study of 5613 mutes, found that 572 attributed their affliction to ear compUcations follow- ing scarlet fever. Renal Complications. — Nephritis is the most serious and, therefore, the most important complication of scarlet fever. There is very often a slight albuminuria during the height of the fever, and it is possible that no more serious consequences will follow it than occur after other cases of febrile al- buminuria. Two serious forms of nephritis are seen in scarlet fever, and although the symptoms of each are distinct, they have been confounded with each other. (a) Septic nephritis is seen in those cases in which the angina is particu- larly severe, with sloughing tonsils, involvement of the soft palate, and general adenitis. In this form of nephritis the urine contains a large amount of albumin, but little or no blood and but few casts. The renal symptoms, if present, are masked by the manifestations of septicemia. Dropsy and uremia are rare, and the fatal termination occurs at the end of the second week of the process. The autopsy shows a kidney riddled with small metas- tatic abscesses. (b) Postscarlatinal nephritis is believed by the majority of writers to be the result of an inflammation of the epithelium lining the uriniferous tubules, similar to that covering the surface of the body. The renal disease may begin at any time from the end of the second to the end of the fourth week of the attack. The onset is insidious : a trace of albumin is first seen; then the amount of albumin increases, blood appears, and blood-casts and epi- thelial casts are found in the sediment. Fever returns, the amount of urine passed in twenty-four hours is diminished, the pulse is rapid and hard, and edema of the face appears; later there is edema of the feet and ankles, hands, and scrotum; vomiting occurs, and the patient is seriously ill of an acute nephritis. The complication may terminate in recovery or in uremia and death. A fatal termination may result from heart failure, due to dilatation following the high blood-pressure, from endocarditis with embolism, or from pericarditis. Sudden death is often the result of acute dilatation of the heart. Gastro-intestinal Complications. — As is to be expected, in all cases of scarlet fever there is some interference with digestion, but true organic changes are unusual. Catarrhal stomatitis occasionally complicates the severer t3^es of scarlet fever, but this condition seldom increases the gravity of the prognosis. Obstinate vomiting, probably nervous or uremic in origin, DIPHTHERIA. 861 may be an early and troublesome complication. Diarrhea, although un- common, tends to deplete the child, and renders the prognosis less favorable. Nervous Complications. — These are extraordinarily rare, except in severe types of infection. Convulsions, which are often present and may constitute the initial sjmiptom, can hardly be regarded as a complication, but when seen late in the disease they are, as a rule, uremic in origin. Per- ipheral neuritis is occasionally observed, as is also meningitis. Hemiplegia and monoplegia may accompany either meningitis or ulcerative endocarditis. DIPHTHERIA (Angina Maligna, Diphtheritis). Pathologic Definition. — An acute, endemic, infectious, and trans- missible disease, caused by the bacillus diphtheriis. It may be sporadic or epidemic. It is characterized anatomically by the development of a grayish- FiG. aiS. — Chart Showing the Number of Oases and Mortality of Diphtheria by Months. Statistical Analysis of 43,997 Cases (M.Sallom.in "Medical Record")- white pseudomemljrane in the throat, which shows a special tendency to spread to the nose and the larjaix. In severe cases there is a marked tendency for cardiac failure, postdiphtheritic paralysis, otitis media, conjunctivitis, bronchopneumonia, and acute nephritis to develop. Varieties. — Among the varieties are to be considered: (1) Tonsillar diphtheria (mild diphtheria) , in which the formation of the pseudomembrane is limited to the surface of the tonsil; (2) malignant diphtheria, in which all the S3aTiptoms are severe; (.3) pharyngeal diphtheria, in which the pharynx appears to be the initial point of involvement; (4) nasal diphtheria, in which the pseudomembrane first develops in the nares, and then spreads to the pharynx; (5) laryngeal diphtheria, which first attacks the mucous membrane of the larynx; (6) conjunctival diphtheria, in which the pseudomembrane 862 ACUTE INFECTIOUS DISEASES. develops on the conjunctiva; and (7) ivound^ diphtheria, which results from infection of an open wound by the bacillus diphtheriae. _ _ Exciting and Predisposing Factors.— The exciting cause of diphtheria is the bachlus diphtheria. Isolation of the bacillus diphtheria; is necessary in order to deternhne whether the membrane present is or is not a true diphtheric membrane, because other microorganisms are capable ot causing similar pseudomembranes upon the mucous surface of the pharynx and the upper air-passages. (a) Prominent among the predis- posing factors are age, the disease usu- ally appearing between the second and the tenth years of life, as is shown by the following table taken from Billings, covering 14,688 deaths from diphtheria occurring in the city of New York: Under one year 1,214 One to five years 9,622 Five to ten years 3,212 Ten to fifteen years 311 Over fifteen years 329 14,688 Diphtheria rarely occurs after the age of fifty, although it may develop at practically any age. (b) A history of exposure to the infection or of an epidemic is of great importance, for it is not uncommon for a large percentage of children attendiag a certain school to develop diphtheria mthin the short period of from two to four weeks. (c) Season. — The greatest number of cases are seen during cold weather (see Fig. 318), as shown by Bosworth's analysis of 18,688 cases from the records of ten years of the Bureau of Health of New York city, where 10,769 deaths were recorded from Octoljer 1st to March 1st inclusive, whereas only 7,919 deaths occurred Ijetween April and September of the same years. This is due, in part, at least, to the fact that during the winter months large num- bers of children are congregated in schools. M. Sallom's analysis of 43,997 cases reported in Philadelphia is given by Figs. 318 and 319. (d) Many writers hold that chronic irritation of the throat, nose, and pharynx predisposes to the development of diphtheria; and it cannot be disputed that such acute conditions as tonsilhtis, pharyngitis, influenza, measles, and scarlet fever enhance the tendency toward its development. (e) Previous attacks predispose to subsequent infection. Instances s,..^ E6 MftRJftPR m JUN JUL|flL;&kEp|0Cl]NDv]Dfc[|J^°J 'V40 440 -^30 410 4J0 410 410 ^ 410 4-00 f 4C» m / ^90 380 3R0 ;m ^ 3T0 iM \ 3f0 350 \ f 358 340 1 l4-( 31C 330 3IC \ 330 110 V A 310 300 300 210 v J<)D m » ■•, JRC 2ID V 3ifO no 250 710 ?4-0 7-10 230 no 33C 220 210 210 HO \ 70 ft 19 V / 110 IBO * m 170 \10 I6C IfcO ISO l^iO 140 I'ffl 130 m \20 12(1 no lie 1 loo l_ J ICC Fig. 319. — Average Number of Cabes op Diphtheria Occurring During Each Month of the Year. Statistical Analysis of 43,997 Cases (M. Sal- lom, in "Medical Record")- DIPHTHERIA. 863 have recently been recorded in which epidemics of diphtheria have broken out among families supplied with milk from a certain dairy; in one case one of the workmen who handled the milk suppHed to the affected district had suffered from a mild attack of diphtheria but a short time previous to the outbreak of the epidemic. There are numerous authentic reports of epidemics that have been traced to an infected milk-supply. In one epi- demic, occurring in Philadelphia, 23 cases of diphtheria developed among families that obtained their provisions from a certain dealer, investigation proving that a child ill with diphtheria was then residing in the rear of this man's store. The mother, who nursed the child, at the same time handled the provisions supplied to customers. (/) Unhygienic surroundings predispose to diphtheritic infection, for besides a lack of cleanliness, there is no attempt made to isolate the sick. Defective drainage and damp cellars have not been shown to bear any direct relation to epidemic outbreaks of diphtheria, although they may, by lowering the resistance of the individuals, serve as predisposing factors. On the other hand, epidemics of diphtheria often develop in rural districts, where sanita- tion is apparently perfect. (g) Climate figures prominently as a predisposing factor, diphtheria being less common in tropical than in temperate zones. Excessive humidity and wet weather seem to promote the spread of diphtheria, probably because in inclement weather the children are closely housed; but they certainly do not exercise any influence upon the development of the diphtheria bacillus. Transmission and Mode of Infection. — In almost aU cities in the temperate zone the disease is endemic, an occasional case developing through- out the year; in such cities, where the population is greatly congested, periodic outbreaks or epidemics are to be expected. Diphtheria often de- velops in the most remote localities and in rural districts, and its transmission in these districts is, as a rule, inexplicable, but they may usually be traced to the fact that a case has not been recognized until several children have been exposed to contagion. Every case of diphtheria has its origin, either directly or remotely, iti some previously existing case, although it is often difficult, and at times impossible, to trace such mode of infection. It has long been held that the bacillus diphtherise may enter the system with the inspired air or with the inhalation of the breath of a person suffering or convalescent from the disease. In view of our present knowledge of infection, however, this theory is questionable, and infection in this way probably does not occur, unless atomized particles of sputum or mucus from the throat of the patient are inhaled. In the majority of cases infection probably takes place through the intro- duction of the diphtheria bacillus into the mouth; thus a child playing with toys that have been used by one suffering from diphtheria is likely to contract the disease by carrying them or his bacillus-laden fingers to his mouth. It must be remembered that the saliva contains the bacilli in great numbers throughout the course of the disease, and that they are also present in the secretions from the nose. We have known diphtheria to spread from a single case to four other children, all of whom used a pencil that had been infected by the original patient. These five children were the only ones who developed diphtheria in a school of 46 pupils, during the entire school term of nine months. We believe that the disease is very often spread in a similar manner. In lar3nageal diphtheria, where coughing is a prominent symptom, so that much spray is atomized in the room, contagion is more likely to take 864 ACUTE INFECTIOtrS DISEASES. place than in cases that show no laryngeal involvement. During the period of convalescence the throat contains virulent diphtheria bacilli for weete, and sometimes for months, and there is Httle doubt, therefore, that diphtheria is often spread by convalescents. " It has been shown that a person may harbor virulent bacilli in his nose and throat, and may even communicate the disease to others, without himself suffering from diphtheria at any time" (Holt). As a rule, virulent diphtheria bacUli may be recovered from the throat for from ten days to three weeks after the membrane has disappeared. In a study of 321 cases we found that the average time at which diphtheria bacilli could not be obtained from cultures after the membrane had disap- peared was eleven days. The infection may be spread by means of clothing, rugs, and carpets, that have been soiled by the expectoration or the vomitus of the patient. Family epideniics are often the result of children playing upon the floor and contaminating their hands, and eventually conveying the bacilU to their lips. Again, epidemics have been known to follow the use of a drinking-cup or of a tooth-brush previously used by an infected individual. According to the researches of Rosenberger, the ordinary clinical thermom- eter is often the means of carrying diphtheria from the infected to the healthy. Domestic animals may suffer from diphtheria, as has been demonstrated by the researches of Ravenel and others. The disease is found in pigeons, chickens, turkeys, and other fowl. Cats may suffer from diphtheria and spread the disease, but more often this is occasioned by a child suffering from the disease playing with the animal, and contaminating its fur with bacilli. Animals handled by sick children may come in contact with pets belonging to other families in the neighborhood, and the bacilli may be con- veyed to these animals and thence to other children. Incubation. — The period of incubation may vary greatly in different children and in different epidemics; e. g., when most of the cases of a given epidemic are severe from the onset, the period of incubation is compara- tively short, — two to four days, — whereas, on the other hand, in epidemics in which the majority of the cases is of a mild type, the incubation stage varies between four and twelve days. Tonsillar Diphtheria (Mild Diphtheria). Principal Complaint. — In this type of diphtheria there are no prodromal symptoms characteristic of the disease, although in the majority of cases the chUd may have refused to play or have stated that he felt in- disposed on the day preceding the development of symptoms. MUd head- ache and soreness of the muscles of the limbs, particiilarly those of the back and shoulders, may be experienced, and the child complains of feeling cold at various intervals throughout the day. Convulsions are rare in this type of diphtheria except in young subjects. Thermic features are not pronounced, an elevation of temperature of from one-half to one and one-half degrees being the rule. There may be sore- ness of the throat during the first twenty-four to forty-eight hours, and a mild degree of discomfort on swallowing is to be expected. Physical Signs. — Inspection. — During the first day the surface of the tonsils, uvula, and soft palate is congested, and presents a livid appear- ance; by the second day a false membrane may be seen upon the tonsils, which may later spread to any portion of the throat or nares. In this mild type of diphtheria the membrane tends to remain localized, and the child may not seem to be extremely ill; in fact, he may not refuse to take his food throughout the entire course of the disease. DIPHTHERIA. 865 It is through the medium of these mild cases of tonsillar diphtheria that epidemics are started, for in many instances the physician is not consulted until other children have been exposed. It must not be forgotten that these mild forms of diphtheria often discharge highly virulent bacilli with the mucus and expectoration from the throat, and, according to the investiga- tions of the New York Board of Health, virulent bacilli are frequently cultivated from such cases. Although many of these cases go undetected, a fairly large percentage ot them develop albuminuria during the stage of convalescence, and, indeed, this may prove to be a true acute parenchymatous nephritis that subsequently becomes chronic. Postdiphtheritic paralysis, affecting the muscles of the throat or of the extremities, may follow mild types of diphtheria, but the complications common to the severer forms are, as a rule, absent. Pharyngeal Diphtheria. Principal Complaint. — In diphtheria locaHzed to the pharynx the symptoms develop insidiously, and often several days elapse before the patient experiences any decided annoyance. During the development of pharyngeal diphtheria, however, such prodromata as languor, chilliness, and lack of energy are complained of. Thermic Features! — ^The temperature usually fluctuates between 99° and 100° F., and may be normal during the morning hours. It must be borne in mind that even mild cases of diphtheria may be accompanied by a high temperature or even by hyperpyrexia; such decided elevation in temperature is, as a rule, due to the presence of complications, e. g., broncho- pneumonia, acute nephritis, and otitis media. Cardiac Symptoms. — There is a slight acceleration of the pulse-beats and as the disease progresses the pulse-rate may be out of all proportion to the mild degree of fever. The pulse may be weak, dicrotic, and intermittent, the quality being dependent upon the degree of intoxication. Physical Signs. — Inspection and Palpation. — The lymph-nodes beneath the jaw are swollen and painful. In the milder types of pharyngeal diphtheria there may be only slight evidence of , glandular enlargement. Glandular involvement, accompanied by a chill, even if the other symptoms are mQd, should be regarded as strong evidence of the existence of diphtheria. Examination of the throat discloses the fact that the mucous membrane of the pharynx is red and swollen, and in certain areas a variable degree of lividity is present. In this type of diphtheria the initial lesion is generally seen upon the mucous membrane of the tonsil, and the character of this exudate closely resembles that described under simple tonsillar diphtheria. The pseudomembrane spreads rapidly over the pharynx, soft palate, and uvula, and may involve the entire pharyngeal wall. It must be remembered that in true pharyngeal diphtheria the tonsils are also swollen and congested, and are not infrequently the site of the false membrane. Nasal Diphtheria. Principal Complaint. — In severe cases of pharyngeal diphtheria the process is likely to extend to the nasal mucosa, and sometimes the initial lesion is situated upon this membrane, whence it may spread to the pharynx, tonsils, and, less often, to the larynx. It must be stated that every case of nasal diphtheria is not accompanied by well-marked constitutional symptoms, although the majority of them are severe in character. In mild types of 55 866 ACUTE INFECTIOUS DISEASES. nasal diphtheria the chief complaint is of inability to breathe freely through the nose and of coryza. Inspection of the nares with the head-mirror and speculum should always be made. Thermic Features. — The thermic features of nasal diphtheria closely resemble those of the pharyngeal type, and are in no way characteristic. In a virulent type of infection the false membrane may extend from the nares to the conjunctiva. Clinical Course and Duration. — In nasal diphtheria the course of the disease should be watched carefully, for there is, as a rule, special liability to the development of bronchopneumonia. Other complications comrnon to pharyngeal diphtheria are also likely to develop in this type of the disease. Conjunctival involvement always renders the prognosis less favorable. Laryngeal Diphtheria. Laryngeal diphtheria is distinguishable from the types previously de- scribed in that the pseudomembrane forms upon the mucous surface of the larynx. Involvement of the laryngeal mucosa may occur without decided extension to the pharynx, nose, or tonsils, although, as a rule, the soft palate and the tonsils are involved. Laryngeal diphtheria differs in its symptomatology from the other types of diphtheria by the existence of a metallic cough and a peculiar harsh tone of voice. The thermic features of laryngeal diphtheria are not characteristic, and mild constitutional symptoms generally occur unless the disease makes such progress as to interfere with respiration. In practically every case of laryngeal diphtheria the local manifestations give rise to alarm because of the obstruction and the fact that the toxic symptoms resulting from imper- fect oxidation of the blood are added to the toxemia of diphtheria. The accessory muscles of respiration are brought into action — one of the earliest alarming symptoms in laryngeal diphtheria. Clinical Course and Duration. — The prognosis rests upon the degree of laryngeal obstruction and the intensity of the cyanosis. When the patient is unable to rest in the recumbent posture, but sits bent forward, grasping some object firmly with both hands, relief is indicated and is abso- lutely essential to recovery. Death may result either from a portion of the detached membrane obstructing the larynx, or from the lodgment of particles of membrane in the bronchi, with the production of pneumonia. Mild cases of laryngeal diphtheria terminate in recovery in from ten to fifteen days. In the severer forms convalescence is more or less protracted, and recovery is not complete for weeks or months. Complications are unusually frequent in laryngeal diphtheria. Before the introduction of the antitoxin treatment the percentage of deaths from laryngeal diphtheria was extremely high, and even now probably exceeds that of anj'- other type of the disease. Wound Diphtheria. Infection of wounds with the bacillus diphtherise is decidedly uncommon, yet a few such cases have been seen. In this connection it may be well to state that the diphtheria bacillus does not live upon the normal human skin. The factors necessary for the development of the bacillus diphtheriae appear to be heat and moisture, and when it is introduced into open wounds, it finds a fairly good soil for its development. Wounds that have become infected with diphtheria bacilli jdeld readily to treatment. Diphtheria of certain mucous surfaces, e. g., the vagina and the conjunctiva, is very uncommon. diphtheria. 867 Further Considerations in the Prognosis of Diphtheria. Illustrative Case of Diphtheria. — Charles A., aged seven years. Family History. — The patient is the youngest of a family of five children all of whom suffered from diphtheria during an epidemic two and one-half years ago. Ex- cept for this illness, these children have enjoyed fair health. Previous History. — The patient had measles and mumps at the age of four years, and diphtheria at the age of five years. Following his attack of diphtheria he had a per- manent enlargement of the tonsils;^ he has been subject to attacks of acute tonsiUitis, and on one occasion the tonsil was incised for peritonsillar abscess. There has also been impairment of the auditory function of the left ear since his first attack of diphtheria. Social History. — He has attended school during the regular school year since he was six years of age. He resides in the city, but is permitted to play upon the street and in the parks the greater portion of each day. Three days before the patient was seen his mother learned that he had been playing with a child suffering from diphtheria. Present Illness. — The child complains of feeling chilly, of headache and sore throat, and shows no disposition to play, but prefers to lie upon a couch the greater portion of the day. The pulse is weak — 110 beats a minute; respirations, 30 a minute. There is slight soreness on swallowing; the voice is husky; and on the fourth day acute pain in the left ear developed. When first seen by the physician, the child's temperature was 99.8° F., and upon the second day it had risen to 100.4° F. in the morning, and 101° F. during the evening. The temperature varied greatly during a period of four days, when it rose suddenly to 104° F. At this time the child complained of intense pain in the left ear and the other cUnical manifestations of otitis media were present. Physical Examination. — General. — The expression was unusually anxious. The patient breathed with his mouth open; there was some playing of the nostrils and little or no inclination to move about the bed. There was swelling at the angles of the jaw, and the glands of this region were extremely hard to the touch. The patient's body was perfectly nourished, but his face, fingers, and lips were pale. Local Examination. — Inspection. — The mucous membrane of the tonsils and pharynx was markedly congested, and a distinct silvery membrane covered the greater portion of the left tonsil and a small area of the soft palate. Upon removing a portion of the membrane from the tonsil a bleeding surface remained, and the membrane re- formed within the course of twelve hours. Palpation. — The glands in the region of the neck were moderately enlarged, this being more marked upon the left side. (See General Examination, p. 865.) The pulse was extremely weak and thready, and showed a tendency toward dicrotism. As the disease progressed the pulse continued irregular, and both force and tension were di- minished. Following the administration of circulatory stimulants the pulse became less frequent and its tension markedly improved. Within the course of twenty-four hours, following the administration of antitoxin, the pulse continued to improve. Auscultation. — The breathing was somewhat labored, and the breath-sounds were distinctly audible at some distance from the bed. Numerous rHIes were heard over the entire surface of both lungs posteriorly. Laboratory Findings. — A smear made from the false membrane removed from the tonsil showed the presence of great numbers of bacilli, which, morphologically, were identical with the bacillus diphtherise. ' Cultures from the throat developed baoiUus . diphtherise and streptococci. The urine obtained on the third day of the disease showed a trace of albumin, and repeated examinations revealed the presence of a moderate amount of albumin until the fourth week; this disappeared during convalescence. Microscopically, the urine contained many leukocytes and a few cylindroids. Diagnosis by Induction from Clinical Data. — Of great importance is the clinical history that the child had been in the company of a playmate suffering from diphtheria three days before his physician declared that he was suffering from the same disease. MUd soreness of the throat, the presence of a distinct false membrane on the tonsils, and the high degree of prostration made the diagnosis fairly positive. The irregular character of the temperature and the additional fact that the false membrane, when removed from the tonsil and examined microscopically, showed the presence of baciUi morphologically identical with the bacillus of diphtheria, left but little room for doubt as to the nature of the disease. Cultures from the throat revealed the presence of colonies both of bacillus diphtherise and of streptococci, the finding of the first being sufficient evidence on which to base the diagnosis. Albuminuria and the general course of the disease bore out the findings. Differential Diagnosis. — On account of the degree of angina and the marked reddening of the tonsillar mucous membrane the question as to the possibility of ton- sillitis being present arose. The clinical evidence that eliminated the possibility of tonsillitis and confirmed that of diphtheria was: (a) The presence of a false membrane 868 ACUTE INFECTIOUS DISEASES. in the throat, which when removed, left a bleeding surface behind; (6) the inembrane contained bacilli resembling the diphtheria baciUus, and on culture true diphtheria bacilli were found; (c) the disease developed less abruptly than does tonsillitis, and the chill was less pronounced; (d) the temperature rose slowly to its maximum elevation, whereas in tonsillitis a more abrupt rise is the rule. Albuminuria, which was well marked and quite persistent, is uncommon in tonsillitis. Course of the Disease. — The false membrane disappeared from the throat upon the third day of the disease, although repeated cultures showed the presence of diph- theria bacilli until the beginning of the third week. The temperature fell about one degree, and the pulse-rate was diminished 10 beats a minute within twenty-four hours following the administration of antitoxin and cardiac stimulants. The agonizing pain in the left ear was promptly relieved by puncture of the drumhead. During the fifth week of the disease, at a time when convalescence was progressing most favorabljr, the mother observed that the child experienced difficulty in swallowing, and that liquid foods were regurgitated through the nostrils (paralysis of the palate), but this somewhat frequent compUcation improved rapidly, and complete recovery ensued. I^aboratory Diagnosis of Diphtheritic Disease of the Throat. — Cultures made from bits of false membrane taken from the different areas and from the saliva develop colonies of the bacillus diphtherise. It must be remembered that the diphtheria bacillus grows best upon a special me- dium made from blood-serum. It is unusual to obtain a pure culture of the bacillus diphtherise from the patches in the throat or the nose, but colonies of other bacilli, cocci, and spirilla are likely to be present in the same culture. Smears made from the culture should be stained with Loffler's alkaline methylene-blue in order to demonstrate the presence of bacUlus diphtherise. In the majority of instances a diagnosis of diphtheria is made from a cultural study of the false membrane, but it must be remembered that other bacilli, whose cultural and tinctorial properties are similar to those of bacillus diphtherise, are also present in the throat. The only positive evidence to be had that we are not dealing with the bacillus pseudodiphtherise (bacillus xerosis) is obtained by injecting a portion of a bouillon culture of the suspected organism into a rabbit or a guinea-pig. The injection of such a culture will kill the animal in twenty-four or forty-eight hours if the organism is the bacillus diphtherise, but bacillus pseudodiphtherise will not kill the animal. Although this precaution is not taken in the routine work of health boards in making a diagnosis of diphtheria, we believe that this experiment should be performed whenever a doubt arises, and before rigid quarantine is established. Early during the course of diphtheria the quantity of urme excreted is greatly diminished; its specific gravity is increased; its color is high; and, as the disease progresses, albuminuria is likely to develop. During the first week of the disease the diazo-reaction will be found positive in from 10 to 15 per cent, of all cases. Microscopically, the urine contains few red blood-cells, many leukocytes, degenerated renal epithehum, and casts. Conradi and Bierast have recovered diphtheria bacilU from the urine of infected children. Summary of Diagnosis.— The detection of the characteristic mem- brane in the throat, the pronounced circulatory symptoms, rmld fever, albuminuria, and prostration, all point strongly toward the existence of diphtheria. The diagnosis is confirmed by the finding of the bacillus diph- therise in the cultures. The hemoglobin content falls to between 75 and 65 per cent, during the first week of diphtheria, and the red cells are greatly decreased in number by the beginning of the third week. Leukocytosis is an early feature of diph- theria, and its degree is dependent, as a rule, on the severity of the infection. Differential Diagnosis.— Infections of the throat that might readily be mistaken for diphtheria are : Acute jollicular tonsillitis, acute pharyngitis, streptococcus angina, and scarlet fever. DIPHTHERIA. 869 Streptococcus angina is a condition in which there is an extensive formation of pseudomembrane on the throat, due to infection with the strep- tococcus. It is to be distinguished from diphtheria by the intense pain, abrupt development, and the absence of albuminuria and of glandular in- volvement. The accompanying table shows the distinctive features of acute follicular tonsillitis, diphtheria, and scarlet fever: Follicular Tonsillitis. 1. Premonitory symp- toms are mild sore throat, headache, and constipation. 2. Onset with a chill, which may be either mild or severe. 3. Temperature reaches 102° to 104° F., within a few hours after the chill, and remains high for a few days unless reduced by the ad- ministration of so- dium salicylate. 4. Pulse, 90 to 110 a min- ute, bounding, but not wiry. The frequency is dependent upon the temperature. 5. Eruption unusual and not characteristic. 6. Lymphatic glands of throat and neck are greatly enlarged, ex- cept when compli- cated by peritonsillar abscess. 7. Tongue is heavily- coated with a whitish or yellowish fur. Lat- er, the tongue may be intensely red and show marking of the teeth along its edges. 8. Redness localized to the tonsils. Small ele- vated yellowish spots over the surface of the tonsils, which, when removed, leave only a reddened surface. Diphtheria. 1. Premonitory symptoms often absent or indis- tinct. 2. No rigor or chiUy sensa- tions may be experienced. 3. Temperature, 99° to 101° F., by the end of the first day. Not influenced by salicylates, but falls after injection of diphtheria antitoxin. 4. Pulse may be rapid, but beats are less forcible than in either tonsillitis or scarlet fever. . Tends to become irregular and compressible. 5. No characteristic eruption, although varied forms of eruption are occasionally seen. 6. Glands of the neck en- larged early, and have a peculiar, stony feel. 7. Tongue slightly coated, but not characteristic. 8. Grayish or silvery mem- brane on the tonsils, but more often on the piUars of the fauces and the soft palate. When removed leaves a bleeding surface. Scarlet Fever. 1. There is usually lassitude for a few hours, and nau- sea and vomiting may be the cardinal symptoms. 2. ChiU may be the initial symptom. 3. Temperature ranges be- tween 102° and 106° F., immediately following the chill. Fever is in propor- tion to the amount of eruption, and usually de- clines as this disappears. 4. Pulse is greatly accele- rated — 120 to 140 a min- ute, bounding, hard, wiry, and out of propor- tion to the temperature. 5. Eruption appears during the first thirty-six hours. It is diffuse, dusky red, with an occasional slightly raised spot. It is seen first in the region of the clavicles and chest, but spreads to all parts of the body. The skin is intensely hot, and pres- sure over the back or chest causes a decided paling. Eruption fades within forty-eight to sev- enty-two hours. 6. Glands not enlarged at first, but later show en- largement. 7. Tongue is coated with a thick white fur, which peels from the edges on the fourth day, leaving a bright-red surface. Small red elevations (straw- berry tongue) are seen scattered here and there. 8. Fauces are either a slight or intense dusky red. Marked swelling of the throat, and in some in- stances isolated white spots, are to be seen. 870 ACUTE INFECTIOUS DISEASES. Follicular Tonsillitis. 9. Membrane, when re- 9. moved, seldom re- forms. 10. Albuminuria absent. 10, 11. No desquamation. 11. Diphtheria. A new pseudomembrane 9. reforms after the initial one has been removed. Albuminuria occurs as 10. early as the second or third day, and may con- tinue throughout conva- lescence. Desquamation absent. 11. 12. Complications rare. are 12. Ear and eye complications 12. are quite common. Pneu- monia and postdiphtheric paralysis frequent. 13. Cultures from the sur- face of the tonsil and from pus from the ab- scess do not show diphtheria bacilli, but contain other organ- isms. 13. Both smears and cultures from the false membrane show diphtheria bacilli. 13. Scarlet Fever. Membrane absent. Albuminuria seldom ap- pears until after desqua- mation has begun. Extensive desquamation, beginning from the sixth to the tenth day, and continuing for from one to several weeks. Des- quamation is pronounced upon the palms of the hands and the soles of feet. Otitis media, with conse- quent deafness, is the most frequent complica- tion. Arthritis, endocar- ditis, and suppuration of the submaxillary glands are less frequent. Peri- carditis, epilepsy, endo- carditis,and mental weak- ness have been observed. Cultures from the throat show streptococci and diplococci, the latter be- ing pathogenic for hogs, rats and other animals. Clinical Course and Duration. — In every case of diphtheria the course of the disease is dependent upon the following conditions: (1) The virulence of the tj^pe of infection; (2) the age of the patient — the older the child, the more favorable the prognosis; (3) the institution of proper treatment within the first twenty-four hours, antitoxin being of limited value imless administered early; (4) the presence or absence of complications (see Complications, p. 870) ; (5) history of previous attacks — in repeated attacks each subsequent infection tends to be more mild than the preceding one, although exceptions to this rule are fairly common. The mortality rate for diphtheria has lately been reduced from 40 to about 20 per cent., and this change coincides closely with the introduction of serum therapy. The prognosis should always be given guardedly, for even the mildest cases may develop serious complications, e. g., nephritis and multiple neuritis. The prognosis is also governed by the rapidity and strength of the heart- beats. In unfavorable cases the pulse becomes weak, rapid, and dicrotic. If the pulse is irregular and the heart action extremely slow, the prognosis is grave. Cases of nephritis usually recover from the initial attack, and the patient is able to get about the house in from six to ten weeks, but the nephritis is likely to recur within the course of a year or more. During the acute stage of diphtheria death may result from laryngeal stenosis, the inspiration of false membrane into the bronchi, with a resultant bronchopneumonia, septic infection, and cardiac paralysis. Complications. — The most frequent complication occurring in MEASLES. 871 diphtheria is bronchopneumonia, and this is most common in cases of diphtheria of the larynx, and when interference with either respiration or deglutition is present. The presence of bronchopneumonia aggravates all the symptoms of diphtheria, and, in addition, is responsible for many of the symptoms known to this infection. (See Bronchopneumonia, p. 107.) Dysphagia occasionally compKcates diphtheria, and its presence, because of the prolonged strain it imposes upon the general economy, is an unfavor- able accompaniment. Neuritis seldom appears until the third or fourth week of the disease, and often not until convalescence is apparently well established. The child suddenly notices that upon attempting to swallow food or liquid it is regurgi- tated through the nose. Paralyses are most likely to involve the muscles of the soft palate, yet paralysis of the extremities is ordinarily seen, when the knee and biceps reflexes are absent. Rarely, indeed, is paralysis of the muscles of the trunk observed. Albuminuria, when marked, should be considered under the head of complications, although a mild degree of albuminuria is a symptom of prac- tically all forms of diphtheria, and, in the absence of a bacteriologic study, is of great importance in formulating a diagnosis. When the amount of albumin excreted is very high, the gravity of the disease is enhanced. In acute nephritis with anuria the prognosis is unfavorable. Ocular Complications. — The false membrane may extend to the con- junctiva, ia which case the prognosis is grave. Strabismus is occasionally seen, and still less often there is paralysis of the ciliary muscles, with dimness of vision and disturbed accommodation. Otitis media is a frequent complication, and with its development all the constitutional symptoms of diphtheria are aggravated. Impairment of hearing, or even total deafness, may follow, and there may also be a chronic otorrhea. Myocarditis.— The heart muscle is perceptibly weakened, and this weak- ness is characterized by a distinctly feeble pulse. The heart-sounds are weak, and in extreme cases the muscular quality of the systolic sound is absent. A moderate degree of cardiac dilatation is present. Not infrequently death results from cardiac failure, the final change being that of acute dilatation. The more marked the myocarditis, the more pronounced is the anemia during convalescence; it is quite impossible to restore the blood to its normal tone unless the heart be well fortified. Both the anemia and the myocarditis are due to the diphtheria toxin. MEASLES. Pathologic Definition. — An acute infectious disease, characterized by the presence of a catarrhal inflammation of the respiratory mucous membrane. The only lesions that are constant are those on the skin and mucous membranes. The cutaneous manifestations consist of a superficial inflammation, accompanied by congestion and by an exudation of round-cells in the region of the smaller blood-vessels and around the sweat-glands. The skin, particularly of the face, is somewhat edematous. The mucous surfaces are involved quite as commonly as is the skin, consequently catarrhal con- junctivitis, rhinitis, pharyngitis, and tracheobronchitis are present. Bxciting and Predisposing Factors. — Bacteriology. — The cause of the disease is unknown. The lesions of the respiratory tract show the presence of staphylococci and streptococci, and in some cases one organism may predominate, whereas in others, almost equally severe, the reverse con- 872 ACUTE INFECTIOUS DISEASES. dition obtains. Both streptococci and staphylococci may be present in tte sputum, and the pneumococcus and other diplococci may also be recovered. In those cases in which bronchopneumonia compUcates measles, the bacte- riologic findings are practically identical with those described under Bron- chopneumonia. (See p. 110.) Parasitology. — Rosenberger and others have studied a doubtful parasite (protozoon?). found in the blood of those suffering from measles. Certain observers assert that they have found specific bacteria in the blood and on incising the lesions of this disease. Measles is usually spread by direct contagion, although the disease is occasionally transmitted by clothing and furniture. Goetze* succeeded in transmitting the disease to swine by injecting the patient's blood during the eruptive stage of measles. Immunity.— One attack of measles generally estabhshes permanent immunity. . _ Age. — Age figures prominently as a predisposing factor, the majority of cases being seen during childhood and after the third year of life. The disease rarely attacks children under one year of age, and the infant members of a family in which all the older children are affected frequently escape infection. The aged who have not suffered from a previous attack of measles are less likely to develop the disease than are those in the first, second, and third decades of life. Experience has shown that measles is highly conta- gious by direct exposure, especially when children are permitted to associate with those ill with the disease. Period of lucubatiou. — Holt, in an analysis of 144 cases in which the incubation period could be definitely determined, gives the following table: Incubation of less than nine days 3 cases " " nine or ten days 22 " " " eleven to fourteen days 95 " " " fifteen to seventeen days 19 " " " eighteen to twenty-five days 5 " It will be seen from the preceding table that in 66 per cent, of cases the incubation period varied between eleven and fourteen days; that in but a single instance was it less than one week; and in but three cases did it de- velop before the ninth day. Duration of the Infective Period. — This is short as compared with scarlet fever, the average time being placed at four weeks, but instances are recorded in which, apparently, a child has conveyed the disease to another thirty days after the appearance of the rash. Those ill of the disease are capable of transmitting it to others after the appearance of the catarrhal symptoms referable to the respiratory tract, and there are apparently au- thentic records of cases in which the disease was transmitted to others two to four days before the eruption developed. Principal Complaint. — There are, as a rule, marked prodromal manifestations, the patient complaining of headache, malaise, constipation, soreness and aching of the muscles, and photophobia for two or three days. Catarrhal Stage. — The early symptoms resemble those of a cold in the head. The child has fever, marked coryza, lacrimation, and a dry cough, and sneezes frequently. The symptoms of a catarrhal laryngitis and bron- chitis are also present, and there is an abundant secretion from the respira- tory mucous membrane, as well as from the conjunctiva. There is aching of the back and limbs. * Jahrbuch ftir Bander, August, 1912. MEASLES. 873 Thermic Features.— There is usually an elevation of temperature of from one to two degrees during the evening hours, with decided morning remis- sions. Physical Signs. — Inspection. — The mucous memlarane of the fauces, tonsils, and pharynx is congested, and an eruption may be seen upon the mucous membrane of the cheeks, palate, and the lips. This eruption, which is known as Koplik's spots, is composed of bluish-white specks sur- rounded by a red areola. It is found on the buccal mucous membrane two or three days before the rash appears on the skin. These spots should be sought for in strong daylight, since artificial light does not bring out the colors nor properly illuminate the spots. Very frequently they are seen only opposite the molar teeth, although they may be present on any part of the buccal mucous membrane. Eruptive Stage. — Principal Complaint. — This is highly characteristic. With the appearance of the erup- tion there may be a slight ameli- oration in certain of the consti- tutional symptoms. (See Thermic Features.) The cough may now become metalhc or ringing in character, and in certain cases this constitutes the most annoy- ing symptom. Headache, which has ijeen persistent during the preemptive stage, may now ame- liorate or subside. Thermic Features. — The tem- perature, which during the pre- emptive stage mav have regis- tered as high as 103° or 105° F., falls with the development of the rash, and remains at a much lower level during the eruptive stage (Fig. 320). At about the fifth or sixth day there is a decided abatement in the severity of all the symptoms, particularly those referable to the respiratory tract and to the eyes. Physical Signs. — Inspection. — Initial Eruption. — At the onset of the disease, and within the first twelve hours after the child shows some indis- position and headache, there is an almost universal reddening of the skin resembling a faint scarlatinal eruption. This initial eruption disappears within a few hours, and at the time of its disappearance Koplik's spots make their appearance on the buccal mucous membrane. The physician seldom detects the initial rash because the patient is not seen until this feature of the disease has disappeared. Experience has shown that it is practically impossible to distinguish between the pre-eruptive measle stage and the mild attack of scarlet fever, and the diagnosis is usually made at the time of the appearance of Koplic's spots or of the typical eruption. The typical rash makes its appearance during the fourth day of the disease, and is seen first upon the face, neck, and forehead, spreading thence to the trunk and extremities. As the result of the swelling the features are somewhat dis- torted, and those portions of the face not affected by the eruption are in- tensely red. There is always a distinct discharge from the conjunctiva;. 1 A ^ J e ' I ■' o A 40-0 /' / y / \/ A 1 / V A i ' \ \ A / V J o / i A s _^fi.n ___ _ 1 Initial fever. Eruptive fever. Eruption. Fig. 320. — Temperature-curve of a Case of Measles) (J. M. Anders). 874 ACUTE INFECTIOUS DISEASES. which are greatly congested. The eruption of measles is composed of small, disk-like papules'^ which show a tendency to coalesce, giving to the skin a more or less blotched appearance. The eruption becomes more and more profuse, and within the course of two or three days the trunk and extremities are well covered. The eruption is rarely papular. By the end of the fifth or the sixth daj^s the eruption has attained its height (Fig. 321), Fig. 321. — Well-marked Measles Eruption on the Fifth Day of the Disease (Welch and Scham- berg). and an appreciable fading now begins, first involving the face and neck, and then extending over the l^ody and extremities. Following this a fine bran- like desquamation spreads over the body in the same topographic manner, the skin now displaying a flushed or somewhat mottled appearance. lyaboratory Diagnosis. — The sputum secreted is increased, and con- tains many microorganisms, staphylococci, and streptococci. Czajkamski Fin. 322.— Measles in a Child (Welch and Schamberg). has described a special motile liacillus, which was decolorized by Gram's method. SchotteHus has isolated the staphylococcus pyogenes aureus from the conjunctivEe, and pathogenic bacteria may also be discovered in the viscera in fatal case.s. Tlie vrine is decreased in quantity and high in color and in .specific gravity, and during the height of the febrile period may contain a trace of albumin. In those cases complicated by nephritis both alliumin and casts are present, and occasionally hematuria is observed. The diazo-readion is found in nearly all cases of measles, at least in the earlier stages. It is not MEASLES. 875 present in German measles, and its occurrence may serve as a means of diagnosis between the two conditions. Constipation obtains during the febrile period, but after the eruption has fully developed, and even during convalescence, diarrhea often forms one of the annoying complications. Illustrative Case of Measles. — James L., aged five and one-half years. Family History — Parents two older sisters, and a brother are living and in good health. Previous History. — Had mumps at the age of three years, tonsillitis and scarlet fever a year ago, since which time he was well. Social History. — His playmates have been members of families in which unques- FlG. 323. — Measles op the Papular Type in an Adult (Welch and Schamberg). Mistaken, during a variolous epidemic, for smallpox. tionable cases of measles have occurred during the past few months. There is, however, no history of direct association with children ^-iho ha\'e recently suffered from the disease. Present Illness. — This began quite abruptly, with distinct chilliness, followed by vomiting. Ho complained of feeling ill, and showed an intolerance to light, and no disposition to play. During the first twenty-four hours there was intense headache, soreness of the limbs, arms, and back, and distress on being moved by his nurse. The throat was sore, and there was pain upon swallowing. Cough developed early, and was harsh and rasping in character, and unaccompanied 876 ACUTE INFECTIOUS DISEASES. by expectoration. It continued until the fifth day of the disease, and showed no ten- dency to subside until the patient had been given mild doses of codein. By the tenth day the cough had practically disappeared, although it occasionally followed exertion. On the third and fourth days the child gave the appearance of being extremely ill, and mild delirium was present during the night. The headache disappeared during the second day, and did not return during the entire course of the disease. Following the chiU the temperature rose abruptly to from 102° to 103° F., and remained near this point for a period of about twelve hours. During the second day of the disease the temperature showed an appreciable decline, but did not reach the normal, and upon the fourth day, with the appearance of the eruption, the temperature again rose to 104° F., after which it fell gradually, reaching the normal between the fifth and the seventh days Physical Examination. — General. — When first seen, the child rested quietly in bed, since movement excited both headache and cough. The head was held in a some- what fixed position. There was an expression of pain on swallowing, and the child was unusually irritable and displayed an intolerance to light. Local Examination. — Inspection. — The face was flushed; the mucous membrane of the tonsils and pharynx was congested, and by the second day of the disease Koplik's spots were present on the soft palate. The nostrils played freely, and the respirations numbered 40 a minute. The conjunctivae were reddened. On the third day of the ill- ness a peculiar erythematous reddening of the skin appeared, which was most marked on the inner surface of the arms and about the neck; this continued to extend until, by the end of the fifth day, the entire body was covered with the typical eruption. Palpation. — The pulse was full and strong at first, the beats numbering 110 a ipinute; during the fourth day, however, and at a time when the fever was highest, the pulse increased to 120 a minute. Auscultation. — Numerous fine and coarse rdles were heard over both lungs, and at the apices of the lungs the respiratory murmur was harsh. Laboratory Findings. — During the height of the fever the urine contained a trace of albumin, but microscopic analysis was negative. Diagnosis by Induction from Clinical Data. — ^The child had probably been associated with other children who were developing the disease. The diagnosis re- mained in doubt in spite of the fact that the onset was characteristic, the harsh, rasping cough, photophobia, and pain in the back and limbs suggesting strongly the existence of measles. A positive diagnosis was not possible until the development of the eruption (Koplik's spots). The temperature was in itself quite characteristic (see Thermic Fea- tures, p. 873), but in no way aided in the early recognition of the disease. Course of the Disease. — After the first twenty-four hours there was a distinct amelioration in all the symptoms except the cough, but during the third day the child's condition became less favorable, and he remained extremely ill until the eruption was well developed. (See Thermic Features, p. 873.) Headache and muscular pains, which were present during the first day, were greatly relieved by the administration of proper medicaments, and the cough also improved following treatment. By the beginning of the third week the child was able to leave his room, and from this period recovery was uninterrupted. Summary of Dias:uosis. — The diagnosis is, as a rule, doubtful until the characteristic eruption appears. During the preemptive stage a provi- sional diagnosis, based upon the following symptoms, may be made: Head- ache, malaise, chilly sensations, anorexia, pain in the eyeballs, intolerance of light, and the presence of Koplik's spots upon the mucous membrane of the mouth. With the appearance of the characteristic eruption the diagnosis is confirmed (see Eruptive Stage, p. 873); this eruption fades from the fifth to the sixth day, and is followed by a branny desquamation. Diflferential Diagnosis.— Measles is to be distinguished, first, from scarlet fever, and the following table sets forth the distinctive clinical features of these two diseases: Measles. Scarlet Fever. 1. History of exposure to measles. 1. History of exposure or of an epidemia of scarlet fever. 2. Prodromal symptoms continue for 2. Prodromal period short, three days. MEASLES. 877 Measles . — {Continued . ) 3. Symptoms become more and more in- tense until the development of the eruption by the end of the third or fourth day. 4. Fever falls just before the rash appears and after the eruption is fuUy de- veloped. 5. Eruption disappears from the fifth to the sixth day. 6. Eruption maculopapular. 7. Cough and catarrhal conjunctivitis. 8. Photophobia is an annoying feature. 9. There may be slight albuminuria. 10. Tongue is heavily coated, and often swollen, with KopHk's spots upon the buccal mucous membrane. 11. Tendency toward the development of bronchopneumonia and eye compli- cations. 12. Pulse fuU and of fair tension, number- ing 100 to 110 beats a minute. 13. Bran-like desquamation by the end of the sixth or beginning of the seventh day, and continuing for approximately one week. 14. The leukocytes are normal or subnor- mal in number. Scarlet Fever. — (Continued.) 3. Symptoms violent both before and after the appearance of the rash, which is seen by the end of the first twenty- four to thirty-six hours. 4. Fever remains high. 5. Eruption disappears by the second to the third day. 6. Eruption erythematous and punctate. 7. Cough less prominent. 8. Photophobia absent. 9. Albuminuria is common, especially during convalescence. 10. Characteristic strawberry tongue. 11. Renal and cardiac complications quite common. 12. Pulse fuU and bounding and of high tension, 120 to 140 beats a minute. 13. Desquamation is scale-like, and may continue for from three to six or more weeks. Entire casts of the hands, fingers, or foot may be given off, and the palms of the hands and the soles of the feet are the last to be concerned in this process. 14. Leukocytosis is present. The absence of leukocytosis also distinguishes measles from variola, varicella, and rubella. The accompanying table, taken from Rotch, shows the differential points between measles and other acute infections for which it is likely to be mistaken: Measles. Variola. Varicella. Scarlet Fbvee. RCBBLLA. Incubation .... 10 days. 12 days. 17 days. 4 days. 21 days. Prodromata. . . 3 " 3 " A few hours. 2 " A few hoiurs. Efflorescence . . Papules. Macules. Papules. Vesicles. Pustules. Vesicles. Erythema. Papules. Desquamation Complications and sequelae . Furfuraceous. Large crusts. Small crusts. Lamellar Eye and lung. Larynx. Kidney, ear Lungs. and heart. Clinical Course and Duration. — The clinical course is divided into three stages: (1) The preemptive stage, previously described; (2) the eruptive stage (see p. 873) ; and (3) the stage of defervescence. The time required for convalescence to be well established varies between ten and six- teen days. In mild cases of the disease in children desquamation may be nearly completed by the tenth or twelfth day, but in adults, in whom the clinical expression of the disease is more severe, a longer period is required. Complications. — ^These consist chiefly of pulmonary affections, among which bronchopneumonia is prominent; lobar pneumonia, 878 ACUTE INFECTIOUS DISEASES. purulent bronchitis, and chronic bronchitis are less frequent. Otitis media and simple catarrh of the middle ear are exceedingly common in measles. Chronic conjunctivitis, blepharitis, and ulceration of the cornea are by no means unusual. Nephritis is occasionally observed when patients are subjected to exposure (cold and wet) during the preemptive stage or before convalescence is completed. Gastro-intestinal catarrh may continue for weeks or even months after an attack of measles, and is usually manifested by exacerbations of diarrhea. Sequelae. — Following an attack of measles the hair may fall, and in many instances a luxurious growth is never restored. Permanent im- pairment or even destruction of the auditory sense is occasionally encoun- tered, as are also chronic conjunctivitis and nephritis. RUBELLA (RoTHELN ; German Heasles). Pathologic Definition. — An acute infectious disease, characterized by enlargement of the postcervical glands and the presence of a cutaneous eruption. Predisposing Factors. — Rubella may occur either epidemically or sporadically. It is generally conceded to be of probable microbic origin, although the specific organism capable of exciting the disease has not as yet been determined. Exposure to the disease appears to be a prominent factor in the majority of instances. House and local epidemics in schools and homes are common. The disease spreads more rapidly in those places in which imhygienic surroundings prevail. The channel through which the disease is conveyed from sick to healthy individuals is not positively known, although it is believed to take place through cutaneous emanation, exhalation of the breath, and by means of clothing and other articles. The infective period is believed to begin some hours, or possibly days, prior to the development of the eruption, and con- tinues until convalescence is well established. Immunity. — One attack usually establishes immunity, although, in 719 cases studied by us, second attacks occurred in 2.5 per cent. Incubation Period. — In the vast majority of instances the stage of incubation continues for from ten to sixteen days, but there are exceptional cases in which typical clinical pictures of the disease are seen for three or four days after exposure; on the other hand, cases have developed as late as from the twentieth to the twenty-fifth days following exposure. Principal Complaint. — Stage of Invasion. — This stage is fairly distinct, and usually persists for from one to three days. The patient com- plains of feeling indisposed for a period of a few days before the appearance of the rash, and mild chills, vague pains in different portions of the body, lassitude, feverishness, moderate soreness of the throat, a mild constriction or band-like sensation about the chest, and the symptoms of acute bronchitis occur. After the eruption has developed, itching may become intolerable. In mild forms of the disease the initial symptoms may be indefinite or absent, the first indication of ill health being the appearance of the eruption. Thermic Features. — The eruption is, as a rule, preceded by the onset of moderate fever, the temperature varying between 99° and 100° F.; in ex- ceptionally severe forms, however, it may reach 102° to 103° F. The tem- perature does not subside with the appearance of the eruption, but remains at or near 100° to 102° F. until the eruptive stage has run its course. RUBELLA. 879 Physical Signs. — Inspection. — The Eruption. — In typical cases there is an ajDpreciable enlargement of the postcerrical hjmph-nodes, and the characteristic eruption consists of papules and is multiform, confluent, and pale rose-red in color. These patches seldom assume any special form, the skin between them being hj-peremic. The rash is completely developed on different part.s of the body in successive crops, and while it may be fading in Fig. 324. — Rubella — Characteristic Eruption upon Trunk (Welch and Schamberg). one portion of the body, it may be appearing in another part. The duration of the eruption varies in different cases, two to five or more days being the usual period. Desquamation occurs in the majority of cases, and there may be slight evidence of pigmentation after the eruption has disappeared, which usually occurs in from three to seven days. The throat is congested, the tonsils are swollen, and their covering mucous membrane is reddened. 880 ACUTE INFECTIOUS DISEASES. Palpation confirms the findings of inspection with reference to the enlarge- ment of the cervical lymph-nodes and the moderate roughening of the skin. The pulse is increased in frequency, of moderate tension, and the respiratory movements are also slightly more frequent than normal. Stunmary of Diagnosis. — The diagnosis is based largely upon the absence of severe constitutional symptoms, the character of the eruption, glandular enlargement, and the establishment of convalescence by the end of the first week. Differential Diagnosis. — Rubella is to be distinguished from measles by the extreme mildness of its course and the absence of marked catarrhal symptoms referable to the respiratory tract and conjunctivae. The eruption of rubella is also a distinctive feature, appearing, as it does, in successive crops. The presence of epidemics should be taken into considera- tion in differentiating rubella from measles. In rubella the fever does not .show a decided fall — a condition that is characteristic of measles. (See Fig. 320.) Scarlet fever is differentiated from rubella by the fact that in the latter the symptoms are exceedingly mild, whereas in the former disease graver symptoms are manifested at some period during its course. The eruption of scarlet fever is erythematous, whereas that of rubella appears in successive crops. The absence of albuminuria and the character of the desquamation will also serve to distinguish this disease from scarlet fever. In general, the short course, the mildness of the attack, and the absence of complications serve to differentiate rubella from scarlet fever, measles, and other more viru- lent infections. The accompanying table, modified from Anders, shows the points of differentiation between rubella, erythema, and urticaria: Rubella. Erythema. Urticaria. 1. The rash occurs first on 1. The eruption is first seen 1. The eruption occurs in the face. on the hands and feet. the form of wheals on the arms and leg. 2. Enlargement of cervical 2. No enlargement of cer- 2. No enlargement present. lymph-nodes. vical lymph-nodes. 3. At first there is no itch- 3. Burning pain present. 3. Intense itching is a ing. prominent feature. 4. The disease is contagious. 4. The disease is not con- 4. The condition is not tagious. contagious. 5. The affection has a prob- 5. This condition is of re- 5. Origin is gastro-intes- able microbic origin. flex origin. tinal. Clinical Course. — Tha average case proceeds to convalescence by the end of the first week. Complications. — These are less common than in measles and scarlet fever, although the following complications may be encountered: severe bronchitis, bronchopneumonia, gastro-intestinal catarrh, and other acute infectious fevers. Relapses are quite common, and each attack may be as severe as the initial seizure. HUMPS (Epidemic Parotitis). Pathologic Definition. — An acute infectious disease, characterized anatomically by enlargement of one or of both parotid glands. Predisposing Factors. — Mumps is spread by contagion, and the disease is transmitted by close contact with a patient so afflicted. There are doubtful cases in which epidemic parotitis may have been conveyed MUMPS. 881 from the sick by one healthy person to another. Mumps is a highly contagi- ous affection, although by no means all persons exposed to it contract the disease. Age is not without influence, the majority of cases occurring between the fourth and the tenth year; cases under one year are very rare. A child may transmit mumps to several other children before displaying any positive symptoms himself, and he may continue to carry the infection to others for from three to ten days after all swelling of the parotid glands has subsided. Period of Incubation. — ^This lasts, as a rule, between ten and four- teen days, the majority of cases developing upon the seventeenth day. Principal Complaint. — The stage of invasion is mild, and such prodromata as lassitude, headache, vague pains in the muscles, and slight stiffness of the jaw muscles are experienced. By the second day there may be considerable pain upon swallowing, more particularly when opening the mouth or upon taking acids (vinegar). Thermic Features. — The temperature ranges between 99° and 101° F., but in severe cases the fever may reach 103° or even 104° F. Ringing in the ears and earache may develop on the second or third day, and the child may manifest a variable degree of deafness. Nausea and epigastric distress may be annoying. Dryness of the Mouth and Salivation. — One of the chief annoyances of epidemic parotitis is the dryness of the mouth, which is frequently persistent from the onset of the disease to the fourth or sixth days, at which time the secretion of saliva may be normal or even increased. . A few authentic cases have been reported in which salivation accompanied epidemic parotitis throughout the entire course of the disease. Clinical Eccentricities. — It may be well to emphazise here that al- though mumps is a mild type of infection, in adults it may be accompanied by severe constitutional symptoms. Deglutition is difficult, and occasion- ally impossible, for an indefinite period. Pressure by the enlarged glands upon the veins of the neck may cause venous congestion of the brain, which is followed by cerebral symptoms, the most marked of which is delirium. Gastro-intestinal symptoms suggestive of the typhoid state may be present, but even in these severe cases the symptoms subside by the seventh day. Physical Signs. — Inspection.— There is a pyriform swelling in front of the ear, extending down into the neck and forward onto the jaw. Both parotid glands are commonly affected, but in more than 50 per cent, of cases iu which unilateral involvement is seen the left parotid is first attacked, and from one to two weeks later the opposite side is similarly affected. As a rule, the second attack of parotitis is milder than the first. Between the third and the seventh day of the disease extensive swelling of the other glands of the neck may take place. Tenderness in the epigastrium is occasionally present and is claimed to be due to associated pancreatitis. Summary of Diagnosis. — The prominent features on which to base a diagnosis of epidemic parotitis are swelling of the parotid glands extending to the front of the ear, stiffness of the jaws, with slight pain, diminished secretion or absence of saliva, acute pain on introducing acids into the mouth, and the presence of mild constitutional symptoms. Clinical Course and Duration. — Uncomplicated cases of epi- demic parotitis tend to go on to spontaneous recovery, which is completed by the end of the second week. In compUcated cases recovery is delayed for from one to three weeks, depending upon the nature of the complications. Complications. — Orchitis is the most frequent complication of 56 882 ACUTE INFECTIOUS DISEASES. epidemic parotitis, and this condition seldom, if ever, develops in patients under twelve years of age. After puberty, and in young men, orchitis is particularly common; it may be either unilateral or bilateral, and is accompanied by more or less swelling, extreme pain, and marked consti- tutional symptoms. Only the substance of the testicles is involved, whereas the epididymis is seldom attacked. Orchitis is usually followed by enlarge- ment of the involved gland for a period of weeks, months, or even years, and there may be atrophy of the glandular structure. Otitis media, although by no means a frequent complication, may occur and result in impairment of the auditory function. Piece collected 40 in- stances from the literature, in which deafness followed epideniic parotitis. _ Mastitis, ovaritis, and vulvitis may complicate epidemic parotitis in adults, but are practically unknown in children. Mastitis is characterized by swelling, pain, and tenderness of one or both breasts. The first symptoms are observed during the second or third week of the disease, and ordinarily last for from two to four days. Ovaritis also develops late, and is charac- terized by intense abdominal pain, which may be cramp-like in character. Vulvitis and vulvovaginitis are somewhat more common than the two pre- ceding conditions, and are characterized by intense inflammation and swelling of the vulvovaginal mucous membrane. Nephritis is extremely uncommon, although a few authentic cases have been recorded. In these cases it is probable that the patient suffered from nephritis prior to the attack of mumps. Nervous complications are unusual in epidemic parotitis, and, together with arthritis, merely deserve mention in this connection. WHOOPING-COUGH (Pertussis). Pathologic Definition. — An acute infectious disease, character- ized by the sudden onset of a catarrhal inflammation of the respiratory mucous membrane, and later by a similar inflammatory process involving the conjunctiva, lacrimal duct, and, less often, the Eustachian tube and middle ear. The inflammatory process may extend to the smaller bronchi and air-cells, and gives rise to isolated areas of pulmonary consolidation or pulmonary collapse. In severe types of the disease pulmonary congestion and edema are present, and bronchopneumonia may develop as a complica- tion. The pathologic changes in the bronchial mucosa are determined largely by physical examination, since uncomplicated cases seldom, if ever, come to autopsy. The mucous surface of both the respiratory and the digestive tract may be covered with a viscid mucous exudate. Experiments of Mallory, Homor, and Henderson point strongly to the Bordet-Gengou bacillus as the exciting factor in pertussis. Incubation Period. — ^This is usually from seven to ten days. i^xciting and Predisposing Factors. — Bacteriology and Para- Bitology. — Alinnseus attributes the disease to the presence of the larvae of certain insects in the nasal cavity, and Kuoloff regards the specific micro- organism as a protozoon, having found it to be present in the sputum of those suffering from the disease. Afanassiff has described a large bacillus (bacillus tussis convulsivae) which he obtained in pure cultures from cases of whooping- cough. Camplewski and Hensel described a bacillus with rounded ends, often occurring in pairs, which they cultivated from the mucous secretions; a peculiarity of this organism is that it is found free in the sputum and also within the pus-cells. Jochmann and Krause, in 1891, described an organism which they isolated in whooping-cough, and which they named the bacillus WHOOPING-COUGH. 883 pertussis eppendorfii. None of these organisms is generally accepted as the cause of the disease. The majority of cases are seen in conjunction with epidemic outbreaks, although a small number of sporadic cases have been studied. Singularly, in rural districts the disease occurs in epidemic form every two years, whereas in large cities it is present at all times. Mode of Infection. — Contact with a patient suffering from the disease is the usual mode of infection, and there can be little doubt but that the disease is propagated in schools, although it is probably less conta- gious than either measles or scarlet fever. Season. — ^This appears to exercise but little influence. The disease is, however, more likely to prevail in epidemic form during the school months. Unhygienic surroundings and environment exercise but a limited influence, and healthy and delicate children alike develop the disease. A more severe clinical type is, however, encountered in infants and in those previously in ill health. Age is an important factor, most cases being seen before the tenth year, although the disease may occur both during and after middle life. In three cases seen by us — two males and one female — the patients were over sixty years of age. Sex is believed by certain writers to serve as a predisposing factor, fe- males being said to be affected more often than males; this observation, however, has not been borne out by general experience. Immunity. — One attack usually bestows permanent immunity, yet second attacks, although uncommon, may occur. Infective Period. — ^The disease is communicated by infected pa- tients to others during the period of the paroxysmal cough. Cases of per- tussis in the new-bom have been reported. Principal Complaint. — Pertussis is characterized by the following clinical stages: (1) Catarrhal Stage. — ^The symptoms in this stage are similar to those of an ordinary cold, the patient complaining of coryza, lacrimation, and cough, all of which increase in intensity until about the tenth day. (2) Paroxysmal Stage. — This stage is marked by the appearance of the characteristic whoop, the cough becoming paroxysmal. The child is con- scious of an approaching seizure just previous to its occurrence, and will invariably make a strenuous effort to restrain the cough. In severe cases he will seize firm hold of some object and then cough violently until he is quite exhausted; following the exacerbation there is a pronounced whooping sound, which usually terminates the paroxysm; rarely two or more whoops may accompany a single seizure. After the paroxysm is over a variable quantity of thick, tenacious mucus is expectorated and vomiting is also com- mon. Both urine and feces may be passed involuntarily. Paroxysms of coughing are excited by undue exercise, talking, laughing, sneezing, etc. When the seizure is violent, it may be accompanied by epistaxis, and at times blood may gush from the mouth. Lacrimation is a prominent symp- tom. The face is flushed at first, and later may become cyanosed. The number of paroxysms occurring during the twenty-four hours will be found to vary greatly in different cases. In mild forms there may be but from four to ten paroxysms a day, whereas in the more severe types the number may exceed 50 during the twenty-four hours. Physical Signs. — Inspection. — During the catarrhal stage the conjunctivae are congested, and there is edema beneath the eyes. The nasal mucosa is also congested, and the general expression of the child is dull. During the paroxysm of coughing the face becomes cyanosed, the veins of the 884 ACUTE INFECTIOUS DISEASES. neck stand out prominently, the conjunctivae are markedly congested, and there is a free mucous discharge from both the conjunctivae and the nose. In young children, and after the disease has continued for several weeks, the chest becomes barrel-shaped, the result of pulmonary emphysema.. The jace presents a characteristic appearance, beiag swollen and dusky in hue; the eyelids are also edematous and pinkish in color, and there is decided red- dening of the conjunctivae; conjunctival hemorrhages may also be seen. _ Palpation, percussion, and auscultation reveal the physical signs characteristic of acute bronchitis with emphysema. Clinical Course. — The duration of the paroxysmal stage varies be- tween three and four weeks. In cases of average severity the patient coughs for approximately six weeks, although not uncommonly the cough may per- sist for three or four months. Having had one attack of whooping-cough the child is likely for some months to suffer a mild relapse whenever he con- tracts an acute " cold." Complications and Sequelae. — In those cases in which the parox- ysms are violent, epistaxis may occur; rarely, indeed, is the hemorrhage sufficiently severe to cause alarm. Hemoptysis and vomiting of blood are unusual, and intestinal hemorrhage is extremely rare. Extensive extravasa- tions of blood beneath the conjunctivae may take place. Among the most serious of the complications are bronchopneumonia and pulmonary collapse. These conditions are, however, extremely un- common, except in children during the first and second years of life. Lobar pneumonia is occasionally seen, and is due to intense straining and rupture of the lung, when either interstitial emphysema or pneumothorax may follow. Pleurisy is also a serious complication, and may be accompanied by pro- nounced enlargement of the bronchial lymph-nodes. Inguinal and femoral hernia may result from sudden strain. Among the nervous complications should be mentioned convulsions, hemiplegia, monoplegia, and subdural hemorrhage. Acute nephritis is oc- casionally seen. Cardiac complications are unusual, and consist in dilatation of the right ventricle and endocarditis. Chronic catarrh of the bronchial mucosa fre- quently follows whooping-cough, and when the disease develops at or near the age of puberty, pulmonary tuberculosis may follow. In selected cases gastro-intestinal irritation may appear during the later stages of the dis- ease, and continue for an indefinite period after the characteristic whoop has disappeared. DENGUE (Break-bone Fever). Pathologic Definition. — An acute, infectious disease, probably transmitted by the bites of infected mosquitos. It is characterized by the occurrence of definite alterations in the blood — e. g., leukopenia, with a de- crease in the polymorphonuclear leukocytes and a marked increase in the small lymphocytes and the presence of a maculopapular eruption. Varieties. — Debrun recognizes the following chnical types: (1) Dengue with high fever and well-marked associated symptoms, including an eruption; (2) afebrile dengue, in which all the symptoms are exceedingly mild, but here, too, the eruption is present; and (3) a type in which the eruption is not only the most conspicuous, but the only, diagnostic feature. Predisposing and :^xciting Factors. — Season appears to influ- ence the development of attacks, the disease occurring, as a rule, in warm weather. DENGUE. 885 Age, race, sex, and environment appear to be without effect. A single attack ordinarily confers immunity to subsequent attacks. No evidence has been adduced to support the fact that dengue is contagious. The report* of P. M. Ashburn and C. F. Craig, who conducted extensive researches and clinical investigations in the Philippine Islands in 1907, shows that dengue is transmitted from man to man through the bites of a mosquito, Culex fatigans. Period of Incubation. — Clinically, this varies between two and one-haK and seven days, the average period being three to four days. Ash- bum and Craig have shown, as the result of inoculation of non-immunes with unfiltered blood, filtered blood, and with infected mosquitos, that the incubation period varies between two and one-half and seven days, with an average of three days and fourteen hours, as shown by the accompanying table : Method of Inoculation. Incubation Period. Inoculation of unfiltered blood 3 days, 18 hours. Inoculation of unfiltered blood 2 Inoculation of unfiltered blood 2 Inoculation of unfiltered blood 2 Inoculation of unfiltered blood 4 Inoculation of unfiltered blood 7 Inoculation of filtered blood 3 Inoculation of filtered blood 2 19 18 12 4 11 12 With infected mosquito About 3 dayS; 16 hours. Principal Complaint. — Invasion. — The onset is abrupt, beginning with a mild chill or cMlly sensations. By the end of the first or the beginning of the second day the patient complains of headache and muscular and joint •pains, and his suffering now becomes intense. He describes the pains as of bone-breaking character — hence the name, "break-bone fever." There is complete anorexia, and nausea and vomiting may occur at different times during the day. Epistaxis and hemorrhage from other mucous surfaces are occasional occurrences. (See Laboratory Diagnosis, p. 886.) Diarrhea may be present. The symptoms of catarrh of the respiratory tract, e. g., coryza, slight bronchial cough, and soreness of the throat, are prominent. In a fair proportion of all cases there is a variable degree of discomfort in the region of the precordium, and distinct precordial pain is occasionally experienced, followed by a sense of suffocation and threatening syncope. A feeling of faintess follows slight exertion during the febrile period. Nervous S5rmptoms. — The severe pains previously referred to constitute the chief annoyance in this particular group of symptoms. Delirium is uncommon, and when present, is usually of a low type. Hysteric seizures and hallucinations have also been observed. Insomnia is frequently an annoying symptom during the febrile period, especially in those cases in which hyperpyrexia exists. Thermic Features. — Following the invasion, the temperature rises quite abruptly, but continuously, to a maximum of from 103° to 106° F. by the end of the first twenty-four hours. The fever continues at or near its maximum point for from one to three days, when it drops by crisis with diuresis, di- aphoresis, diarrhea, or epistaxis, to normal. With the first fall of tempera- ture the erythema disappears, and the symptoms are much improved. This improvement may last twenty-four hours, when the temperature rises grad- * Philippine Jour. Sci., May, 1907, p. 93. 886 ACUTE INFECTIOUS DISEASES. ually and the terminal eruption appeai-s. The second febrile period may be overlooked, but it usually lasts one or two days and declines by crisis, which is likely to be accompanied by a critical discharge. Physical Signs. — Inspection. — ^The joints are red and swollen, and an eiythematous rash, the so-called initial rash, is present. The face is deeply flushed, and the conjunctivae are congested. As a rule, this erup- tion is most profuse over the exposed parts — c. g., face, neck, and hands. Ashburn and Craig assert that this rash is not the true eruption, but a general capillary dilatation, resembling in appearance a mild simbiirn or flushing the result of a hot bath. The characteristic eruption of dengue usually appears on the fourth day, although it may be delayed in some cases until the sixth or the seventh day. It fii-st appeare on the backs or on the palms of the hands, extends up the forearms, and then invades the back, the chest, the arms, and the thighs. The lesions are round, duskj- red, slightly ele- vated, and about the size of a small pea. They are surrounded by healthy skin at first, but they have a tendency to spread, forming irregular patches, sometimes as large as three inches in diameter, and separated by normal skin. The eruption disappears in a few days, and is followed bj' a branny desquamation. Jaundice may be present throughout the greater part of the febrile period, and may even continue during the convalescence. The tongue is at firet covered by a light, creamy coat, which thickens rapidly and becomes darkened in the center, the edges showing an appreciable fading. Late during the course of the disease the tongue displays a heavy, yellowish central coat, whereas the edges and tips are bright red; the tongue remains moist throughout the entire illness. Palpation elicits tenderness over the large joints, and firm pressure ex- cites pain. With the beginning of the disease the pulse is accelerated, and follows the temperature — a characteristic difference between this disease and yellow fever. Ashburn and Craig, in their study of a somewhat large series of cases of dengue, found the pulse to be moderately accelerated and to follow the coui-se of the fever fairly closely. I^aboratory Diagnosis. — Vomiting occurs in a small percentage of all cases, and the vomitus may give off a foul odor; in such cases the breath is offensive. The vomiting of blood has been reported. Diarrhea is also an occasional symptom, and some writere believe that the stool may contain blood and mucus. The urine was found to contain a trace of serum-albumin in 41 per cent, of cases studied by Guit^ras and Cartaya, but other observers believe that pathologic albuminuria does not occur in uncomplicated cases. The question of the occurrence of albuminuria is one that will be largely influenced by the findings of certain epidemics, and, therefore, statistics gathered from a single epidemic would have but limited clinical value. The urine may be bile stained. Up to the present time no microorganisms of any kind have been de- tected in the blood of dengue. The number of red blood-cells in a cubic millimeter approximates that of the normal. A fairly well-marked leuko- penia is present, the polymorphonuclear leukoc5rtes displaying a decided decrease, the proportionate number of small lymphocytes showing a corre- sponding increase (30 to 60 per cent.). The blood-platelets are normal in number. Differential Diagnosis. — Yellow fever has often been mistaken for dengue, and the . two affections may be present simultaneously. A ERYSIPELAS. 887 differential diagnosis is made only with great difficulty, as the two diseases present many points of similarity. The following table, modified from Anders, shows the differential features: Dengue. Yellow Fever. 1. Affects all races. 1. Caucasians more especially affected. 2. Facies characteristic; face flushed. 2. Mucous membranes injected. 3. Irregular rise of fever, followed by re- 3. The temperature rises regularly. Dura- mission, and then a second moderate tion of fever, about seventy-two hours, rise. Duration, five to seven days. 4. The pulse keeps pace with the fever. 4. The pulse falls while the fever is rising. 5. Maculopapular eruption present. 5. Eruption unusual. 6. Vomiting rare. 6. Vomiting frequent. 7. Urine seldom contains albumin in un- 7. Albuminuria common; reaction for complicated cases. bile present. 8. Jaundice unusual. 8. Jaundice present early. 9 Hemorrhage from mucous membranes, 9. Hemorrhages common and severe. generally slight, and black vomit rare. Black vomit an alarming symptom. 10. Nervous symptoms absent or mild. 10. Nervous symptoms of a grave nature present ERYSIPELAS (St. Anthony's Fire). Pathologic Definition. — An acute infectious disease, engendered by the streptococcus, and characterized by the presence of congestion, in- flammation, and edema of the skin and subcutaneous cellular tissue, with distention of the cutaneous lymph-channels. Suppurative inflammation may attack the subcutaneous tissue. Blisters, blebs, and buUae appear upon the cutaneous surfaces. Varieties. — (1) The ordinary type, which will be described at length. (2) Phlegmonous (cellulocutaneous) erysipelas, which is charac- terized by the appearance of a severe inflammation of the subcutaneous con- nective tissue, with a tendency to go on to suppuration. (3) Migratory erysipelas, a condition in which the erysipelatous process is very acute at first, but tends, as the disease advances, to assume a sub- acute form and to spread over all portions of the body. We have seen cases of this type in which the erysipelatous process extended from the face to the feet, covering practically the entire body surface, from twelve to twenty weeks being consumed in completing the process. (4) Relapsing erysipelas, a condition in which the inflammatory process is of unusually low grade and tends to recur at longer or shorter intervals. (5) Erysipelas neonatorum, or the erysipelas of infants, follows in- fection of the umbilical cord. The erysipelatous process spreads rapidly from the umbilicus over the lower portion of the abdomen, and frequently extends to the face, chest, and less often to the back. This is an exceedingly grave variety of erysipelas, and usually terminates fatally within the course of from two to five days. (6) Pneumo-erysipelas, a form in which the specific infection may set up a bronchopneumonia as a complication. (7) Nephro-erysipelas. — Nephritis may develop as a complication, and the nephritic tissue be infiltrated with cocci. The symptoms of acute nephri- tis are also present. ISxciting and Predisposing: Factors. — Bacteriology. — It is generally agreed that the specific cause of erysipelas is the streptococcus erysipelatis of Fehleisen, which is probably identical with the pus-producing organism commonly encountered. An erysipelatous process may, however, 888 ACUTE INFECTIOUS DISEASES. be produced by inoculating the skin with the streptococcus, and, indeed, inoculation with other bacteria will produce an inflammation that is in- distinguishable from that of true erysipelas. In 1900 Pfahler cultivated a diplococcus from the blebs in 8 cases of erysipelas at the Philadelphia Hos- pital, and we produced an erysipelatous process in rabbits by injecting an emulsion containing Pfahler's diplococcus beneath the animal's skin; similar inoculations with other pus-producing organisms in laboratory animals gave rise to an erysipelatous inflammation. In our own experience, cover- ing a bacteriologic study of approximately 40 cases of erysipelas, streptococci were found present in every instance in which cultures were made from several different blebs. Staphylococci and diplococci were also present in many of the cultures, at least two pathogenic bacteria being found in each culture. A detailed study of the bacteria recovered from erysipelas, however, showed these organisms to be practically indistinguishable from those that may be cultivated from the surface of the human skin. Season. — Anders,* in a statistical analysis of 2010 cases of erysipelas, showed that 19.5 per cent, of all cases develop during the month of April, and one-half of all cases during the months of February, March, April, and May. Boston and Blackburn, in a report of 546 cases of erysipelas seen in the wards of the Philadelphia Hospital, found that 20.3 per cent, of all cases were admitted during the month of April, and that 423 of the whole number, or 77.8 per cent., developed during the months of January, February, March, April, and May. The accompan5ang table, by Boston and Blackburn, sets forth the influence of season upon the development of erysipelas, and gives an estimate of the severity of the type of infection encountered at different seasons: INFLUENCE OF SEASON ON ERYSIPELAS. Percentage op Month. Total Cases. Total Deaths. Mortality. January 66 12 18.0 February 77 8 14.0 March 104 11 10.6 April Ill 15 13.3 May 65 9 13.8 June 11 0.0 July 4 0.0 August 6 0.0 September 10 1 10.0 October 16 2 8.0 November 30 6 20.0 December 46 5 11.0 Total 546 69 Age. — In an analysis of 1894 cases, Boston and Blackburn found that 25.8 per cent, developed during the third decade, and that the disease was far less common after the age of fifty, whereas 15 per cent, of all the cases de- veloped before the age of twenty. Sex. — An analysis of the records of 1767 cases showed that males are attacked more often than females, in a ratio of 3 to 2; Boston and Black- bum's analysis of 539 cases gave 342 males and 197 females. Race. — ^The African negro rarely suffers from erysipelas, as is shown by the previously named writers' analysis of 545 cases, in which only 5.3 per * Proc. Amer. Climatolog. Assoc, 1893. ERYSIPELAS. 889 cent, were negroes. Nationality appeared to be a marked predisposing factor, 42.2 per cent, of cases developing in Americans and 20 per cent, of those afflicted being of Irish birth. Previous Attacks. — One attack predisposes to others, and a second, third, and even a fourth attack is not unusual. We have seen a number of cases ia which erysipelas developed during the winter months for two or more successive years. In an analysis of 450 cases, we obtained a history of previous attacks in 8.6 per cent. Coryza. — Acute coryza markedly predisposes to the development of erysipelas of the nose and face, as is shown by M. B. Miller's statistical analy- sis of 301 cases, in which coryza occurred as an antecedent in 13 instances (4.3 per cent.). Chronic maladies, after they have appreciably impoverished the system, favor the development of erysipelas. The occurrence of the disease is to be feared late during the course of nephritis, hepatic cirrhosis, valvular heart disease, chronic tuberculosis, diabetes, arteriosclerosis, and in those addicted to the use of alcohol. Injuries. — An abrasion of the cutaneous surface favors the develop- ment of the erysipelatous process, and is said to be essential to the invasion of the specific bacterium. Those whose occupations subject them to fre- quent abrasions of the skin of the hands, nose, and face, as well as to slight injuries, are especially prone to acquire the disease, although it is often im- possible to obtain a definite history substantiating this fact. In an analysis of 643 cases, but 13 gave a history of injuries to the cutaneous surface. Erysipelas is especially likely to develop after surgical treatment, particularly after operations in which it has been impossible thoroughly to cleanse the parts incised. Puerperium. — Women are especially likely to become infected with erysipelas after delivery, particularly when either the nurse or the physician is also attending patients suffering from the disease. The epidemic out- breaks of erysipelas occurring in hospitals and institutes are possibly ex- plained by the fact that certain of the attendants convey the disease from one patient to another, although it may be transmitted by clothing, towels, napkins, and other objects. Period of Incubation. — In cutaneous eiysipelas this usually varies between one and two weeks, but when erysipelas develops after sur- gical interference, a much shorter incubation period (three to seven days) ,may occur. Experimentally, we have found it possible to produce an erysipelatous process in from twenty-four to forty-eight hours by inoculat- ing the skin of rabbits' ears with bacteria cultivated from blebs. Prodromal Symptoms. — These are often indefinite, and consist in headache, restlessness, slight soreness of the throat, mild cough, fever, and anorexia. The duration of the prodromal symptoms will be found to vary from a few hours to several days. Principal Complaint. — Following the prodromata, the attack sets in quite abruptly, with a distinct chill or a sensation of chilliness. The evi- dence of constitutional depression may not be well marked in those who have previously enjoyed health, but in the debilitated, and particularly in al- coholics, prostration comes on early. The patient complains of a localized sense of tension over the part affected, and later a distinct burning sensation is felt throughout the erysipelatous area; pain is, however, unusual, unless the subcutaneous cellular tissue is involved. Nervous S3miptoms. — In uncomplicated cases the nervous symptoms 890 ACUTE INFECTIOUS DISEASES. are, as a rule, mild, and consist of headache, restlessness, and aching in the back and loins. When complications arise, and, indeed, in the_ more severe t3^es of erysipelatous infection, delirium occurs during the night. When nephritis and bronchopneumonia develop as complications, maniacal delirium and coma may follow. Thermic Features. — Following the chill the temperature rises somewhat abruptly, and usually reaches 102° to 104° F. during the first twenty-four hours. The fever remains high, with moderate remissions, for a period of from five to seven days, when, in uncomplicated cases, it falls rapidly to the normal. As each new area becomes involved in the erysipelatous process (relapse) the temperature again rises one, two, or three degrees, but the period of pyrexia is comparatively shorter in each succeeding relapse. Physical Signs (I/Ocal). — ^The area most often affected is the face, as shown by Boston and Blackburn's statistical analysis of 545 cases, in which the face served as the initial site of infection in 485 instances. The affected part at first is reddened, and later becomes intensely congested, swollen, and edematous, and the features may be distorted. Immediately beyond the congested area the swelling ends abruptly — the so-called "line of demarcation." The inflammation may extend from one side of the face across the median line, a feature that was observed in 78.8 per cent, of the series of cases just mentioned. The reddened surface of the skin is often studded with small blebs or blisters, which are filled with serum. When these blisters rupture, an angry, suppurating surface may remain. In the series of cases previously referred to, the spread of the erysipelatous inflamma- tion appeared to be limited by the following: the median line of the body, in 21.2 per cent.; the folds of the skin, and the hair (beard); it is also very unusual for the process to extend beyond the junction of skin and mucous membrane. Cutaneous edema may be so pronounced as to distort the features, making recognition of the iudividual often impossible; the eyes are often closed. The congested portion of the skin is hot to the touch, and firmer than the adjacent surface. On drawing the finger over the healthy sldn to the in- volved area, a distinct hardening is felt at the junction of the healthy and diseased epidermis, resulting from infiltration of the lymphatics; this is the so-called "line of demarcation." Pressure over the affected area seldom elicits pain unless the deeper structures are infiltrated with pus. The tongue is heavily coated; the mouth is dry and parched; the throat is often congested, and the patient finds it difficult to open the mouth. The pulse is rapid, — 100 to 120 beats a minute, — and in severe compli- cated cases its tension becomes diminished with the progress of the disease, whereas later it is weak, dicrotic, and intermittent. Constipation obtains in the majority of cases, although diarrhea with the passage of serous stools is occasionally observed. I/aboratory Diagnosis. — The urine is of high color, increased in specific gravity, and in uncomplicated cases may contain a trace of albumin. Nephritis is a somewhat common complication, occurring, as it did, in 29 per cent, of 548 cases analyzed by Boston and Blackburn; when present, the urinary findings are those of acute nephritis. The diazo-reaction is present during high fever. A leukocytosis in which the white cells number from 15,000 to 30,000 per c.mm. is to be expected during the initial attack of erysipelas. The in- crease in the number of leukocytes affects chiefly the polymorphonuclear elements. In cases in which repeated relapses have occurred, the heme- ERYSIPELAS. 891 globin and red cells become markedly reduced, and the general blood- picture is that of secondary anemia plus moderate leukocytosis. Cultures from the serum obtained from the cutaneous blisters, as well as those made from the blood-serum that exudes from the skin after incision over an erysipelatous area, will be found to contain streptococci, staphylo- cocci, and diplococci. In the majority of instances, however, streptococci alone are present. _ Summary of Diagnosis. — This is based first upon the history of a chill and the characteristic temperature, which are soon followed by swelling and redness of the part, and, later, the formation of blebs upon the surface of the skin and the appearance of a distinct line of demarcation. When the deeper cellular tissue is not involved, a sense of burning and the absence of pain are valuable diagnostic points. The duration of the febrile period — ^four to seven days — and its charac- teristic decline by rapid lysis are of great diagnostic importance, as is also the comparatively short febrile period of each successive relapse. Differential Diagnosis. — Erythema produces superficial redness, differing from erysipelas in that it is not attended with heat, swelling, or fever. The eruption of urticaria assumes the form of pale-red, circular wheals, which cause marked itching and appear in successive crops, often disappear- ing in the course of a few hours. In this condition the initial chill, blebs, and rise in temperature are absent. Acute eczema of the face, when severe, may somewhat resemble ery- sipelas, but lacks the peculiar line of demarcation and mode of progression characteristic of erysipelas. Again, eczema is accompanied by trouble- some itching, the swelling is less pronounced than in erysipelas, and fever is also absent in uncomplicated cases. Eczema nodosum is characterized by the presence of nodosities situated near the articular surfaces, and is devoid of the constitutional symptoms seen in erysipelas. Clinical Course and Duration. — The average duration of a case of erysipelas, including the prodromal stage in early adult life, is fourteen days (J^ders). In each relapse the condition is prolonged for from five to seven days, consequently in those cases in which frequent relapses have occurred from four to six and even eight weeks may elapse before convales- cence is established. The clinical course of erysipelas is appreciably longer in the aged and the debilitated than it is during the second and third decades. Complications materially retard convalescence. Complications. — ^These are numerous, and often unusually serious — e. g., abscess formation, lobar pneumonia, phlebitis, catarrhal pneumonia, nephritis, otitis media, acute bronchitis, laryngitis, and pleurisy may de- velop. Sequelae. — In those cases in which the erysipelatous inflammation involves the scalp the hair falls out, but a rich growth usually returns. When erysipelas attacks persons who have previously suffered from some chronic disease of the skin, a cure of the latter may be effected. As an ex- ample, may be mentioned the case of a male, aged sixty-six years, who had been under treatment for twelve years for lupus involving both sides of the face. He suffered a severe attack of erysipelas, which extended only over the right half of the face, and after recovery it was found that the half of the face attacked by the erysipelatous process was free from lupus, whereas the other side remained unchanged. Chronic eczema may also be similarly 892 ACUTE INFECTIOUS DISEASES. affected by erysipelas, and some writers maintain that this disease is an- tagonistic to the development of malignant disease. ACUTE ARTICULAR RHEUMATISM. Pathologic Definition. — An acute infectious disease, characterized by the presence of an acute inflammation of the synovial membranes of various joints, with the accumulation of fluid. The surface of the synovial membrane of the affected joints is injected and swollen, and may be more or less completely covered with a fibrinous exudate. Later the effusion con- tains fibrin and leukocytes. The tendinous sheaths in relation with the diseased articulation may be attacked, and in severe cases erosion of the cartilages may occur. A similar inflammatory process generally affects the other serous surfaces, particularly the endocardium and pericardium, and less often the meninges, pleura, and peritoneum are involved. Exciting and Predisposing Factors. — Bacteriology. — A bac- teriologic study of the exudate obtained from the synovial sacs may reveal the presence of bacteria, staphylococci, streptococci, and diplococci. Singer, in a study of 92 cases, asserted that, in the majority of them, either strepto- cocci or staphylococci were present. Pierre Achalme has described a bacillus that he recovered from the blood of those suffering from acute articular rheumatism. In certain cases anaerobic diplococci are present in the syno- vial fluid, and many observers believe that this is the probable cause of the disease, although streptococci are more commonly encountered in this situation. Those suffering from other acute infectious conditions appear to be more susceptible to the disease than healthy individuals; indeed, acute articular rheumatism often follows an attack of acute tonsillitis. Season. — The greatest number of cases are seen during the months of February, March, and April, although the disease is also quite common dur- ing October, November, December, and January. At times the disease is so prevalent as to suggest the possible existence of an epidemic. It occasion- ally prevails during the summer months. Exposure to cold and wet is a prominent predisposing factor, males being consequently attacked more often than females. Age. — ^The majority of cases occur during early adult life, or between the years of fifteen and thirty-five, although the disease may be encountered in the young and in those over fifty years of age. Heredity is believed by many writers to play an important role. Epidemic Influence. — Distinct epidemics may arise in certain localities at any time during the year, although they occur most commonly during cold weather. One attack does not establish immunity, but appears to predispose to subsequent attacks. Incubation Period. — ^The occurrence of an incubation period is doubtful, although certain prodromal symptoms are occasionally experi- enced, and usually consist in the following: malaise, a slight degree of fever, soreness of the throat, laryngitis, and the like. These may continue for a day or two, and then be followed rapidly by definite local symptoms. Principal Complaint.— Onset.— This is quite abrupt, often begin- ning with a chill, followed by other constitutional symptoms. (See Thermic Features.) Nervous Symptoms. — Pain is a prominent feature, and is localized to one ACUTE ARTICULAR RHEUMATISM. 893 or more joints. The medium-sized and larger joints (ankle, knee, wrist) are most often attacked at the time of onset. The initial site of synovitis may also be at the shoulder, hip, or elbow, and still less frequently the joints of the fingers and toes are attacked primarily. In severe types of the disease the articular surfaces of the vertebrae may manifest tenderness. The pain increases on moving the joint, and the, patient usually places the affected part in a certain position, which he claims appreciably lessens the pain. A characteristic feature of articular rheumastim is that from time to time dur- ing the course of each attack different joints become involved, and in each the pain is equally fugacious and out of proportion to the anatomic distor- tion of the part. In some cases in which cardiac complications exist pre- cordial pain is present. In those cases in which hyperpyrexia is present, other nervous symptoms are prominent; but certain nervous manifestations may also be observed even when high temperatures are absent. The patient is usually restless and unable to sleep. Delirium is rarely present, except in complicated cases and when the temperature exceeds 104° F. In the adynamic type of the disease, which is rare, delirium, stupor, and coma may develop. The pres- ence of endocarditis is likely to intensify the nervous symptoms, and out- breaks of maniacal excitement are prone to occur as the result of cerebral embolism. Involvement of the pericardium is also accompanied by more marked nervous symptoms, which may lead to stupor. When alcoholics are attacked by acute articular rheumatism maniacal delirium is apt to develop. Convulsive seizures, although rare, may precede the onset of coma. The writers have recently encountered the case of a young female in whom melancholia developed during convalescence from acute articular rheumatism. Meningitis and chorea are nervous conditions rarely seen to accompany or complicate this disease. Symptoms referable to the pulmonary system are by no means un- common, pleuritic pain being a frequent symptom. The general clinical features of acute bronchitis frequently coexist with articular rheumatism. Pulmonary complications occurring during the course of acute articular rheumatism are always of severe type. Thermic Features. — Following the chill the temperature rises abruptly to from 100° to 104° F. ; the fever is remittent in character. A hectic type of fever is never seen except in those cases in which suppuration exists. Hyperpyrexia may develop somewhat suddenly at any time during the course of the disease, but occurs most often during the second week (seventh to tenth days); it is generally accompanied by other severe constitutional symptoms, such as delirium and stupor. In severe and complicated forms the temperature may even reach 106° to 108° F. Physical Signs. — Inspection. — ^The involved joints are swollen and reddened at first, and the patient holds the affected limb in one position, usually a partially flexed one. When he is asked to move the part, he does so guardedly, an expression of pain accompanying each movement. After the disease has persisted for some days or weeks, extreme enlargement of the affected joint may take place, especially if one of the larger articular surfaces, such as the knee, elbow, wrist, or ankle, is affected. During convalescence, and after an attack of acute articular rheumatism, small subcutaneous nodosi- ties may appear along the course of the tendinous insertions and within the fascise. The skin overlying these nodules is merely elevated, but does not display the usual evidences of inflammation. The face is flushed, but the expression remains unaltered except when an 894 ACUTE INFECTIOUS DISEASES. effort is made to move the affected part. The entire body is bathed in perspiration several times during the twenty-four hours, the excretion hav- ing an acid reaction, although during the later stages of the disease it may become alkaline. iSudamina appear in successive crops during the febrile period. Occasionally a distinct erythema may develop, and erythema nodo- sum may also occur. Urticaria occasionally develops during the febrile period, and in severe types of the disease there may be jDurpura hzemorrhagica (the so-called hemorrhagic polyarthritis, also considered under the heading Peliosis Rheumatica). Cutaneous hemorrhages may become extensive, and coalesce to foi'm ecchymotic areas in both the skin and mucous membranes. Palpation. — The affected joints are tender to the touch, and firm pres- sure elicits pain. The muscles of the region are spastic, and prevent move- ment of the joint. Within the course of a few days an exudate into the synovial sac takes place, and fluctuation may then be easily elicited. Dur- ing convalescence the joints become less sensitive, and within the course of a few weeks there may be impairment of movement, the result of an apparent ankylosis. In the region of the affected joint nodular enlargements may be Fig. 325. — Fingers in Acute Akticdlar Rheumatism. detected along the sheaths of the tendons, and usually remain for an indefi- nite period after the patient has apparently recovered. In exceptional cases infiltration into the sheaths of certain tendons occurs; a well-marked case representing this type of the condition recently came under our per- sonal observation. The skin is hot to the touch, bathed in acid perspiration, and nodules of urticaria may be felt. In selected cases the spleen is enlarged. The pulse is increased in frequency, even in mild types of the disease, and is soft and full, numlDering 100 beats a minute. In certain cases it be- comes unusuaUy rapid (120 to 140 beats a minute), and when hyperpyrexia and other grave constitutional manifestations are displayed, tlie pulse be- comes feelile, decidedly irregular, and often compressible. The apex-beat becomes forcible and quickened, this feature ])ecoming especially prominent when endocarditis develops as a complication. According to Anders, endocarditis is seen in from 2.5 to 30 per cent, of all cases, "if pericardial involvement has taken place, a friction fremitus synchronous with the heart's action may be detected. ACUTE ARTICULAB RHEUMATISM. 895 Percussion is of but limited value, except in those instances in which effusion accumulates in the pericardial or pleural sacs. Auscultation. — During convalescence, and in those cases in which deformities or loss of mobility of the joint have become permanent, a pecuHar friction crepitus may be present for a long period upon movement of the joint. This sign is elicited by placing the stethoscope over the articular surface, and then forcibly manipulating the part. The characteristic signs of endocarditis are commonly elicited, and even before true cardiac murmurs can be detected there is an appreciable irrita- bility of the heart's action and a sHght prolongation or loss of distinctness of the first sound. The physical signs of bronchitis may be distinct over the entire surface of both lungs, although in mild cases these signs are absent. (See Acute Bronchitis, p. 88.) I^aboratory Diagnosis. — Secondary anemia develops early and is progressive in character, and a moderate leukocytosis generally occurs. The saliva may display an acid reaction during the acute symptoms, and in selected cases the sulphocyanids are in excess. The fluid obtained from the synovial sacs is usually clear, and may be free from bacteria, although pathogenic bacteria may be cultivated from such exudates. (See Bacteriology, p. 892.) The urine is diminished in quantity during the febrile period, and is high in color and unusually acid. On standing, it often deposits a heavy sediment, made up for the most part of amorphous urates. A trace of albumin may be present, and the reaction for chlorids is, as a rule, present. Illustrative Case of Acute Articular Rheumatism. — Charles M., aged four- teen years. Family History. — Parents and one brother living and in good health; no history of rheumatism, tuberculosis, or carcinoma in the family. Previous History. — ^The patient had the diseases of childhood, but does not remember whether any compUcations occurred. He has been subjected to repeated and somewhat periodic attacks of tonsillitis, which usually develop during the faU, and upon one occasion his tonsils were lanced. Four years ago he suffered from a mild attack of what his physician regarded as rheumatism ; at that time the right knee was swoUen and painful, and he was compelled to remain indoors for at least one week. Social History. — Family environment good. The patient has always been prop- erly nourished. He is a messenger boy by occupation, and is therefore exposed to cold and wet. Present Illness. — On March 14th he complained of slightly chiUy sensations, ma- laise, and anorexia, and on the following morning, on attempting to put his weight upon the right foot, he found that the right ankle was extremely painful. The ankle continued to swell, and when seen on the second day of his illness the swelling was marked and the slightest movement caused extreme pain. Anorexia, obstinate con- stipation, and mild headache were present. Upon the tnird day after the appearance of joint symptoms a similar inflammatory process attacked the left ankle, the right ankle . showing marked improvement simultaneously. The wrist and left knee then became similarly affected. Profuse sweating occurred during the night, making it necessary to change the garments and bed linen in the morning. Pain was increased upon moving either of the affected joints, this painful condition continuing for a period of about three weeks, when the sensitiveness gradually lessened. During the third week of the illness he complained of a sense of weight in the region of the heart, and although this was never referred to as distinctly painful, yet he was conscious of some distress in the precordium for a period of about one week. When seen upon the second day of the illness, the temperature was 101° F.; it continued to fluctuate between 99° and 101.4° F. until involvement of the left knee occurred, when the temperature rose to 102° F. ; it soon fell to its usual level, however, and continued of irregular type for a period of about two weeks, when it feU to the normal. Physical Examination. — General. — The skin was bathed with perspiration, the lower extremities could not be moved without eliciting an expression of pain. The body 896 ACUTE INFECTIOUS DISEASES. appeared well nourished, the skin and mucous membranes and the tone of the muscles normal. The face was flushed, and the expression one of pain; the tongue was heavily- coated. The right ankle was swollen during the first week, when the left ankle becarne involved, and later also the wrists and left knee became markedly swollen. The skin over the affected joints was red, and pressure caused paUng of the skin. Local Examination. — Palpation.— ^h.B involved joints were extremely tender, and even moderate palpation, as well as movement of the joint, produced great pain. Late during the third week of the disease, and at the time when precordial distress was present, there was a distinct irritability of the cardiac impulse, and the pulse was full and strong, numbering 100 to 120 beats a minute. From the third to the fifth week of the disease there was distinct fluctuation at the left knee, the fluid present being gradually absorbed and fluctuation disappearing by the seventh week. Percussion. — ^The area of cardiac dullness was found to extend slightly to the left and downward, showing dilatation of the left ventricle. Auscultation. — From the third to the fifth week of the illness the heart-sounds were rapid, the first sound evinced alteration (mufiiing), and a distinct murmur, soft and blowing in quality, was audible. The murmur became clearer and clearer from the fifth to the tenth week, and during this time dyspnea, cyanosis, coldness of the extremi- ties, and evidence of cardiac weakening were present. Laboratory Findings. — ^The quantity of urine voided during the day varied between 25 and 35 ounces; it was high colored, with a specific gravity of 1.025, and at times it showed a trace of albumin Diagnosis by Induction from Clinical Data. — ^The age of the patient, the history of repeated attacks of tonsillitis and of an attack of acute articular rheumatism four years ago, go far to suggest at least the nature of the condition. This evidence, together with the onset and the characteristic appearance of the ankle on the second day of the illness, was quite sufficient to warrant tne belief that acute articular rheumatism was present. A similar involvement of a joint of another limb rendered the diagnosis positive. Pain was an important symptom, and the fact that pressure upon the in- volved joints and movement of the affected limbs increased the pain were not without significance. Precordial distress, even though it never became severe, was highly sug- gestive of the existence of cardiac involvement. The temperature was that of acute articular rheumatism, rather than of other acute infections known to attack the serous surface of the joints. Differential Diagnosis. — ^The fact that the larger joints were attacked made a gonorrheal origin possible, but the condition was differentiated from gonorrhea by the absence of a history of urethritis. In certain respects the condition simulates tuberculosis of the joint, but the acute- ness of the onset, the involvement of other joints, and the clinical course all distinguish it from a tuberculous process. Course of the Disease. — This appeared to be modified as the result of treatment, the pain being greatly lessened as the result of the judicious administration of saUcy- lates. The quantity of lu-ine voided during the twenty-four hours soon increased from 35 to 50 ounces, this being probably attributable to the fact that the patient drank a large quantity of water. He was able to leave his bed during the sixth week of the disease, but owing to the fact that both lower extremities were involved in the process, he was unable to walk about the room until the tenth week, after which time he im- proved rapidly. When seen one year later, a systolic murmur was heard at the apex of the heart, and a slight degree of hypertrophy was present. Sutntnary of Diagnosis. — The history of previous attacks and of recurring attacks of tonsillitis is of considerable importance in formulating a diagnosis. The characteristic features of the disease are few — chill followed by a rapid rise in temperature, the fever running an irregularly remittent course, pain, swelling, redness, and tenderness of the affected joints, and the influence of motion upon the degree of pain. The occurrence of intercurrent acute endocarditis is also strongly confirmatory. Differential Diagnosis. — Tuberculous arthritis in children may be confounded with acute rheumatic arthritis. The former is less indurating, the swelling is less symmetric, and it runs a far less acute course than the latter condition. In acute articular rheumatism the pain is definitely localized to the joint and the general clinical course is acute, whereas tuber- culous arthritis runs a more chronic course. ACUTE ARTICULAR RHEUMATISM. 897 Gonorrheal arthritis may closely resemble acute articular rheumatism; here, however, a history of an attack of gonorrhea, the character of the pain, the less marked constitutional disturbances, and the tendency toward chron- icity strongly favor a diagnosis of gonorrheal infection and discourage the possibility of the existence of acute articular rheumatism. In gonorrheal arthritis aspiration of the aflected joint will result in the recovery of fluid in which gonococci will be found. Scurvy. — During the course of scurvy and the allied conditions, purpura and hemophilia, an effusion into the synovial sacs takes place, but in these conditions the effusion is likely to consist of blood, which will differentiate if from the serous effusion that collects in acute articular rheumatism. The tendency toward hemorrhage from the mucous surfaces is a marked feature of scurvy, but uncommon in acute rheumatism. In the so-called " peliosis rheumatica," petechial hemorrhages may occur in both the skin and the mucous membranes, but even in this disease hemorrhage into the serous sacs is uncommon. A history of the patient's life during the past year, the char- acter of food he has eaten, as well as a general knowledge of his environment during that time will often be of great value in differentiating acute articular rheumatism from scurvy. Pyemia. — Here the general condition is more grave; fever of the irregular intermittent type precedes the local manifestations. Rigors also occur at varying intervals, accompanied by a marked elevation of temperature — symptoms that are absent in rheumatism. In pyemia suppurative processes occur in the various viscera and skin, and slight jaundice is present. Rheu- matic symptoms fluctuate greatly, wJaereas those of pyemia do not. The multiple swelling of the joints which develops after child-birth is to be regarded as septic in nature. In these cases arthritis leads rapidly to suppuration, with more or less destruction of the joints. Clinical Course. — In an average case of acute articular rheumatism in which a single joint is involved the febrile period lasts from seven to four- teen days, and is followed by convalescence, the patient being able to leave his room by the end of the third or during the fourth week. When several of the articulations are attacked in succession, the illness may be prolonged to from six weeks to several months. Cardiac complications practically always retard convalescence, and may leave a permanently damaged heart in their wake. Judicious treatment materially shortens the course of the disease, whereas retention of the serous fluid in the synovial sacs may in turn retard convalescence for weeks, and even necessitate aspiration for the removal of such fluid. Complications. — Acute endocarditis is the most frequent complica- tion. Pericarditis and pleurisy are occasionally encountered. Bronchitis, bronchopneumonia, and lobar pneumonia are rare complications. Gonorrheal Arthritis. Pathologic Definition. — An acute septic inflammation involving both the synovial membranes and the periarticular tissue of the larger joints. The inflammation may extend along the tendon-sheaths. Effusion into the synovial sac usually follows, and may, in some cases, be purulent in character. The joint may become edematous and swollen in proportion to the virulence of the inflammatory process, and ankylosis may follow. Bxcitingr and Predisposing Factors.— Bacteriology.— The ex- citing factor is the gonococcus, although other bacteria may also be present .57 898 ACUTE INFECTIOUS DISEASES. in the purulent exudate recovered from the synovial sacs._ If the blood- current becomes contaminated by the gonococcus, endocarditis results, and positive blood cultures are then obtained. An attack of gonorrhea is an essential factor in the development of the disease, although the urethral mucosa may not be involved; Lucas collected 23 cases in which gonor- rheal arthritis followed gonorrheal ophthalmia. Sex. — The disease appears in both sexes, and, according to Gather, it occurs in about 22 per cent, of all cases of gonorrheal urethritis. Invasion of the synovial sacs by the gonococcus is less common in females, yet such cases have come under our observation. Principal Complaint. — A history of gonorrheal infection is usuaUy obtained, but when such history is not elicited, careful clinical research is necessary. Two distinct subclasses of gonorrheal arthritis have been de- scribed: (a) A type in which the inflammatory changes are mild and in which the patient suffers a moderate amount of pain in one or probably in two or three joints, but in which the affected joints show but little, if any, evidence of inflammation. (b) Typical Form. — In this variety the pain is more pronounced, and a single joint becomes markedly incapacitated in the course of a few days. Soreness radiates from the joints and runs along the tendons, and despite treatment the patient's condition goes from bad to worse. Polyarthritis is present in a small proportion of all cases, the more pronounced symptoms being confined to one or two of the large joints, e. g., the knee, wrist, elbow. Transitory arthritis may be seen during childhood. Physical Signs. — Inspection.— The affected joint is swollen, red- dened, and partly flexed. If arthritis persists for some weeks, extreme pallor of the skin and mucous membranes and emaciation take place. Palpation. — The affected joint or joints are found to be greatly enlarged and tender upon even mild pressure. Following the accumulation of an ex- udate in the synovial sacs fluctuation is present, and aspiration results in the recovery of fluid. In long-standing cases a fibrinous ankylosis may develop and complete motion of the joint becomes impossible. In those cases in which the endocardium becomes involved the pulse is increased in frequency. I^aboratory Diagnosis. — If a urethral discharge is present, a specimen must be examined for the presence of the gonococcus. Cultures on blood-serum or glucose-agar should be made from the fluid obtained by aspirating the synovial sacs. The gonococcus will be obtained in a large proportion of cases. Other bacteria may also be present in the synovial fluid, e. g., staphylococci, pneumococci, and streptococci. If the type of gonorrheal infection has been unusually severe and has continued for several weeks or even months, the blood-picture is that of chloranemia. Following the accumulation of pus in the synovial sacs a well-marked leukocytosis may be present, although this is not a constant finding. If the condition is complicated by endocarditis, the gonococcus may be cultivated from the circulating blood. Summary and Differential Diagnosis. — (a) History of gonor- rheal infection, urethritis, leukorrhea, or ophthalmia; (6) involvement of the articular surface some weeks or months after the initial symptoms of gonorrhea; (c) detection of the gonococcus in the synovial fluid. The foregoing diagnostic features serve to distinguish gonorrheal arthritis from other forms of joint inflammations. The following table sets forth the differential features between gonorrheal and tuberculous arthritis : VARIOLA. 899 Gonorrheal Arthritis. Tuberculous Arthritis. 1. Histroy of gonorrheal infection from a 1. May be a history of tuberculosis prior few months to a year prior to the de- to the development of articular symp- velopment of articular symptoms. toms. 2. Fluid in synovial sacs, purulent in 2. Fluid in synovial sacs serous in char- most cases. acter. 3. Synovial fluid contains the gonococcus, 3. Synovial fluid may contain tubercle and possibly other bacteria. . bacilli. 4. TubercuUn reaction negative. 4. Tuberculin test positive. Clinical Course.— Despite the apparent virulence of the articular inflammation, the process tends to become subacute or chronic in nature. Surgical treatment is usually necessary, and materially shortens the course of the disease. VARIOLA (Smallpox). Pathologic Definition. — An acute infectious disease characterized by the appearance of an eruption that presents four distinct stages: (1) The macule; (2) the papule; (3) the vesicle; and (4) the pustule. During the healing process the lesion is covered with a scab, which, when removed, leaves a scar. The mucous membrane of the mouth, pharynx, and esophagus may also display a characteristic eruption. In the severe type of the infection, known as hemorrhagic smallpox, extensive cutaneous hemorrhages and hemorrhages into the muscular tissue may occur; hemorrhagic infarction of the lung and of other viscera is also occasionally seen. Varieties. — (1) Discrete smallpox, which may be mild or moder- ately severe. (See Fig. 326.) (2) The confluent form, which appears to follow a severe type of infection, and in which the disease is ushered in by grave constitutional symptoms. The eruption appears early and is profuse, and the pustules may coalesce, with extensive destruction of tissue and resulting deformity. The thermic features and the nervous manifestations of this type of the disease are pronounced, the patient soon entering into the typhoid state. The lymph-nodes become markedly swollen, the features are distorted, and salivation is frequently an annoying symptom. The cardiovascular dis- turbances are marked, the pulse being frequent, weak, and irregular; and there may be unusually severe gastro-intestinal symptoms, such as nausea, vomiting, and diarrhea. In favorable cases convalescence is retarded. .(3) The hemorrhagic form (black smallpox), another extremely malig- nant type of the disease, in which, owing to certain hemic changes or to changes in the other tissues, hemorrhagic extravasations into the skin (Fig. 327), mucous membrane, and viscera take place. This type of smallpox is divided clinically into the following subvarieties: (a) A form in which there is an effusion of blood into the pustules, brought about probably by per- mitting the patient to leave his bed too soon or as the result of undue ex- citement during convalescence. In this subvariety of hemorrhagic small- pox the lower extremities are involved in the majority of instances, (b) During the eruptive stage of the ordinary type of variola, to be subsequently described, a moderate amount of hemorrhage may take place into certain of the pustules, (c) The patient may manifest a hemorrhagic tendency dur- ing any portion of the eruptive stage of the disease, and there may be bleed- ing from the mucous surfaces (mouth, lungs, kidneys, uterus, bladder). 900 ACUTE INFECTIOUS DISEASES. In this grave form of the disease the initial symptoms are intense, the erup- tion is profuse, and collapse ma)' follow the lienKjrrhages. In this sub- variety complications are unusually common; among these are pneumonia and nephritis, [d) Rarely tlo we encounter cases of variola in which the hemorrhagic tendency is displayed during the period of invasion, with ec- chymoses into the skin and mucous surfaces as early as the second day of the disease; these hemorrhagic areas develop rapidly, and may involve the greater portion of the body. In these cases the typical eruption of variola is not present, and the thermic manifestations are also unusual, the fever being Ijut moderately elevated. A fatal termination usually occurs early. (4) Varioloid is a mild form of smallpox de\-elo]3ing in an indi- vidual who has lieen protected by one or more successful vaccmations. This mild form of smallpox may, however, occur in those who possess a variable degree of natural immu- nity, and who have not been vac- cinated. The initial sj^mptoms of varioloid are practically identical with those of variola, but the gen- eral clinical course of the disease is usually somewhat milder, the erup> tion displaying certain irregularis ties. Immunity and Suscepti- bility. — One attack establishes poimanent immiuiity, and success- ful vaccinations produce the same effect in a A^ast majority of cases. Practicall}' every case of small- pox must have had its origin in some previous case, the specific virus being conveyed from one patient to another thr(iugh various chan- nels and liy ^'arious methods. (See Modes of Infection.) The disease usually spreads with great rapidity among Caucasians who have not been vaccinated, whereas among ... . American negroes and American Indians it is disseminated with still greater rapidity. Bxciting and Predisposing Factors". — Parasitology. — The more recent m^'estigations regarding the etiology of smallpox, made by Councilman and his associates, have resulted in'^the finthng of a body be- lieved to lie a protozoan parasite in the epithelial cells and in the fluid of the vesicles and the pustules. Councilman's findings have been confirmed by othermvestigators. Funk has described a protozoon found in this disease, and Ffeiffer discovered a protozoon in the pustules of vaccinia Among other observers who have detected the presence of protozoa in vaccinia are iskigami, Rosenberger, Haushalter, and Etienne. Fig. 32(3. — Discrete Smallpox in an Uxvac- riN-ATED CJiRL. Eightlnlay of eruption (Welch and Schamberg). VARIOLA. 901 Bacteriology. — Streptococci and the other bacteria commonly present on the cutaneous surface may be recovered from the pustules of smallpox, but they have no etiologic significance. Age. — Smallpox occurs during all periods of life. It is especially common in children, and may affect the fetus in utcro. The disease may develop during the puerperal state in those exposed to the infection. Period of Incubation. — This varies; six or seven days usually constitute the period of incubation when the disease is directly inoculated from man to man; when, however, it develops as the result of exposure, the incubation period ranges from ten to fourteen daj'S. Ill-defined prodromal symptoms are present at times. Principal Complaint. — Following the history of exposure to a case of smallpox, there develop, within the course of approximately twelve days, the following symptoms: A rigor, accompanied l)y intense headache, and followed by a sense of chilliness that persists for from twelve to t\\-enty-four Fig. 327. — Hemorrhagic Smallpox in a Puerperal Woman; Fatal. Cutaneous surface covered with petechiip and ecchymose.s. A few ill-formed papules were pres- ent (Welch and Schamberg). hours, lumbar pains, and aching muscles. The patient's complaint at the onset of the disease wUl be found to vary greatly in different epidemics; we have observed epidemics in which these symptoms were unusually mild. (See Thermic Features, p. 902.) Following the chill there generally occur ano- rexia, constipation, nausea, and, in severe types of infection, vomiting. The constipation may disappear later and be replaced by diarrhea. Sore throat is common, and the patient may complain of a shooting pain, extending from the throat into one or both ears; suppurative otitis media occasionally occurs during convalescence, and should probably be regarded as a compli- cation. Coryza develops early and persists for several days, and severe lacrimation is also pre.sent. Nervous Symptoms. — The nervous manifestations are usually in direct relation to the severity of the type of the disease in question. Restlessness, and frequently mild delirium, are always present, whereas in severe cases maniacal outbreaks, low muttering delirium, and even coma are observed, 902 ACUTE INFECTIOUS DISEASES. In children convulsions not uncommonly occur. Paraplegia and multiple neuritis and myelitis may appear during convalescence, and, indeed, these grave nerv^ous conditions may develop as a sequel rather than as a symptom of the disease. Insanity, hemiplegia, aphasia, and epilepsy may also follow an attack of variola. Cutaneous Features. — After the development of the pustule there is intense itching of the skin. (See Inspection, p. 903.) Respiratory Symptoms. — There is always an associated pharyngitis and a laryngitis, both of which result from eruption upon the mucous sur- faces. The laryngeal condition may be so severe as to result in the de\-elop- mentof a perichondritis, which is likely to be followed by edema of the glottis. In variola, as in most acute febrile conditions in which acute bronchitis ac- companies the disease, pulmonary congestion and bronchopneumonia are to be dreaded as complications. As in certain other acute infections, variola shows a predilection to attack the serous surfaces, consequently pleurisy may develop during the acute stage of the disease and during convalescence; 107° +__ ^^^^^ I E 1 1 III { 1 1 T =-- 1 1 II 1 l|l l| l|l 1 1 i 11 1 II yj^wlEuU '"'MttE 1 EmIttmiTn 104 Epl?J- I 103°=—- 101°- = = =?' ^ j I I =^^i^EE--i|-i^i-::lE=^E|-;IM: 100° -- — 99° i— a: iff 7 -Z -r:^ _l . — ^ — ^ En-_EE3E-=T.. = *^-EE^rc^SE:E|E^:E „.„„J,i-^? 3 4 5 6 7 8 9 10 11 12 la 1 4 15 16 17 18 19 20 21 22 23 2t 25 2e 27 28 2P 30 31 32 33 Fig. 328. — Temperature-chart of a Case of Variola, from a Patient in the Municipal Hospi- tal, Philadelphia (J. M. Anders). A. F , aged three years; not vaccinated. its onset is indicated by the presence of intense lancinating pain in the chest. Cough IS an early symptom, and may continue until convalescence is es- tabhshed; m those cases in which pulmonary complications develop, the cough persists for some time. Thermic Features.— At the onset of the disease the temperature will be found to rise rapidly, reaching 103° to 10.5° F. by the end of the first twenty-four hours following the chill. The fever is of the continued type, remaining high until the papular eruption appears,— about the third day,— when there is a decided fall in the temperature. Following the appearance of the papular eruption the temperature continues slfghtly elevated until the development of suppuration, when it again rises — the so-called secondary fever. (See Fig. 328.) This secondary exacerba- tion of temperature is decidedly irregular or septic in character^ displaying exaggerated points of elevation and of marked remission. In mild cases of variola the secondary febrile expression may be feeble or even absent. In cases of average virulence the secondary fever continues for three or four days, and declines gradually with the improvement of the general symptoms. VARIOLA. 903 A third febrile exacerbation should be regarded as due to the presence of some complication. Physical Signs. — Inspection. — With the beginning of the fever a difi'use erythema is frequently seen en the arms, legs, and trunk. This is sometimes called the initial eruption, but it has nothing to do with the char- acteristic rash of the disease, Ijeing caused by the capillary dilatation, the result of the influence of toxins on the vessels, wliich is seen in the early stages of nearly all acute febrile diseases. This erythema in some cases reseml)les the exanthem of scarlet fever, when it is called scarlatinijorm, and in other cases it resembles the eruption of measles, when it is said to be morbilUlonn. The true eruption develops upon both the skin and the visible mucous surfaces, appearing first upon the face, forehead, and scalp, and extending in a downward direction to the thighs, and finally to the legs. The femoral region is more likely to escape than are other portions of the cutaneous surface. Each pock passes through the following stages: Fia. 329. -Smallpox — Dried Pocks Embedded in the Horny Layer of the Palms (Welch and Schamberg). (1) Macule, in which the mark is reddish in color, resembling the bite of an insect; it increases in size for twenty-four hours, at the end of which period each macule is developed into a distinct papule. (2) The papule continues as such for a period of three days, up to the sixth day of the disease, when the conical apices of the papules become filled with liquid, and vesicles are formed. (3) The vesicles increase in size until the entire lesion Ijecomes filled with exudate, its apex being depressed — the so-called umbilicated vesicle. At this stage puncturing of the vesicle does not cause it to collapse, but is fol- lowed liy the escape of but a small portion of the liquid contents — a clinical fact that indicates that the vesicular lesion of smallpox is divided into several compartments. As the ve,sicle increases in size its contained fluid becomes opaque, and three days later — the ninth clay of the disease and the sixth day of the erup- tion — it is converted into a pustule. Lesions are seen upon the soles of the feet and upon the palms of the hands (Fig. 329). With the development of the pustular stage the umbilicated appearance 904 ACUTE INFECTIOUS DISEASES. of the lesion is lost and the pustule is surrounded by an inflammatory areola. In those cases in which the pustules are in close proximity, generally upon the wrist, face, and fingers (Figs. 326 and 329), the skin connecting the pustules becomes edematous. In confluent smallpox the pustules coalesce and there is marked swelling of the skin, which is often so severe as to dis- tort the features. The pustules usually rupture soon after they appear. (4) Following the escape of the purulent exudate from the pustule a scab is formed, which remains until about the twelfth day of the eruption. After the scabs have been shed, a permanent whitening of the spot, with a depression of the skin, remains. Extensive cutaneous gangrene, bed-sores, abscesses, and the develop- ment of erysipelatous processes are among the annoying features, and should be classed as cutaneous complications. The face is swollen, and in many instances the eyes are completely closed; the lips and mucous membrane of the mouth and throat, the buccal and pharyngeal mucosae, and the tongue are swollen and coated, and a false membrane may be detected upon the pharynx and tonsils. Ocular Phenomena. — The conjunctivae are congested, and pustules and ulcerations may be present upon them; one of the most serious of the ocular phenomena that may occur is ulceration of the cornea. Keratitis, choroiditis, and panophthalmitis are among the less common ocular disturbances. The joints are often swollen. Owing to pain, the patient may persist in holding the arm or limb partially flexed. As the result of an associated peritonitis the thighs may also be flexed upon the abdomen. Palpation. — Immediately after the appearance of the eruption the skin is dry and hot, and later it is slightly roughened along those areas in which the initial eruption appears. During the papular stage the papules upon the forehead and about the wrists have a distinct, shot-like feel; after pus has accumulated within the lesion, the intervening skin pits upon pressure, the result of edema. Following the onset of the disease, the pidse is accelerated, reaching 100 to 120 beats a minute ; it is of good volume and of moderate tension. During the stage of remission the pulse is diminished in frequency, and may be but slightly above that of the normal; with the development of the secondary fever, however, the pulse is again markedly accelerated, the number of beats varying in frequency between 100 and 130 a minute. If the disease occurs in a patient who has previously suffered from cardiac disease, or if cardiac complications, such as endocarditis, pericarditis, or myocarditis, are present, the pulse may become weak, dicrotic, irregular, intermittent, and easily compressible. The liver and the spleen are often palpable, and the apex-beat of the heart is forcible. Auscultation. — The signs of acute bronchitis are present (p. 88). The heart action is rapid, and in severe and in complicated cases the muscular element of the first sound is deficient. I/aboratory Diagnosis. — Fluid obtained from the vesicles may be sterile, although some observers assert that they have found it to contain bodies that appear to be parasites. (See Parasitology, p. 900.) After the serum has become infected with pathogenic bacteria, the pus will be found to contain a variety of pus-producing organisms. (See Parasitology, p. 900.) According to the reports of Welch and Schamberg, albuminuria is present in 65 per cent, of all cases of smallpox, whereas casts were found in 45 per cent, of a series of 128 cases. Hematuria, although rare, may occur in those VARIOLA. 905 cases having a hemorrhagic diathesis. Constipation is present, as a rule, but it may be replaced by diarrhea, and rarely there is profuse hemorrhage from the bowel. R. G. Curtin has reported a case where intestinal hemor- rhage caused a fatal termination before the eruption had fully developed. Vomiting of blood is also an unusual complication. The sputum may be blood-streaked, although such blood may have its origin in the buccal cavity or pharynx. If otitis media develops, a purulent bloody discharge will be recovered from the external auditory canal. Summary of Diagnosis. — The history of an epidemic or of exposure to a case is of great importance, as is also the evidence of a previous vaccina- tion. Sudden onset with a chill, followed by a rapid rise in temperature, which continues for a period of about three days, when first a macular, then a papular, later a vesicular, and finally a pustular eruption develops, accom- panied by secondary fever, forms a highly characteristic grouping of features. Prior to the development of the eruption, pain in the back and loins, cough, acute bronchitis, and sore throat are to be considered, although these symp- toms may be present in the other acute infections; hence in the preemptive stage the diagnosis is made not only with difficulty, but is often impossible. Differential Diagnosis. — Scarlet fever is to be distinguished early from the erythematous (scarlatinous) rash that is often a precursor of the variolous eruption; this is, as a rule, neither so intense nor so uniformly distributed over the surface of the body as in true scarlatina. Hemorrhagic scarlatina, which is extremely uncommon, closely resembles "black" small- pox. Measles. — During the first three days of the development of the small- pox eruption, while the rash is still in the macular stage, the disease may be mistaken for measles. The latter disease, however, presents more marked evidences of respiratory disturbance than does smallpox. In measles the conjunctivitis, photophobia, and coryza are more marked than in smallpox. In the papular stage of the variola eruption the shot-like feel of the lesion will distinguish it from the papule of measles. Typhus Fever. — ^The onset of typhus fever resembles closely that of smallpox. The former disease is usually imported, and is not prevalent in America. The appearance of the eruption first upon the trunk (chest and abdomen), in the form of macules, later becoming petechial, is characteristic of typhus fever. Moreover, in typhus the temperature does not remit with the appearance of the eruption. The temperature chart of typhus (see p. 760), when compared with that of variola (p. 902), will be found to display distinctive characteristics. It is at times extremely difficult to distinguish between hemorrhagic small- pox and virulent types of typhus fever. The nodular or shot-like feel of the papules, so characteristic of smallpox, is, however, absent in typhus. Cerebrospinal fever may be mistaken for hemorrhagic smallpox, but the history of the case, the prominence of nervous symptoms (see Meningitis, p. 838), together with the evidence obtained from lumbar puncture and an analysis of the cerebrospinal fluid, will serve to differentiate these maladies from each other. Syphilis is marked by a milder initial stage, by the indurated base of the pustule, and by the appearance in crops of the skin lesions and their poly- morphous character. The pitting characteristic of smallpox does not follow syphilis, although a copper-like tint of the skin, the result of pig- mentation, is seen. Impetigo contagiosa does not present an initial stage, but begins as 906 ACUTE INFECTIOUS DISEASES. vesico-pustules that appear on the normal skin and enlarge by peripheral extension. In impetigo the characteristic febrile expression is absent. The accompanying table, modified from Anders, sets forth the distinctive features between variola (smallpox) and varicella (chicken-pox) : Variola. Varicella. History. 1. Previous or existing case in the vicin- 1. Traceable to previous or present case ity. of varicella. 2. Not successfully vaccinated. 2. Negative. 3. Occurs at any age 3. Is more common in childhood. 4. Characteristic preemptive stage, rash 4. Eruption not preceded by prodromes, on the third day. 5. Sacral pain, high fever, and vomiting 5. Pain, high fever, and vomiting un- common, common. Eruption. 6. Appears first upon the forehead, ex- 6. Appears first over the parts covered tending downward. by clothing. No regular distribution over the body. 7. Vesicles uniform in size, umbilicated, 7. Vesicles vary much in size, are rarely and deep seated. umbilicated, and feel soft and velvety. 8. Contains serum and later pus. 8. Contains only serum, giving it a pearly translucency. 9. Most abundant on face and fingers. 9. Most abundant upon back and lower extremities. 10. Appears in a single crop. 10. Various lesions present side by side. 11. Pin-prick does not cause coUapse of 11. Pin-prick causes collapse, vesicles be- vesicles, they being multiloculaj. ing unilocular. 12. Secondary fever usually present. 12. Secondary fever absent. Clinical Course and Duration. — This wiU be found to vary greatly, depending upon the severity of the type of infection and upon the presence or absence of complications. In uncomplicated cases the eruption will have advanced to the pustular stage by the ninth day, and if it is but moderately extensive, the formation of scabs will be observed after the twelfth day, when, in favorable cases, the secondary fever wiU gradually decline, reaching the normal during the third week of the disease. The disease runs a somewhat shorter course in the aged than in young subjects. Complications. — Among the more serious complications are broncho- pneumonia, lobar pneumonia, hemorrhage from the bowel, acute nephritis with hematuria, grave nervous manifestations, ulceration of the cornea, purulent conjunctivitis, and otitis media. Almost all these complications have been considered in the general description of the disease. VACCINIA (Cowpox). Pathologic Definition. — An attenuated form of smallpox resulting from vaccination with serum collected from bovines that have previously been inoculated with the disease. Clinical Characteristics. — Within the course of three to five days following vaccination a distinct papule appears at the site of the lesion, which is surrounded by a red areola. The congested area extends, and by the sixth day a well-marked umbilicated vesicle or a crop of vesicles are present. These often show distinct umbUication, and by the tenth day they contain purulent fluid. On or about the twelfth day following vaccination the lesion tends to disappear, and within the course of three or four weeks the scab is shed and distinct pitting remains at the site of each papule. Thermic Features. — In from four to six days following vaccination VARICELLA. 907 mild fever and constitutional disturbances appear, and may continue until the ninth day. The lymph-nodes in the corresponding axilla are often enlarged, and may be tender or even painful. Atypical Forms. — If the patient is especially susceptible to the virus, or if the virus is unusually active, extensive erythema and a papular eruption may occur, and go on to suppuration, leaving distinct pock-marks on certain portions of the body. Complications.— Those resulting from external infection of the wound are erysipelas, impetigo, extensive ulceration, and tetanus. Tetanus has been found to follow vaccination in 33 out of 863 cases in which the disease occurred after operation, injury, and the like (Anders and Morgan). The transmission of syphUis through vaccination has been reported. VARICELLA (Chicken-pox), Pathologic Definition. — An acute infectious disease characterized by the presence of a cutaneous eruption of vesicles distributed over the body. Bxciting and Predisposing Factors. — Bacteriology. — Various investigators have isolated different bacteria from the vesicles, but the etio- logic factor is as yet unknown. The disease is seldom, if ever, conveyed by clothing, etc., personal con- tact being necessary to produce the disease. Incubation Period. — ^The eruption develops in from fourteen to sixteen days after exposure. Principal Complaint. — Slight prodromal symptoms may be experi- enced, but these, as a rule, are so mild as to be unappreciated by the patient. Thermic Features. — Upon the second and third days of the disease the temperature will be found to range between 100° and 102° F. ; occasionally a higher temperature is observed. The fever decUnes by lysis. Physical Signs. — Inspection. — ErujAive Stage. — In many instances the patient appears to be in perfect health until the eruption appears. The latter is characteristic, appearing in the form of small reddish puncta that later develop into rose-colored macules. As the disease progresses the mac- ules may become converted into papules, and later into vesicles, the lesions becoming distended to approximately the size of a pea. The distribution of the eruption is somewhat characteristic, appearing first upon the upper portion of the body — i. e., the chest, back, neck, and scalp. The face is, as a rule, but sparingly covered, whereas the scalp con- tains many lesions. Vesicles may also appear upon the lips, within the buccal cavity, and on the palate. These are transparent at first, but later become translucent, and the vesicular contents may become seropurulent. A narrow areola the result of congestion surrounds each vesicle. Later crusts form, which drop off in from the sixth to the twentieth day after the appearance of the eruption. Pitting is not common, and is rarely seen on those portions of the body covered by clothing. Some of the lesions may go on to form well-marked pustules, although this manifestation is by no means characteristic of the disease. When the eruption begins to fade, intense itching of the scalp occurs, and in those cases in which the eruption is pro^ fuse, itching of the entire body may be an annoying feature. The, enijption of chicken-pox appears in successive crops, so th9,t macules, papules; and vesicles may be seen side by side in a given cutaneoi^s area. This ^ a dis- tinctive feature between varicella and variola. In the latter disease the 908 ACUTE INFECTIOUS DISEASES. eruption involves the entire body at one time, and the lesions in various situations are of the same degree of evolution. Complications. — These are unusual, although the disease is occasion- ally complicated by erysipelas, which may extend from certain of the in- fected areas, and is most likely to affect those sections in which there has been distinct ulceration. Isolated abscesses and adenitis are occasionally seen. Acute nephritis may develop when the surroundings are unhygienic, and when the patient has been unduly exposed to cold and wet. HYDROPHOBIA (Rabies). Pathologic Definition. — An acute infectious disease, character- ized, according to Van Gehuchten and Nelis, by lesions in the ganglia, on the posterior roots of the spinal nerves and of the sympathetic system. These lesions consist of atrophy and invasion and destruction of the nerve- cells by newly formed cells derived from the endothelial cells of the capsule of the ganglion. • The cerebral vessels may contain soft thrombi, and hemor- rhagic extravasations into the perivascular spaces may take place, as has been stated by Fitz. General Remarks. — The specific infection is conveyed to man by the bite of an infected animal. Rabies is constantly present in certain parts of the country. In 1906 there was hardly a county in Pennsylvania in which the disease had not been reported. In Chester County, Pennsylvania, during the summer of 1907, the destruction of 154 dogs, 25 cows, and 10 horses was necessitated by reason of the fact that they had been exposed to the bites of rabid dogs. The increasing prevalence of hydrophobia is further supported by the statistics of the State of Connecticut for 1906, when, in the city of Waterbury, several persons were bitten by rabid animals and 175 dogs were destroyed. At Torrington, Conn., seven cows died of hydrophobia. In 1905-06 the disease prevailed extensively in Florida, and Hill reports the necessary destruction of 1200 dogs. Twelve persons were bitten, and of these three died of hy- drophobia. In Norfolk, Va., nine persons have been bitten by rabid dogs during the past five years, and a large number of domestic animals have been destroyed. At Charleston, W. Va., 12 cows and 40 dogs are reported as having died from the disease during the past few years. This brief statis- tical r&ume is in itself sufficient to convince the most skeptical of the in- creasing prevalence of hydrophobia in the United States. The reader is referred for further information to the detailed report issued by the Bureau of Animal Industry, January, 1908. Bxciting: and Predisposing I^actors.— No specific organism has as yet been detected. In 1903 bodies were found in the large gang- hon-cells of the brain; particularly in the hippocampus major; these were described by Negri, and are known as Negri bodies. Some authors believe them to be protozoan parasites, and the cause of the disease. The bodies are round, oval, or triangular in shape, and vary in size from 1 to 23 microns in diarneter. They are composed of a homogeneous, non-granular substance, which is strongly eosinophiHc, and which resembles coagulated albumin. The bites of infected dogs are the usual cause in man. Clinical Stages.— The prodromal stage lasts from two weeks to four months, the average case developing symptoms in from six to eight weeks after exposure. , George H. Heart, V.M.D., cites the case of a dog that received a bite from a rabid animal and developed hydrophobia just HYDROPHOBIA. 909 one year later. The diagnosis in both animals was made from a pathologic study of their tissues and by the inoculation of rabbits. In experimental hydrophobia, when the virus is introduced directly into the nervous system (meninges), definite symptoms develop in from fourteen to twenty-one days. _ An unusually prolonged incubation period, extending over months, is occasionally seen, and is explained in the following way: If a rabid animal bites a human subject through the clothing or inflicts but a sUght wound, the virus is not introduced directly into the circulation, but is taken up by the lymphatics and held within the lymphatic system, for an indefinite period (weeks, months); when, however, the virus passes beyond the barriers of the lymphatics and reaches the nervous system, the charac- teristic symptoms of the disease follow in from fifteen to twenty-one days. Among the initial sjrmptoms are depression of spirits, malaise, headache, impaired appetite, insomnia, slight fever, photophobia, intolerance of sound, and alterations in the voice, such as hoarseness and dysphagia. Second Stage. — At this time the patient becomes extremely excitable, and there is hyperesthesia of the special senses and of the skin. The muscles of the throat become more or less fixed, and attempts at swallowing are followed by violent spasms that involve the muscles of the pharynx, mouth, and upper portion of the chest. During the spasm the patient becomes cyanosed and presents a picture of great distress. Owing to the hyper- sensitiveness of the nerves, the paroxysms may be excited by drafts, the sight of water or of food, an attempt to swallow, startling noises, or even by an attempt to move the patient in bed. Intense thirst is present. Con- sciousness may be retained during the attacks, although in certain cases delirium occurs. Thermic Features. — ^MUd fever is usually present during this stage of the disease, the temperature ranging between 99° and 103° F. This stage of the disease continues for from thirty-six to seventy-two hours. 1 Third Stage. — ^This is often referred to as the paralytic stage, and is characterized by the absence of spasms and the development of stupor, followed by coma, which terminates in death in from six to eighteen hours. Summary of Diagnosis. — A history of being bitten by an animal believed to be suffering from the disease at the time, together with the charac- teristic symptoms, is strong evidence of the existence of hydrophobia. The animal that inflicted the bite should in no case be immediately killed. Instead, he should be placed in a safe cage, and given both food and water. If the dog has rabies, he wiU die within two or three days, and an autopsy will determine the cause of death. It is unfortunate that so many animals are shot immediately after inflicting a bite upon either man or domestic animals, for if he were immediately placed under the care of a veterinarian, definite knowledge could be ascertained as to the presence or absence of rabies, and proper treatment of the bitten individual accordingly instituted. I/yssophobia (Pseudo-hydrophobia) is a condition affecting per- sons of neurotic or hysteric temperament some months after being bitten by a dog. They then develop symptoms simulating those of hydrophobia. Among the characteristics that differentiate this condition from true hy- drophobia are the following: Irritability, despondency, emotional seizures, absence of fever, and the fact that the disease does not progress through the successive clinical stages. Clinical Course. — Hydrophobia usually terminates fatally on about the third day. Dogs generally die on the third day, rabbits on the ninth day, and monkeys on the fourteenth day. 910 ACUTE INFECTIOUS DISEASES. TETANUS (TRISMUS) Lock-jaw). Pathologic Definition. — An acute infectious disease caused by the bacillus tetani. The toxins act upon the nerve-cells of the medulla and the spinal cord, resulting in congestion, edema, inflammation, and softening of the gray matter. An ascending neuritis extends from the initial wound, and is characterized by reddening and swelling of the neurilemma. Clinical Types. — The disease, as a rule, follows the infliction of punctured or lacerated wounds. In the new-born it results from infection of the umbilical cord. Varieties. — (.1) Acute tetanus; (2) chronic tetanus; and (3) cephalic tetanus. Bxciting and Predisposing Factors. — Bacteriology. — The bacillus of tetanus was first recovered from the tissues of man by Rosenbach in 1886, although it had been described in 1884 or 1885 by Nicolaier. It is a long, slender rod, clubbed at one extremity, and is anaerobic. Animals inoculated with cultures of this organism develop typical attacks of tetanus. The tetanus bacillus is a normal inhabitant of the soil of certain localities, and is also present in the intestine of the horse. Modes of Infection. — Anders and Morgan's analysis of the records of 1201 cases of tetanus shows conclusively that the introduction of the tetanus bacillus is usually effected through a lesion of the skin, and that the so-called idiopathic or rheumatic type of the disease does not exist. Season. — ^The accompanying tables, taken from the paper of Anders, in collaboration with A. C. Morgan, the result of an analysis of 687 cases, is of special value as showing the influence of season upon tetanus : SEASONAL OCCURRENCE OP TETANUS. Number of Cases. Numbeb of Cases. January 35 August 59 February 36 September 68 March 41 October 75 April 42 November 47 May 57 December 37 June 61 July 129 Total 687 SEASONAL OCCURRENCE OF TETANUS NEONATORUM. January 12 August 8 February 10 September 14 March 24 October 9 April >. 5 November 9 May 6 December 7 June 11 July 18 Total 133 Immunity. — Animals may be rendered immune by injecting them with cultures of the tetanus bacillus after such bacteria have been treated with iodin trichlorid. Incubation Period. — The duration of the period of incubation is de- pendent entirely upon whether the case pursues an acute or a chronic course. In acute tetanus the incubation period lasts from one to two weeks, whereas in the chronic type the first symptoms are manifest after the second week. The accompanying table, taken from the paper just cited, shows the average incubation periods in infants and in adults developing the disease : TETANUS. 911 TABLE OF AGES OF PATIENTS IN TETANUS CASES. Number of Numbeh oi Patients. Patients. 3 to 15 days 13 Over 50 14 1 to 5 years 24 5 to 10 years 99 Total 583 10 to 15 years 130 Unclassified 618 15 to 20 years 70 20 to 25 years 75 Total 1201 25 to 30 years 44 30 to 35 years 42 Males 778 35 to 40 years 37 Females 203 40 to 45 years 22 45 to 50 years 13 Total 981 Sex.— Males, as seen from the foregoing table, are far more likely to develop the disease than are females, a clinical fact that is probably explained, in part, at least, by the exposure to which males are subjected in the vari- ous trades. The disease appears to attack most frequently those who have previously enjoyed good health. " Age. — An analysis of 593 cases gave 229, or 39.3 per cent., of them from the fifteenth to the twenty-fifth years; while there were 86 cases, or 14.8 per cent., between twenty-five and thirty-five years. After the fiftieth year only 14 cases occurred" (Anders). Acute Tetanus. — Clinical Picture. — The patient usually experiences mild prodromal symptoms, such as languor, headache, mental hebetude, and anorexia. The characteristic symptoms develop somewhat insidiously, the patient's first complaint being of stiffness of the muscles of mastication and of those at the back of the neck. Tonic spasms soon follow, the muscles of the face become spastic, and there is locking of the jaws. Spasm. — Severe convulsive seizures are often excited by slight movement of the patient, by sounds, or by currents of air; the attacks are accompanied by excruciating pain. Rigidity of the cervical muscles becomes marked, and the patient is unable to bring the chin forward upon the chest; retraction of the head soon follows. The fades is characteristic, the forehead being wrinkled and the comers of the mouth drawn down, giving to the face the expression of a peculiar sardonic smile. Further examination shows that the reflexes are increased. The skin is beaded with perspiration. The pulse is increased in frequency even in mild cases, and in the more severe types it varies from 140 to 160 beats a minute; it is small, irregular, dicrotic, later becoming compressible. The muscles of the body are next attacked, in the following order: First, those of the trunk and spine are affected, causing the body to assume a bowed or arched attitude (opisthotonos), and there may be lateral arching (pleurothotonos) ; the abdominal muscles are next affected, becoming unduly rigid, and their spasmodic contraction may incline the body forward (em- prosthotonos). Later the legs become involved, the arms, however, being in most cases capable of some movement. The patient complains of thoracic oppression and agonizing pain at the base of the chest. Thermic Features. — Moderate fever is present, as a rule, although in selected cases the temperature may suddenly rise to 105° or even 110° F. In other instances fever may be absent throughout the attack. Laboratory Diagnosis. — Constipation continues throughout the attack. The urine is usually voided with each spasmodic seizure. Scrapings from 912 ACUTE INFECTIOUS DISEASES. the initial wound may show the presence of the bacillus tetani. Moderate leukocytosis — 12,000 to 14,000 — has been observed. Chronic Tetanus. — Clinical Picture. — Here practically all the symptoms previously outlined under the acute form of the disease are pres- ent, but they develop less rapidly. The painful spasms may disappear, making the administration of hquid food possible. A feature that is charac- teristic of the chronic form of the disease is that the patient experiences partial freedom from painful seizures, the intervals becoming longer and longer as convalescence proceeds. Relapses are prone to occur. Cephalic Tetanus. — Clinical Picture. — Rose described this type of tetanus, which follows injuries to the face. Among the most characteristic features are spasms of the masseter muscles and the pharyngeal muscles, causing dysphagia and rarely contraction of the muscles of the neck and abdomen. Paralysis of the facial nerve may take place. Approximately 25 per cent, of all cases of cephalic tetanus go on to recovery. Summary and Differential Diagnosis. — Given the history of a punctured wound or of an abrasion of the skin, the diagnosis is based upon the following clinical features: The presence of rigidity of the muscles of the jaw and of the neck, with retraction of the head, spasm of the muscles of the trunk, and later of the lower extremities and of the arms. The detection of the specific microorganism in scrapings from the wound makes the diag- nosis positive, even in those cases in which the symptoms are atypical. Tetany diJEfers from tetanus first by its clinical history, and second by the fact that the extremities (hands) and larynx are involved intermittently. Tetany is a disease of the young, and the attitude of the patient is unlike that seen in tetanus. Hydrophobia. — Here there is a history of being bitten by an animal in practically all cases, and the spasmodic seizures are limited more especially to the respiratory system. In hydrophobia the jaws are free and opisthot- onos is practically unknown. Strychnin Poisoning. — The distinctive features between strychnin pois- oning and tetanus are set forth in the accompanying table taken from Anders: Tetanus. Strychnin Poisoning. 1. The receipt of a wound, generally fol- 1. Ingestion of strychnin, immediately lowed by a period of incubation. followed by the symptoms. 2. Begins with lock-jaw; later spreads 2. Begins with gastric disturbance or a downward, the arms and hands es- tetanic contraction of the extremities, caping. Hyperesthesia of the retina occurs and objects appear green. 3. Reflex spasms not present at the onset. 3. Violent convulsions present from the onset. 4. Rigidity is persistent, except in the 4. Intervals of complete relaxation occur. chronic form. 5. The course is prolonged into days or S. The course is brief, terminating in weeks. death or recovery. 6. Cultures made from the discharges of 6. Examination of the gastric contents the wound show the presence of the shows the presence of strychnin, bacillus tetani. Clinical Course. — In cases in which the symptoms develop within one or two weeks following an injury the disease usually runs a rapid course, terminating fatally in a few days. In the chronic type the disease may be- come much protracted. Tetanus neonatorum is probably the most fatal form of the disease, and pursues a rapid clinical course. Of 870 cases an- alyzed by Anders and Morgan, 338 terminated fatally before the fifth day; GLANDERS. 913 275 died between the fifth and the tenth day, and 211 cases lived for more than fifteen days. GLANDERS (Farcy). Pathologic Definition. — An acute infectious disease caused by the presence of the Bacillus mallei. It is characterized by the development of granulomata. These growths are nodular, and when situated upon the nasal mucous membrane, become soft and eventually ulcerate. On the other hand, when they are situated on the skin, multiple abscesses result. Microscopically, sections from the new-growth are seen to contain numerous bacilli. Clinical Varieties. — (1) Acute glanders. (2) Chronic Glanders. — This is a mild and unusual form of the disease. The symptoms are vague, nasal catarrh being the most significant indication. (3) Acute farcy is a form of cutaneous glanders in which the nasal manifestations may be mild or absent. In this type of the disease the local symptoms at the seat of the primary lesion may be acute, and numerous cutaneous abscesses which are distributed along the lines of the lymphatics develop later. The constitutional symptoms of pyemia are manifested early. (4) Chronic Farcy. — This form of the disease is characterized by the formation of granulomatous tumors of the skin and subcutaneous tissue, which eventually result in abscesses. The lesions are most commonly seen in the neighborhood of the large joints. In chronic farcy the abscesses usually discharge their contents externally, leaving behind an offensive iilcer. Owing to suppuration, the temperature takes a hectic curve. Bxciting and Predisposing Factors. — Bacteriology. — The dis- ease is due to infection with the bacillus mallei, an organism that is readily cultivated, and is found present in sections of the granulomatous mass, and in the purulent discharge from the nasal mucous membrane, as well as from abscesses and ulcers. Sex. — This disease is usually transmitted directly from domestic animals to man, being generally contracted from horses; hence males are most often affected. Modes of Infection. — The medium of conveyance from the equine family to man is usually through the purulent nasal secretion, which is expelled from the animal's nostrils and alights upon open wounds, upon abrasions of the skin, or upon the mucous surface. Incubation Period. — This varies, lasting usually from three to five days. Immunity. — ^Man possesses an almost complete natural immunity to this disease, and Singer asserts that he has produced immunity by making intravenous injections of sterilized cultures of the bacillus mallei. Acute Glanders. — Clinical Picture. — The first evidence of the disease is the presence of inflammation at and surrounding the point of infection. Lymphangitis follows within the course of a few days, and all the adjacent lymph-nodes become involved. Later a distinct eruption involving the face and trunk is seen, the extremities, particularly in the region of the joints, becoming finally affected. The papules rapidly become converted into pustules, discharging a seropurulent fluid that contains the specific organism of the disease. Following the accumulation of pus in the lesions extensive swelling of the nose and of other portions of the body occurs. In practically all cases the conjunctivae are attacked, and lesions may extend to the mucous surfaces of the mouth and pharynx, and, rarely, the respiratory 58 914 ACUTE INFECTIOUS DISEASES. and gastro-intestinal tracts may become involved. Necrosis of the bones is occasionally seen. Summary of Diagnosis.— The diagnosis of glanders is made with difficulty unless a clear history of exposure to an infected animal is obtained. In doubtful cases the pus from the lesions should be injected into the peri- toneal cavity of a male guinea-pig. The early development of edema and the formation of pus within the tunica vaginalis testis of the animal will give an opportunity for the cultivation of the bacillus mallei. The detection of the specific organism in the exudate recovered from the pustules and nasal mucous membrane confirms the diagnosis. ANTHRAX (Malignant Pustule, Splenic Fever, 'Wool-sorter's Disease, etc.) Pathologic Definition. — An acute infectious disease due to the presence of the bacillus anthracis, and characterized by the formation of a rapidly extending pustule, by a bacteriemia, or by lesions of the gastro- intestinal tract or the lungs. The bacillus or its spores may be readily demonstrated in the lesions. The local manifestations of the disease are inflammation, ulceration, gangrene, and edematous infiltration, together with degenerative changes in the heart muscle and in the kidneys. Hemor- rhagic and gangrenous infiltration of the intestinal tract and of the retro- peritoneal lymph-nodes may also be present. Enlargement of the spleen may be a conspicuous symptom. Clinical Varieties. — External anthrax (malignant pustule); in- ternal anthrax (intestinal mycosis). iBxciting and Predisposing Factors. — Bacteriology. — The ex- citing cause of the disease is the bacillus anthracis. Incubation Period. — This lasts, as a rule, between one and three days. Immunity. — Pasteur has prepared an attenuated virus that has been used extensively in localities in which anthrax is common, and good results are said to have followed its use. Other investigators have obtained less satisfactory results, the majority agreeing that temporary immunity can be effected by its use. Modes of Infection. — It is highly probable that the bacUlus gains en- trance into the human body through slight wounds, abrasions, and scratches of the cutaneous surface. The intestinal form of the disease probably follows the ingestion of food containing the specific organism. Primary lesions of the lung occur, but they are rare, and the channel through which the exciting bacterium gains extrance to the pulmonary tissue remains in question. It is asserted that the bite of certain insects, particularly the fly and the mosquito, may convey the disease to man. Occupation is a prominent predisposing factor, the disease being more prevalent among those brought in direct contact with infected animals or with their hides or wool. It follows, therefore, that those employed in woolen mills and those engaged in handling cattle and sheep are especially prone to contract the disease. Persons engaged in the manufacture of mattresses, rugs, and hair goods are also frequent sufferers from the disease. Sex. — The disease is more commonly seen in males. Malignant Pustule. — Clinical Picture. — Three days after infection has taken place an appreciable reddening is seen at the wound of entrance, and at this site a papule forms, rapidly developing into a vesicle containing bloody fluid. During the papular and vesicular stages the patient may ANTHRAX. 915 complain of intense burning in the region of the lesion. The vesicle soon ruptures, leaving behind a blackish scab, surrounded by a brawny area of edematous induration. Radiating from the initial lesion red Hnes, corre- sponding to the lymphatic vessels, are to be seen, and within the course of from twenty-four to thirty-six hours vesicles form at variable distances from the initial lesion. During the second day of the disease the patient may display constitutional symptoms, such as high fever, extreme prostration, nausea, vomiting, profuse sweats, appreciable enlargement of the spleen, and, in severe cases, delirium, followed by coma and death. Internal Anthrax. — Clinical Picture. — For convenience of descrip- tion and clinical study this type of the disease is divided into two sub-classes : (a) Wool-sorter's Disease. — This is marked by sudden onset with a severe chill, followed by a rapid rise in temperature, which may reach 103° F. or even higher. Prostration is apparent early, and there are severe pains in the back and in the muscles of the legs, and intense headache. As the disease progresses the heart becomes rapid, the pulse weak and irregular, and severe gastro-intestinal symptoms, e. g., nausea, vomiting, and diarrhea, are apt to occur. Nervous symptoms may also be prominent, de- lirium being followed by coma. (b) Intestinal Form {Intestinal Mycosis). — In this variety the disease de- velops abruptly with a chill, followed by well-marked constitutional symptoms and by pain in the head, back, and legs. Nausea and vomiting develop early, and are usually followed by intestinal cramp and diarrhea. Hemor- rhages from the mucous surfaces, bowel, stomach, and pharynx may occur, and petechial hemorrhage is also occasionally observed. Muscular spasms are not infrequent, and in all cases extreme restlessness in a conspicuous feature. Moderate fever is, as a rule, present. I Fiedler's Diseases Weil's Disease, Epidemic Catarrhal Jaundice). Pathologic Definition. — An acute infectious disease, character- ized by jaundice, wasting, moderate enlargement and cloudy swelling of the liver and spleen, the former occasionally showing small foci of fatty 938 PBOBABLE INFECTIOUS DISEASES. degeneration. The kidneys are also the seat of a diffuse tubular nephritis, and hemorrhages into the serous sacs and the spleen have been observed. Infectious jaundice comprises a group of conditions intermediate between catarrhal jaundice and grave destructive jaundice (acute yellow atrophy), all grades of transition toward these extremes being observed. Remarks. — ^There are several more or less distinct types of acute in- fectious jaundice, all of which are characterized by sudden onset with fever, gastro-intestinal symptoms, and jaundice. Some of the cases exhibit en- largement and tenderness of the liver and spleen, as well as the clinical mani- festations of nephritis. Nervous symptoms are prominent in some epidemics, whereas in others in which the disease is of milder type, the nervous features are not pronounced. As early as 1866 French observers described both isolated cases and epidemics, but it was not until 1886 that WeU gave a de- tailed report of epidemic jaundice. "Many English and French authors, however, demur to the designation of Weil's disease as separate from other types of benign infectious jaundice" (Osier). Bxciting and Predisposing Factors. — The exciting cause of epidemic jaundice remains in doubt, in spite of many laboratory attempts to isolate a specific microorganism. Anders believes that the condition may be an acute febrile jaundice of varied etiology. Infectious jaundice occurs most often in those between twenty and forty years of age. Butchers have been found to suffer from the disease more often than those engaged in other occupations, and, judging from the recorded cases, men are more often at- tacked than women. Season is believed to exert a sHght influence, the majority of cases developing during the summer months. General Complaint and Characteristic Signs. — ^The onset is usually sudden, and may be fulminating, although such prodromal symp- toms as lassitude, headache, and anorexia are occasionally encountered. The disease is generally ushered in with a chill, followed by fever, which rises quickly to 103° or 104° F., and is of the remittent type, continuing from ten to fourteen days, and terminating by lysis. Headache, vertigo, nausea, vomiting, and at times diarrhea are present. Jaundice usually appears in from the second to the fourth day, and may be slight or intense. If the disease is due to obstruction, the stools may be clay-colored, showing the absence of bUe. The liver and spleen are often enlarged, and the latter may be tender on pressure. In grave cases cerebral symptoms, such as delirium, convulsions, and coma, may rarely occur. Herpes, diffuse or macular ery- thema, and urticaria are occasionally seen. In certain cases hemorrhages may occur — e. g., epistaxis, hemoptysis, petechial eruptions, and bleeding into the serous cavities and from the in- testine. I^aboratory Diagnosis. — ^The urine is high-colored, bile-stained, and shows the presence of albumin, casts, and sometimes of blood. Diagnosis. — ^This is based on the acute onset, fever, pains in the mus- cles, joints, and epigastrium, nephritis, icterus, a tendency toward hemor- rhages, and the frequent occurrence of relapses. Clinical Course. — ^The prognosis, both as to life and recovery, is good. W. E. Hughes, notwithstanding, records two cases that proved fatal within forty-eight hours of the onset. In cases of average severity the temperature shows a tendency to decline in from the fourth to the ninth days, and reaches the normal about five days later. Muscle pains, however, disappear slowly, and may be present even when convalescence is apparently well established. The nervous symptoms, AXJTUMNAL CATARRH. 939 the enlargement of the liver and spleen, and the evidences of nephritis gradually subside. There is usually a marked loss in weight, and convales- cence is somewhat protracted. Relapses occur in approximately 40 per cent, of all cases, and are prone to appear in from three to eight days after the temperature has reached the normal. The period of each relapse is ordin- arily shorter than that of the initial attack. AUTUMNAL CATARRH (Hay-fever, Hay Asthma). Pathologic Definition. — A disease of doubtful origin, in which many predisposing factors are concerned, and which is characterized patho- logically by congestion of the nasal mucosa, with overactivity of the glands. Congestion may extend from the nasal mucous membrane to the conjunc- tivae, the pharynx, and the larynx, and in some instances to the bronchi. The inflammatory process frequently extends along the Eustachian tube, and hyperemia of the middle ear may follow. Predisposing and Bxciting Factors. — Age and Sex. — Age is a prominent predisposing factor, since practically one-third of all cases develop before the twentieth year. Males are affected more often than females. Nasal polypi, spurs, defective septa, and other abnormalities of the nasal mucous surface may serve as predisposing factors in some cases. Reflex irritation is also known to figure in the production of this disease, and heredity is a potent factor. Season acts as the most important predisposing factor, since in the United States the majority of cases are seen during the months of August and September and in the early part of October. A limited number of cases are also encountered during the months of May and June — the so- called "rose fever." Exposure to the pollen of certain plants may excite the disease in those who have previously been free from it. But dust of any kind will bring on a paroxysm. Attacks of sneezing are more likely to develop during the middle of the day and when the sun is hot, than during the early morning and evening hours. The application of local treatment to the nasal mucous membrane is, in many instances, sufficient to precipitate an attack of hay-fever, and such an attack may continue for weeks. Walking against a strong wind and riding upon both steam and electric cars intensify the symptoms in those suffering from the disease, and are often sufficient to precipitate an attack in persons previously healthy. There are certain cases in which the patient suffers more or less from hay-fever during the entire year, but the vast majority of all cases are free from the disease from the first appearance of frost (October or November) until May or June of the following year. The patient frequently states that he is positive there has been a frost in the immediate vicinity, although he has not been out of the house, and may have no other evidence except that his breathing is improved. Change of location of patients who are already suffering from an at- tack may, in certain instances, intensify the symptoms, whereas in others they may become ameliorated. Patients seldom suffer from the disease when on the high seas, whereas the symptoms usually develop promptly when such individuals reach the land; the disease is extremely uncommon at an elevation of from 4000 to 6000 feet. Odors. — The odor of certain plants, ammonia, and other gases may not 940 PROBABLE INFECTIOUS DISEASES. only predispose to, but appears to excite, an attack, and hay-fever may also follow great excitement and the inhalation of inorganic and organic dusts. Prodromal Symptoms. — These are common to the majority of all patients, and in tjrpical cases consist of the following: For several days prior to the initial attack of paroxysmal sneezing a variable degree of constipation occurs, which may be obstinate in some cases; undue itching of the skin, and particularly of the scalp, may also be present, and at the same time there is likely to be itching of the eyelids and of the nose; vague pains and soreness of the muscles upon movement are by no means unusual, although these are of a mild nature. Upon rising after a night's rest certain of the joints feel stiff, a condition that more commonly involves the ankles and feet. The mental condition is somewhat sluggish, and victims of the disease find it impossible to concentrate their mental faculties both immediately before and during an attack of hay-fever. Drowsiness is often present during the day, and in severe cases the patient may sleep for hours during the afternoon, and still secure restful sleep at night. Varieties. — (1) At times pathologic lesions of the upper air-passages are to be found, such as a deflected nasal septum, disease of the turbinated bones, disease of the sinuses that communicate with the nasal fossae, and the like. (2) A somewhat larger class includes those cases in which no disease of the respiratory tract is detectable, and stiU, for some unknown reason, these patients develop typical attacks of hay-fever during the autumn months, and some have two or more attacks (one in May or June — rose fever) during each year. (3) There is a special class of sufferers from this disease in whom there is a hypersensitiveness of the nasal mucous membrane for certain odors or for dust. Such patients may develop an attack of hay-fever whenever they are exposed to the particular excitant for which they possess an idiosyncrasy. Principal Complaint. — A history of previous attacks is usually obtainable in all but that small proportion of cases in which the patient con- sults his physician during the primary attack. Most patients assert that they have had similar mild attacks at intervals during the past few years, but that they always regarded such attacks as acute " colds." These early mild attacks of hay-fever may last for but from twenty-four to forty-eight hours, during which time the patient sneezes frequently and suffers from in- creased lacrimation and a copious discharge from the nose. The symptoms of hay-fever may be divided into two great clinical classes: (1) Local; (2) general. (1) Local Sjonptoms. — Following the prodromal stage, the onset of the disease is abrupt, and the attacks tend to return annually at approximately the same day; the invasion is ushered in by a paroxysmal attack of sneezing, which is accompanied by the other symptoms of severe coryza, such as temporary obstruction of the nasal passages and profuse rhinorrhea, the dis- charge being thin and of the consistence of water, although in some cases the nasal secretion may be mucopurulent. The conjunctivse are greatly con- gested, and the patient experiences intense itching of the eyelids, con- junctivae, and tip of the nose. In typical cases of hay-fever the patient will be seen to be continually rubbing the tip of the nose; this he does uncon- sciously, while at the same time he may irritate his scalp by scratching; with the onset of the disease there is more or less itching over the entire body. As the disease progresses paroxysmal attacks of sneezing and coryza be- come more and more frequent, and occur at intervals of from a few hours to a few minutes. In severe cases, during a paroxysm the patient will continue AUTUMNAL CATARRH. 941 to sneeze every few seconds for from two minutes to one-half hour, and after he has sneezed from ten to forty times, his body becomes immedi- ately covered with beads of perspiration, and, indeed, this sweating may be so profuse as to saturate his linen. The more profuse the perspiration at these paroxysms, the more profound is the prostration following each of them. In nearly every case of hay-fever a peculiar scaly exudate develops upon the scalp during the attack. In many patients, however, the scalp remains imusually clean. Paroxysm.^— As a precursor of each paroxysm, both nostrils appear to be more or less completely closed as the result of edema or of swelling of the nasal mucosa. Following this difficulty in breathing the following symptoms occur: (a) The patient experiences a peculiar tingling sensation of the palate and the tip of the nose, and within the course of a few seconds this sensation is communicated to the nasal cavity, and especially to the region of the tur- binated bones. (6) The patient sneezes violently several times, following which there are profuse discharges from the conjunctivae and the nose. Attacks are com- monly provoked by irritation of- the nose or by rubbing of the eyes. Cleans- ing of the nose serves as one of the commonest causes for a precipitation of these attacks, and we have found that in the majority of cases local treat- ment renders the attacks more frequent except in those instances in which cocain or adrenalin chlorid is employed, and even here violent paroxysms commonly occur between the treatments. Withdut apparent cause the local symptoms become appreciably ameHo- rated for periods of one or more days, but following such amelioration there is likely to be a temporary exacerbation in both the local and the general symptoms. Exacerbations are frequently attributed to exposure to the air, to the inhalation of dust, and to climatic changes, paroxysms being more common during those hours of the day when the sun is brightest, and ap- preciably more frequent when there is a strong breeze. In other words, the pleasanter the day, the more does the victim of hay-fever suffer. (2) General Symptoms, — ^These are, as a rule, mild, and consist of chilly sensations, alternating with slight flushings of the face and a sense of feverishness; there are also lassitude and a moderate degree of anorexia; insomnia may be present, and results directly from interference with respira- tion during sleep. Late during the course of the disease the catarrhal process may invade the larynx, and even the bronchi, as previously stated (see Pathologic Definition, p. 939), and in consequence of congestion of the mucous surface of these organs, the patient is annoyed by cough, and attacks of asthma (see Bronchial Asthma, p. 96) may be experienced. I/aboratory Diagnosis. — During the prodromal stage, in special cases, the quantity of urine voided during the twenty-four hours is appre- ciably diminished, but at or near the time of the initial paroxysm the patient may void an unusually large quantity of pale urine of low specific gravity. Throughout the course of hay-fever the quantity of urine voided during the twenty-four hours bears a more or less close relation to the severity of the paroxysmal attacks and the degree of sweating. The nasal secretion contains a few epithelial cells, leukocytes, some bac- teria, and occasionally red blood-ceUs. Summary of Diagnosis. — ^This depends upon the following: (a) A history of previous attacks of either autumnal or rose fever, (b) The 942 PROBABLE INFECTIOUS DISEASES. characteristic paroxysms, accompanied by profuse sweating and prostra- tion, (c) Congestion and itching of the conjunctivae and nasal mucosa. (d) Cutaneous itching, particularly of the scalp; (e) chilliness and feverish sensations, together with the characteristic sensation at the palate and nose. Clinical Course. — In typical cases of autumnal catarrh this lasts for from four to six or even eight weeks, but those who develop an attack during the spring months (rose fever) are seldom aimoyed for more than two weeks. In certain years sufferers from attacks of autiimnal catarrh ex- perience immediate relief after the first frost, but occasionally such rehef is felt through portions of the country in which frost has not yet been seen. Many cases end abruptly as soon as the patient is at sea. Change of chmate may also be followed by an almost immediate disappearance of the annoying symptoms. A change of location from the city or country to a mountainous section containing dense forests is commonly followed by relief. A sea- voyage may give similar relief. Not infrequently a patient going from Amer- ica to Europe will not suffer from the disease while in Europe, even though he reside in a climate in which hay-fever is common. HEHORRHAGIC DISEASES OF THE NEW-BORN. EPIDEMIC HEMOGLOBINURIA (WiNCKEL's Disease). Pathologic Definition. — An affection, probably septic in nature, occasionally seen in lying-in hospitals, and occurring in infants in from one to ten days after birth. General Features. — The infants refuse the breast and exhibit hematogenous jaundice. Gastro-enteric catarrh is present, and hemorrhages occur into the viscera and into the mucous membranes. MUd fever, rapid emaciation, and convulsive seizures are present. I/aboratory Diagnosis. — The stools contain meconium; the urine is scanty, dark colored (from methemoglobin), often albuminous, and may contain casts. Kilham and Mercelis, of New York, isolated a diplococcus from 10 cases, but, in all probability, this organism is not the true cause of the disease. ACUTE FATTY DEGENERATION OF THE NEW-BORN (BuHL's Disease). General Remarks. — This disease is probably similar to Winckel's in nature. It was first described by Hecker and Buhl as an infectious disease of the new-born. Clinical Characteristics. — There are cyanosis, jaundice, and profuse visceral hemorrhages. The chief pathologic change is an acute fatty degeneration of the viscera. MORBUS MACULOSUS NEONATORUM. General Remarks. — In this affection there is hemorrhage from the gastro-intestinal mucosa of the new-bom (melaena neonatorum), due prob- ably to intracranial lesions the result of pressure received during birth, al- though the condition may take place independently of the latter. Preuschen SUNSTROKE. 943 collected the reports of 37 cases, in 5 of which the brain was examinedj and in all of these cerebral hemorrhage was found. Townsend found 459 cases among the records of 6700 births. Gartner believes the disease to be of in- fectious origin, and asserts that in two cases he was able to identify a bacillus. Hemorrhage may also take place from the mouth, nose, umbilicus, etc. General rather than local bleeding is the rule. Clinical Course. — Hemorrhage is usually marked during the first week of life, and continues for from a day to a week, at the end of which time practically 50- per cent, of cases enter upon a stage of convalescence and go on to recovery. HISTOPLASHOSIS. Remarks. — A fatal disease somewhat resembling kala-azar, due ap- parently to an organism similar to Leishmania donovani, which has been ob- served in persons in the canal zone, Panama. Among the characteristic features are splenomegaly, irregular remittent fever, leukopenia, and emaciation. Glandular enlargement, tenderness over the spleen and liver, and absence of the patellar reflexes were also observed. Thus far only three cases have been reported.* The parasite recovered from the splenic tissue resembles in some respects the Leishman-Donovan body, but is regarded by Darling and others as being distinguishable from the last- named parasite. Darling suggests for it the name histoplasma capsulatum. I/aboratory Diagnosis. — According to Darling's observations, oval and round bodies were found free in the blood-plasma at autopsy, and were also present in smears made from the marrow of the ribs and from the spleen. SUNSTROKE. Pathologic Definition. — Following undue exposure to heat, the blood is fluid, dark in color, and there is degeneration of the red cells and an absence of Rouleaux formation. Parenchymatous degeneration of the kidneys and liver and of the whole neural axis may be present. The cere- brospinal fluid is albuminous, occasionally blood-stained and under in- creased tension. Predisposing and Exciting Factors. — Practically, anything that lessens bodily resistance to external high heat predisposes to heat-stroke. Thus, privation, unsanitary surroundings, fatigue of body or mind, emotional excitement, worry, overeating, indulgence in alcohohcs, and previous at- tacks of sunstroke are conducive to heat-stroke on exposure to high tem- perature. Heat-stroke and thermic fever are terms more appropriately applied to those similarly affected in midsummer while working in places not exposed to the sun, but yet close, confined, and excessively hot. Heat-exhaustion (prostratio thermica) is caused under similar conditions as the preceding, but manifests dissimilar effects. The majority of the cases of sunstroke occur between 2 and 5 p. M., although heat-stroke and heat-exhaustion may occur at night as late as 10 or 11 p. m. Clinical Varieties.— Two forms of heat- or sunstroke are com- mon: (1) The asphyxial or apoplectic form; (2) the hyperpyrexial form. The majority of the cases of sunstroke are possibly combinations of apoplexy and exhaustion. "Valin puts all cases of insolation into two classes: the first, * Samuel T. Darling, M. D., Archives of Internal Medicine, September, 1908. 944 SUNSTROKE. sthenic or asphyxial, corresponding to our hyperpyrexia! or congestive variety; the second, asthenic or syncopal, corresponding to our heat- exhaustion. Mixed forms may occur quite frequently, the most prominent symptoms being referable to the organs suffering the most, as the cerebro- spinal system, heart, lungs" (Anders). . General Complaint.— There may be sudden premonitions or dizzi- ness, chromatopsia, throbbing headache, cessation of sweating, or dyspnea. The patient while working in the sun may suddenly fall unconscious, con- vulsions may occur, and in this state he may die from cardiac failure. More often unconsciousness is not so profound, but there is much restless- 107 106° 105° 104° 103° 102° 101° 100° 96° 98° 97" 96° 9j° 94° DATE 2l q1 - r- 1 — — TTT ■-f'- 1 — P - ^- — — — — _l_. — — — — — _ — — — — — — _^„ 1 . -r ■QJ — — 4 — p- — - p- - - — — - 1— - — - - - - 1— — - - - - - - -^ ' ? r S: — — — \iS (X — — — — s ■J. - — — 3^ T. r Ti X T_ ~ :r TI T. T. ~ ^ = = = ; Jl ± 21 ^ ~ ~ ~ 1 -~ — — ~ U- "< .-_ — — — o il ::: X ir "- ^ X = ;: = = ^ X - 7rl "'-- 3- - — - - -^ — — 1— — — — — -. - t- T — — — — — — — — - — — — — — — - - - — — — -i — — - - -?^ — -^ — — — — — i — O — — — — -1 — — — -H — .5 — — - — — - - - — — — — — — - - V < o it' . 0| 4 ri= ; R E ^- 2, \. -. .L'^ < < 9. r^ 1 ■?. s o _ _ _ _, _ o / _ _ _ \ c^ m J- —i _ _. -r '^ .; h ;: o o A .o — — — — — — 1 — ;j- 7 — — — — — ^J -* — — — — — -\^ n - - < k X ■c' cJJ - 2 z V" 1 \ \ S '\ ' ■■ Sk < ;; -)l-- *ir — ^ I ■-- - \ "7 c / i - ^ ^ / a, f \ V L 2 ^ . / V 1 10 u 1 AUGUST Fig. 334. — Ch.A-RT of a Case of Sunstroke. fC. B., aged twenty-nine years. Recove^>^> (J. M. .Anders.) ness, and epigastric "cramp" may be present. Also a sense of thoracic oppression, and occasionally there are nausea and vomiting. There are often prodromes as cramp-like pains on the abdomen, blur- ring of vision, mental hebetude, anorexia, intense headache, irritability of the bladder, general nervousness, and progressive weakness. Thermic Features. — These fluctuate within wide limits, for example, the temperature may be subnormal in certain cases, while in others it may reach 101° to 102° F. Again, the mouth or rectal temperature may be found to register 104° to 106° F. In the hyperpyrexia! variety high tem- perature is practically always observed, and may fluctuate between 106° SUNSTROKE. 945 to 112° r., and there are on record many instances where a much higher temperature has been observed. (See Fig. 334.) Physical Signs. — General. — In ordinarily severe types of heat-ex- haustion the face is flushed, the vessels of the neck are seen to pulsate, res- pirations are labored, and the skin is hot, dry, and may display minute hemorrhages. At times the skin is clammy, and there is also present ex- treme cyanosis. In the more severe type the general appearance of the patient is that seen in profound exhaustion and in coma. The patient may be restless, and occasionally delirious. The movements of the chest are increased in frequency, varying between 25 and 50 per minute. I/Ocal Examination. — ^laspection. — The tongue is usually coated with a heavy whitish fur. The eyes are suffused, the pupils pin-point, and there may be a rather fixed stare. In the nervous types there is picking at the bed-clothes. Palpation. — The skin is at first hot and dry, or may later be cold and clammy. The pulse may vary between 90 and 160 beats per minute. Its force, frequency, and general characteristics correspond more or less closely to the degree of temperature, becoming weak, dicrotic, and irregular in severe cases. I/aboratory Diagnosis.— The blood is decidedly fluid and shows no tendency to Rouleaux formation; and in cases displaying cyanosis it is dark in color. In mild cases there is a tendency to frequent urination, with the passing of the urine of normal color. In the more severe forms of heat- exhaustion the urine is scanty and albuminous. The cerebrospinal fluid is found upon aspiration of the spinal canal to be under imusually high pressure. The spinal fluid is often blood tinged or slightly turbid, and contains an abnormal number of cellular elements. 60 ANIMAL PARASITIC DISEASES. Man is subject to diseases that are caused by animal parasites that belong to the following subclasses: Protozoa, Vermes, and Arthropoda. Among the parasites belonging to the class Protozoa we find members of the orders Rhizopoda, Sporozoa, Flagellata, and Ciliata. Among the parasites belong- ing to the class Vermes we find members of the orders Nematoda, Cestoda, and Trematoda. Of the parasites belonging to the class Arthropoda we find members of the orders Diptera, Hemiptera, and Acarina. Some of these parasites five on the surface of the body, and are therefore called ectopara- sites; others develop within the tissues, and are therefore called endo- parasites. In order to follow the zoologic classification the diseases produced by these parasites should be considered in order from lowest to highest posi- tion of the causative factor in the zoologic scale. There are certain con- siderations that make such a method of discussion inadvisable, and for this reason the diseases produced by animal parasites are considered in order of their frequency and importance in human pathology. PROTOZOAN DISEASE. MALARIA. Pathologic Definition. — An acute infectious disease caused by a member of the genus Plasmodium, transmitted to man by the bites of in- fected mosquitos, and characterized by destruction of the red blood-cells and the deposition of pigment in the organs, notably the spleen, the liver, and the bone-marrow. In some varieties of the infection the blood-vessels of the brain and of other organs may become plugged with sporulating para- sites. Remarks.^ — Clinically, the important features of the symptom-complex of malaria are the periodic occurrence of paroxysms of chill, fever, and sweat- ing, which are followed by prostration, headache, drowsiness, and sleep. The presence of one of the species of Plasmodium in the peripheral blood or in blood obtained by splenic puncture is requisite for the establishment of a diagnosis. Extreme prostration, emaciation, pallor, secondary anemia, ner- vous symptoms, hemoglobinuria, hematuria, hemorrhages from the mucous membranes, and purpura may supervene. Bxciting and Predisposing Factors. — (1) The exciting factor of malarial fever is a species of the Plasmodium that is transmitted to man by the bites of infected female mosquitos of the family Anophelinse. The pre- disposing factors to this infection are, therefore, conditions favorable to the development of the variety of mosquito known to convey the disease. A warm climate with a high degree of humidity and heavy rainfall, so that pools of stagnant or slowly flowing water are numerous, with thick vegetation, .946 MALARIA. 947 favor the propagation of mosquitos. It has been repeatedly shown that highly malarial districts may be rendered non-malarial by draining pools of stagnant water, and quickening the flow of streams by clearing and deepen- ing their channels. Race appears to exercise little influence, although in the United States the full-blooded Negro is shghtly less susceptible to malarial infection than other races. Sex exerts no influence when men and women are equally exposed, al- though males who follow certain outdoor occupations are especially prone to become infected. Children are likely to develop the disease when exposed. A natural immunity is occasionally observed, but persons who cannot be infected with malaria are rarely seen. Age. — Malaria may occur at any age, but young men are affected oftener than persons at the extremes of life. Incubation. — The period of incubation varies slightly in different types of the malarial infection, and at times there is a slight variation in the same type of parasite. Bignami and Bastianelli give the incubation period of benign tertian malaria as fifteen days; of estivo-autumnal tertian, as five days. Celli reports cases in which the period of incubation of the tertian para- site was twenty-two days, and of the estivo-autumnal parasite, seventeen days. Clinical Classification. — Clinically, four varieties of malaria are recognized: (1) Benign tertian malaria, characterized by the occurrence of a paroxysm every other day. (2) Quartan malaria, in which a parox- ysm occurs every third day. (3) Estivo-autumnal malaria, characterized by paroxysms that occur at irregular intervals. (4) Chronic malarial cachexia. Other classifications of malaria have been made, based on the type of the temperature-curve or other clinical manifestations, as intermittent fever, remittent fever, pernicious malaria, malarial cachexia, malarial hematuria, malarial hemoglobinuria, latent malaria, and recurrent malaria. Explanation. — The benign tertian parasite (plasmodmm vivax) re- quires forty-eight hours for its endogenous cycle of development; as a consequence, when there is a single infection or an infection with but one crop of this parasite, the malarial paroxysms recur every other day. If the patient is infected with two crops of this parasite, he will have a paroxysm every day — the so-called double tertian fever (quotidian malaria). This double tertian type of malarial fever is common in the northern portion of the United States. The quartan parasite (plasmodium malarim) requires seventy-two hours for its endogenous cycle of development, consequently when there is in- fection with but one crop of the quartan parasites, the paroxysms occur every third day. In cases of infection with two crops of this parasite, the paroxysms occur two days in succession, after which there is a day on which no paroxysm occurs. Should the patient be infected with three crops of the quartan parasite, he would have a paroxysm every day. The estivo-autumnal parasite (plasmodium falciparum) has a develop- mental period that appears to vary from twenty-four to forty-eight hours. On this account some writers declare that there are two forms of estivo- autumnal parasite — the plasmodium falciparum quotidianum, and the Plasmodium fa,lciparum tertianum (Craig). In case of infection with the former variety of parasite, the patient has a paroxysm every day; in in- fection with the latter variety, the paroxysm appears every other day. The paroxysms of estivo-autumnal infection are more severe and last longer than 948 ANIMAL PARASITIC DISEASES. those of benign tertian malaria, so that, particulariy in case of infection with Plasmodium falciparum quotidianum, one paroxysm is likely to extend into a second paroxysm, producing a continued type of fever. In malarial infection the fever may be one of three types: (1) The inter- mittent type; (2) the remittent type; (3) the continued type. The inter- mittent type of fever generally occurs in infection with the benign tertian parasite and with the quartan parasite. In some cases of infection with the estivo-autumnal parasite an intermittent fever is seen (pernicious intermit- tent), but the remittent and continued fevers are the types most commonly met. Intermittent Fever. In intermittent fever the patient experiences certain prodromal symptoms, among which are mental apathy, dull headache, pain or stiffness of the neck muscles, and an expression of imperfect oxidation of the blood, shown by frequent yawning. It must be remembered, however, that the paroxysm not infrequently develops abruptly. In intermittent fever there is a decided rigor, and the patient shivers incessantly and the teeth chatter. The chill may occur at any time, but is most likely to take place between midnight and midday. It usually lasts from one to two hours, but may continue for several hours. Physical Signs and Description of Paroxysm. — The Cold Stage. — Inspection. — The patient is seen to be resting under a blanket, or is well wrapped and sitting near the fire or in the sunlight. The skin is often pale, and cyanosis of the lips is not uncommon; later the face be- comes flushed. If the patient has suffered from malaria for several weeks, a decided yellowish-brown- tinging of the skin is apparent, said to be due to a deposition of blood-pigment in the cutaneous tissues. Jaundice may be present. Herpes involving the lips and nose is quite common during the course of intermittent fever, and such other cutaneous manifestations as purpura and urticaria have been observed. Palpation. — During the chill the skin is cold, the muscles of the arms and legs are tender and at times painful, and the pulse increases in fre- quency, becoming rapid, bounding, and of high tension. Before the chill has subsided the internal, and at times the external, temperature begins to rise. The Hot Stage. — The patient passes from the cold to the hot stage in quite rapid succession. Inspection. — The face is flushed, and the skin becomes hotter and hotter. The muscle soreness is now less decided than it was during the chill. The spleen is enlarged and slightly tender. Palpation. — The pulse remains rapid and full, although in cases of viru- lent infection it may become weak, rapid, and even irregular, due probably to acute dilatation of the heart following extreme toxemia. Percussion. — The splenic dullness will be found to increase slightly after each succeeding paroxysm. Palpation and percussion reveal the fact that the liver is moderately enlarged. Auscultation. — The respirations are at times hurried, and hemic murmurs are heard over the base of the heart. The temperature, which has begun to rise before the close of the first stage, continues to mount rapidly until it reaches 104° to 106° F. (See Fig. 335.) It may remain near the maximum point for one or more hours, or it may fall suddenly by crisis; in either case there may be two moderate remissions MALARIA. 949 before there is a decided lowering of the temperature, but it must be re- membered that, as a rule, there is a rapid decline at the close of the febrile stage which lasts from three to six hours. (See Fig. 335.) Sircating. — Profuse sweating is followed by an amehoration of all the symptoms of the hot stage. The temperature falls by crisis to the normal, as is shown in the accompanying chart (Fig. 335). After treatment has been instituted the temperature may fall to the normal and remain at or M E M E M E M E M E M £ M E M E M E M E M E M E M E M E M E M E M E ^ n E OOWKLS Jiaity Atn'l n%' ¥ — 1 ^- — -^ -S ^^l V r^ .^ \N - - ,$> *^ - - - - jk^ ■s*- t-i^'- ^ r^ "* - ■ ^ 5 iii ^ "V va cw ^ ^ H^ ^ ••y J-vo, <:v y. >^, SjV ^J^ <>; ^ * ^ o^ i ^ !^* ■^ a- ■-i ^ ■> ^ ■^ ■ >Mf /fl htri .' '^'^ ^ _ 7 -41" ^ 3 '•-,, '\ 5 i , , \ ' 2 ^ ' § inRO ^ \ ; \ > 1 ^ 1 i 3 1 5 ^ ' !} -40° jl In1 3 In \ . \A '-0 5 LH , <\ ,v C ^ I v; J < >j 1 5i t^ ^ « /" -5 -38' M 1 Ujl \ K ■1 "^ - -^ — - - \ - " ? ■, * » \, , \ 3 1 ^ . > ^ f t ^ •^"■S J -37" 5 .-• A ' l- ■ ^ A ^ /■ s, A / t — ^ / i/ > O-TO / v _2 97° -36° V ii — * q ^ Day qf Lis Pulse. U"hf % ^% %s % ^^/ H >% ^Hi ^V^ 'H. ""iy % '''^ % '^6Z' ''6Z Besp. y }^^'ii ^i. '^. % '^ ^^ 'h's ■.zc "y's % ''ir '.^/ "n ^"> 4 ^'k ^'/f 1-36° D.U. ,§ ^ •' ^^ 27 ■■ - ^/ - Fia. 335. — Temperature-curve in near that point. If the tre current ele^'ation (if tcmpe scribed. Follo^\'inp; these cur\'e is occasionally seen tc degrees and then remaining in this step-like defervescei normal. K Ca ye atn- ratu reel ) fal at ice SE O ara.) ent re, rrei 1 in thit onl F (J h ^\ It a ^ 1 V Do . I a. it e s 30 a UI 1. 1 If te in f( A ao tl V p- t id t le It li fc ?rs b( a io ke r ho ) ^e ss r a u AN n 0( nf 1 rs I SI Df m in a ^E^ IC itc t ne d( re ?.es Hi en- ^fin « ^fu ph ipe drc ite qu 1 ei ra 'P ir F. th 10 tl pi )e c er Ql in ^}^ ric 1 > s e en :i T id bo gcd wL a th , b re for 1 b lUSt ? fe > or ut ach y-one = re- de- ver- two ?ven the 950 ANIMAL PARASITIC DISEASES. I^aboratory Diag^uosis. — During the chill and even a few hours prior to the rise in temperature blood obtained from the peripheral circula- tion, when studied m the fresh state under a ^inch oil-immersion objective, shows the presence of liviag malarial parasites. The number of parasites present in the fresh blood varies greatly in different persons, but the morphologic characteristics of the parasite are constant. (See Plate XV.) When the disease has progressed for some time, the red blood-cells show marked evidences of degeneration, as, for example, imperfect distribution of hemoglobin, cracks and fissures, streaks, irregular areas of decoloration, and pdildlocytosis. The number of red cells in a cubic mil- limeter is reduced in direct proportion to the length of time the disease has existed and the severity of the type of infection. The hemoglobin also un- dergoes destruction. When iatermittent fever has continued for a long time pigment particles are seen in the blood-plasma. In uncomplicated cases of malaria leukopenia is a characteristic feature. The stained blood shows all the changes more clearly than the fresh films. The change in size and shape of the erythrocjrtes, the various degenerations of the erythrocyte, the morphologic characters and the stage of develop- ment of the parasite, the characters of the leukocytes, and the presence or absence of malarial pigment are much better appreciated in stained smears. A differential leukocyte count will show an increase in the percentage of the large mononuclears. The urine not infrequently contains traces of albumin, and in severe types of the infection one occasionally finds the evidences of acute nephritis — e. g., albumin, casts, red and white blood-cells. This condition may be regarded as a complication, and is said by Jones to occur quite commonly in the Amer- ican negro. Jaccoud asserts that the amount of urine excreted is increased for from three to six hours prior to the development of the chill. There are certain symptoms that point strongly to the existence of gastro-intestinal catarrh, but a clinical analysis of the stomach-contents does not disclose anything of special importance. Summary of Diagnosis.— Prodromata are of little value in making the diagnosis of malaria. The occurrence of exacerbations, consisting of a chill, a hot and a sweating stage, which occur periodically and are accompa- nied by prostration and blood destruction, with the occasional presence of herpes, point strongly to malarial infection. The diagnosis is confirmed by the finding of the Plasmodium in either the living or the stained peripheral blood. Diflferential Diagnosis. — Malaria is to be distinguished from certain other infectious maladies, among which infection with pyogenic organisms occupies a prominent place. In the presence of abscess, whether deep or superficial, there are likely to be periodic paroxysms of chill, fever, and sweating, which simulate those seen in malaria. The presence of a leukocytosis and the absence of the malarial parasite from the blood serve to distinguish such a suppurative process from malaria. Pulmonary Tuberculosis. — After the stage of cavity formation periodic exacerbations of fever commonly occur, which are followed by profuse sweats. Here the distinguishing features are: the history of pulmonary tuberculosis, with the presence of a cavity, leukocytosis, and the absence of the malarial parasite from the blood. An intermittent fever, accompanied by chill and nocturnal sweats, is occasionally observed in the earlier stages of pulmonary tuberculosis. A physical examination may make the MALARIA. 951 diagnosis clear, but if it does not, the blood should be examined micro- scopically. Hepatic colic not infrequently gives rise to a temperature that may be mistaken for that of malaria — the so-called Charcot's intermittent fever. Tenderness over the liver, with pain in the region of the gall-bladder radiat- ing to the right scapula, the presence of jaundice, and the findings of a blood examination will exclude malarial fever. Renal calculi may at times excite a temperature that resembles in many respects that of malaria, but the abdominal pain and the area of dis- tribution of the pain, with the passing of bloody urine, precludes the diag- nosis of malaria. Urethral fever frequently closely resembles malarial fever. Clinical Course. — In the ordinary type of intermittent malarial fever the prognosis is favorable, and in cases in which treatment is instituted early complete recovery ensues. If, however, the infection is permitted to exist for a long period before treatment is instituted, recovery is delayed, and the condition tends to assume a chronic form. ESTrVO -AUTUMNAL (MALARIAL) FeVER. Pathologic Definition. — Estivo-autumnal malarial fever is a type of malarial infection due to the presence of the Plasmodium falciparum in the blood. Two varieties of this organism may be present: Plasmodium falciparum tertianum, in which the cycle of development is forty-eight hours, and Plasmodium falciparum quotidianum, in which the cycle of development is twenty-four hours. Remarks. — Plasmodium falciparum produces the most severe types of malaria clinically. The paroxysms are of longer duration than are those produced by infection with Plasmodium vivax and Plasmodium malariae. The paroxysms are likely to anticipate one another, so that one has not ended before another seizure begins. The sporulation of the parasites takes place almost exclusively in the internal organs, the rosets often blocking the blood-vessels of the brain, the heart, the liver, the spleen, or the kidneys, producing the various types of pernicious fever, depending upon the organ involved. Varieties.- — Algid Form. — The algid form of estivo-autumnal mal- aria is characterized by the occurrence of purging, vomiting, intestinal pain, and collapse. The condition closely resembles dysentery or cholera. Jaun- dice and severe nervous symptoms are present. The fever may be inter- mittent, and reach a maximum of 106° or 107° F. (pernicious intermittent), or it may be remittent. This form is due to the sporulation of the parasites in the blood-vessels of the intestine. Comatose Form. — ^This variety is characterized by the sudden develop- ment of coma, with cyanosis, contracted pupils, stertorous breathing, rapidly failing pulse, and death. In some cases the coma appears gradually after the development of restlessness, delirium, or mental depression. This form of the disease is due to the sporulation of the parasites in the blood-vessels of the brain. Cardialgic Form. — In this type of estivo-autumnal malaria the para- sites sporulate in the heart muscle. There are precordial or epigastric pain, vomiting of blood, hiccough, dyspnea, weak, rapid pulse, collapse, and death. • A hemorrhagic form, a choleraic form, a dysenteric form, and a 952 ANIMAL PARASITIC DISEASES. pneumonic form have also been described. The most common variety of estivo-autumnal infection, however, is the so-called bilious remittent fever. Period of Incubation. — Celli gives the period of incubation of the estivo-autumnal parasite as five days. General Complaint. — Such prodromal symptoms as headache, epi- gastric oppression, uneasiness, and anorexia occur, and a distinct chill may or may not take place. Sweating Stage. — Following the remission in the temperature profuse sweating occurs, and during this stage the headache and epigastric symptoms disappear. Nervous S3rmptoms. — The patient may be extremely nervous, and delirium is occasionally seen. Thermic Features. — One or even two elevations in the temperature may occur during the twenty-four hours, and these resemble closely the fever of intermittent malaria, except that in estivo-autumnal fever the paroxysms are considerably longer, and may last from twelve to twenty hours. The temperature rises more gradually in estivo-autumnal fever than in the ordinary intermittent type of malaria, and the decline of the fever likewise requires a longer period; consequently the temperature may not reach the normal after one exacerbation until a second elevation has set in. The peculiarities of estivo-autumnal fever just described have caused it to be regarded as a form of continued malarial fever, in which case the periods of intermission become progressively shorter with the progress of the disease. The patient may give a history of but one initial chill, which was soon followed by fever, the temperature rising gradually to from 104° to 105° F. within twelve hours. Physical Signs. — Inspection. — During the attack the patient may become slightly cyanosed, and if the paroxysm is a severe one, there is a peculiar pallor of the cheeks that may be followed by a hectic flush. The tongue is parched and coated, the conjunctivae are congested, the skin is slightly jaundiced, and herpes labialis is commonly present. Palpation and percussion show the spleen to be moderately enlarged, and there is also slight increase in the area of liver dullness. I/aboratory Diagnosis. — Microscopic examination of the blood dis- closes the presence of the estivo-autumnal parasite. (See Plate XVI.) Early during the course of remittent malarial fever there is a moderate re- duction in the percentage of hemoglobin and in the number of red cells, but in neglected cases, and when repeated infections have occurred, the red'cells become fewer and the hemoglobin shows a decided reduction in percentage. Leukopenia is an important feature of uncomplicated remittent fever. In stained blood the red cells show the usual evidences of degeneration, the presence of the small ring forms of the parasites, and the characteristic crescentic gametocytes. There is an increase in the percentage of large mononuclear leukocytes. Urine.— During the course of remittent fever the urine is diminished in quantity, its specific gravity is higher, and albumin is present. In about 5 per cent, of the cases true nephritis develops, in which case the color be- comes high and casts are present. Mild types of remittent fever are seen in which the recurring paroxysms grow shorter day by day. DiflFerential Diagnosis.— The following tables show the distinctive features between remittent malarial fever and typhoid fever, and remittent malarial fever and puerperal sepsis. DESCRIPTION OF PLATES XV and XVI.i The drawings were made with the assistance of the camera lucida from specimens of fresh blood. A Winekel microscope, objective M (oil immersion), ocular 4, was used. Figures 4, 13, 23, 24, and 42 of Plate XV were drawn from fresh blood, without the camera lucida. PLATE XV. ^ The Parasite op Tertian Fever. 1.— Normal red corpuscle. 2, 3, 4.— Young hyaline forms. In 4, a corpuscle contains three distinct parasites. 5, 21.— Beginning of pigmentation. The parasite was observed to form a true ring by the con- fluence of two pseudopodia. During observation the body burst from the corpuscle, which became decolorized and disappeared from view. The parasite became, almost immediately, deformed and motionless, as shown in Fig. 21. 6, 7, 8.— Partly developed pigmented forms. 9.— Full-grown body. 10-14.— Segraenting bodies. . . 15.— Form simulating a segmenting body. The significance of these forms, several of which havelaeen observed, was not clear to Drs. Thayer and Hewetson, who had never met with similar bodies in stained specimens so as to be able to study the structure of the individual segments. 16, 17.— Precocious segmentation. 18, 19, 20.— Large swollen and fragmenting extracellular bodies. 22.— Flagellatebody. 23, 24.— Vacuolization. The Parasite of Quartan Fever. 25.— Normal red corpuscle. 26.— Young hyaline form. 27-34.— Gradual development of the intracorpuscular bodies. 35.— Full-grown body. The substance of the red corpuscle is ho more visible in the fresh specimen. 36-39.— Segmenting bodies. 40.— Large swollen extracellular form. 41.— Flagellate body. 42.— Vacuolization. PLATE XVI. The Parasite of Estivo-autumnal Fever. 1, 2.,— Small refractive ring-like bodies. 3-6.— Larger disk-like and ameboid forms. I'i;^i?^;'5''®cS'"^y ^"'' * ^^Y pigment-granules in a brassy, shrunken corpuscle. 8, 9, 10, 12.— Similar pigmented bodies. ■ r""*-*";. 11.— Ameboid body with pigment. 13.— Body with a central dfump of pigment in a corpuscle, showing a retraction of the hemo- globin-containing substance about the parasite. =i.mvi,iuu ui me nemo 14-20.— Larger bodies with central pigment clumps or blocks 21-24.-Segmenting bodies from the spleen. Figs. 21-23 represent one body where' the entire process of segmentation was observed. The segSients, eigfiteeu in nuiXi, were accutatelv counted before separation, as _^m Fig. 23. The sSdden seplration of the sera^ents occum'SsM though some retaining membrane were ruptured, was observed »egmems, occurring as 25-33.— Crescents and ovoid bodies. Figs. 30 and 31 represent one body which was seen to extrude slowly, and later to withdraw, two rounded protrusions 34, 36.— Round bodies. 36.—" Gemmation," fragmentation. 37.— Vacuolization of a crescent. . /^^■~"^^°'l®P,lHS"-->. '^^^ figures represent one organism. The blood was taken from the par at 4.15 pm, at 4.17 the body was as represented in Fig 38. At 4 27 the flaeella anneared^ at 4 q? two of the flagella had already broken away from the mother bodv ^^S^^^^ appeared, at 4.33 "41-45.- Phagocytosis. .Traced with the camera lucida. iThese illustrations are reproduced by permission from the article bv Dra. Thaver anri TTowot son in The Johns Hopkins HoepOal Reports, vol. v., 1895. araoie ny urs. inayer and Hewet- The Parasite of Tertian Fever. PLATE XV -v;5>^' 7!' .,V ei t:, .1 ■^.-. '\. f • The Parasite of Quartan Fever. IS i > ^ 'h I.'. \ r% PLATE XVI The Parasite of Estivo Autumnal Fever 3 t = „ 31 o W ^^^ % » o o t> *"«■ ■v,^ * fcV- MALARIA. 953 DIFFERENTIAL DIAGNOSIS BETWEEN REMITTENT MALARIAL FEVER AND TYPHOID FEVER Remittent Malakiai Fever. 1. There may or may not be a history of exposure to the bites of mosquitos, or of having had malaria during the past few weeks or months. 2. Begins abruptly with a chill or a series of chiQs, which are followed by head- ache, and the characteristic fever and sweating stage. 3. An examination of the fresh blood re- veals the presence of the Plasmodium. Pigment granules may be sqen free in the plasma. 4. The Widal reaction is negative. 5. The temperature rises abruptly and may display decided remissions for one, two, or even more days, when an- other elevation takes place. These elevations and remissions dispW a variable degree of periodicity. When treatment is not instituted, the fever continues over a period of several weeks. 6. The skin may show periodic flushings. 7. Constipation the rulei 8. Intestinal hemorrhage is rare. 9. The abdomen is normal or scaphoid. 10. Nervous symptoms slight, and de- lirium unusual. 11. Hemoglobinuria and hematuria with pronounced albuminuria quite com- mon. Typhoid Fever. 1. The history of an epidemic is often obtained. A distinctive rigor is extremely un- common, although chiUy sensations may be experienced, but are not fol- lowed by high fever. A blood examination is negative. 4. The Widal reaction is positive in dilu- tion of 1 : 50 or higher. 5. There is but slight fever at first (99° to 100° F.); the temperature then rises gradually for a period of from five to seven days, and reaches its height in from ten to fourteen days; it con- tinues high until between the seven- teenth and twenty-first days, after which it gradually declines. 6. A characteristic eruption appears on the abdomen in from the seventh to the ninth days, and continues to ap- pear in two or more successive crops. 7. At first there is constipation, but diarrhea develops toward the end of the first week, and there are usually from 3 to 12 pea-soup-like stools daily by the end of the second week. 8. Intestinal hemorrhage is a frequent complication. 9. Tympanites is a prominent symptom after the second week. 10. Nervous symptoms pronounced; de- lirium common. 11. A mild grade of albuminuria in un- complicated cases. Urine contains typhoid bacilli in from 6 to 20 per cent, of cases. THE DISTINCTIVE FEATURES BETWEEN REMITTENT MALARIAL FEVER AND PUERPERAL SEPSIS. Remittent Malarial Fever. 1. Chill may develop at any time during the puerperium, and recurs with a varisible degree of periodicity. 2. A study of the blood shows lemcopenia. 3. Plasmodia present in the blood. 4. Differential leukocyte count shows an increase in the percentage of large mononuclear leukocytes. 6. The lochia remains normal. Puerperal Sepsis. 1. Chill from the third to the ninth day after delivery. 2. Leukocytosis 10,000 to 30,000 in a cubic millimeter. 3. Blood examination negative. 4. Increase in the polymorphonuclear cells, 85 to 96 per cent. 5. Lochia diminished prior to the develop- ment of the chill and fever, but may become profuse and of an offensive odor later. 954 ANIMAL PARASITIC DISEASES. Remittent Malarial Fever. — {Con- tinued.) 6. No tenderness either in the uterine or in the pelvic regions. 7. Involution of the uterus nonnal. 8. Temperature affected by the adminis- tration of quinin. Puerperal Sepsis. — {Continued.) 6. Pelvic and uterine tenderness common, though by no means a constant feature. 7. Subinvolution the rule. 8. Quinin exercises but little influence, but temperature declines following intrauterine douches and curetment. Malarial Cachexia. Pathologic Definition. — ^Malarial cachexia is the resulting anemia and wasting, with splenomegaly and enlargement of the liver, which follow repeated attacks of malarial infection. There riiay be hemorrhages from the various mucous surfaces, hemorrhages into the skin, and joint and muscle tenderness. Those affected with chronic malarial cachexia often display chronic nephritis, myocarditis, etc., and are especially likely to develop tuberculosis. (See Latent Malaria, p. 956.) Recurrent Halaria. Pathologic Definition. — As its name implies, in this form of malarial infection there is a reappearance of the general symptoms, due to the same group of parasites that caused the original infection, the symptoms recurring after an initial attack without reinfection by another group of Plasmodia having taken place. Remarks. — The exact time that has elapsed between the initial attack of malaria and the recurrence should be ascertained. This clinical problem is solved most satisfactorily by reference to the accompanying tables by Craig: TIME OF RECURRENCES IN 18 CASES OF TERTIAN INFECTION. Case No. Date of Ini- First Re- Second Re- Third Re- FonRTH Re- Fifth Re- tial Attack. CDBRENCE. CDHKENCE. currence. currence. currence. 1 Nov. 2 20 days 21 days 20 '^ 2 Aug. 4 18 ' 3 Aug. 28 19 ' 30 " 26 days 46 days 4 Nov. 6 20 ' 24 " 5 Jan. 17 20 ' 32 " 30 days 24 days 6 Nov. 23 21 ' 20 " 26 " 7 Oct. 6 21 ' 30 " 8 Sept. 17 21 ' 22 " 27 days 9 Aug. 27 22 ' 36 " 10 Feb. 12 22 ' 18 " 16 days 27 days 30 days 11 Jan. 17 27 ' 12 July 20 30 ' 13 May 3 30 ' 14 Nov. 1 30 ' 15 Sept. 22 33 ' 16 Sept. 1 37 ' 17 Dec. 13 38 ' 18 Sept. 22 41 ' MALARIA. 955 ESTIVO-AUTUMNAL TERTIAN RECURRENCES. TIME OF THE VARIOUS RECURRENCES IN 55 CASES OP TERTIAN ESTIVO-AUTUMNAL INFECTION. Case No. Date op Ini- tial Attack. First Re- ccrbence. Second Re- CtTHRENCE. Thtkti Re- currence. Fourth Re- currence. Fifth Recur- rence. 1 Oct. 12 10 days 12 '^ 30 days 36 days 2 Nov. 19 3 Feb. 27 15 " 20 days 30 days 4 Nov. 2 18 " 30 " 30 " 5 Mar. 30 19 " 20 " 6 Dec. 8 19 " • 7 Jan. 24 20 " 8 Feb. 12 20 " 60 days 9 Dec. 24 20 " 10 Feb. 6 20 " 20 days 11 Feb. 6 20 " 48 " 12 Dec. 25 21 " 33 " 13 Mar. 1 22 " 14 Nov. 29 22 " 15 Nov. 14 24 " 16 Feb. 4 24 " 20 days 38 days 30 days *16i Oct. 30 24 " 16 " 17 Aug. 29 24 " 26 " 18 Mar. 17 24 " 19 Feb. 4 25 " 16 days 20 days 20 ; Dec. 30 26 " 36 " 30 " 90 days 30 days 21 Jan. 26 26 " 48 " 90 " 22 Jan. 11 26 " 22 " 23 Oct. 2 27 " 24 Nov. 2 27 " 25 Mar. 2 27 " 52 days 26 Feb. 5 28 " 21 " 20 days 21 days 27 Dec. 12 28 " 28 " 28 Oct. 29 29 " 48 " 15 days 29 Jan. 17 30 " 30 Jan. 1 30 " 30 days 31 Jan. 19 30 " 32 Jan. 20 32 " 33 Oct. 19 33 " 26 days 90 days 34 Jan. 19 34 " 40 " 35 Oct. 18 34 " 50 " 36 Jan. 25 34 " 26 " 17 days 37 Oct. 21 36 " 56 " 38 Feb. 30 36 " 66 " 39 Aug. 13 36 " 35 " 40 Nov. 27 36 " 41 Sept. 1 37 " 49 days 42 Oct. 18 38 " 43 Oct. 17 38 " 44 Aug. 13 38 " 45 Sept. 6 41 " 46 Oct. 31 42 " 20 days 47 Jan. 1 45 " 30 " 48 Nov. 3 46 " 21 " 49 Dec. 7 49 " 50 Feb. 24 50 " 24 days 41 days 51 Oct. 24 51 " 39 " 52 Jan. 18 61 " 156 " 53 June 14 64 " 66 " 14 days 96 '^ 20 days 20 days 54 Mar. 3 80 " 120 " * The case numbered 16K brings the total of the table to 55 cases. 956 ANIMAL PARASITIC DISEASES. It is frequently impossible to estimate with any degree of accuracy the in- terval between the initial attack of malaria and that of the recurrence, and while it shall not be our purpose to outline such difficulties, we are inclined to believe that in many instances the time cannot be determined. The time will also be found to differ somewhat depending upon the type of organism represented by the case in question. The exact method as to how these re- currences are produced has bafHed even the most competent students of the age, and at present various theories are offered. Hemoglobinuria and Hematuria. In malarial infection the detection of red corpuscles (hematuria) or of hemoglobin (hemoglobinuria) in the urine constitutes the most important finding. The number of red cells in the peripheral blood is generally re- duced, and may fall below 2,000,000 in a cubic millimeter; in fact, cases have been reported in which the number of red cells was below 1,000,000. The peripheral blood shows great numbers of pigmented malarial para- sites, and many of the leukocytes show pigmentation. The general history obtained is that of a mild cold stage, following which the temperature becomes subnormal and remains so for an indefinite period, when hemoglobinuria and hematuria develop. These paroxysms occur with decided periodicity, although in some patients bloody urine may be voided daily or even hourly. Hemoglobinuria is occasionally observed to occur at irregular intervals. Chemically, the urine is found to contain a considerable amount of albumin, and in a small percentage of cases casts are foimd. In the hemoglobinuric variety red blood-cells are also present, but in the hematuric type it is unusual to find many erythrocjrtes. Latent Malaria. Pathologic Definition. — By the term latent malaria is meant a condition in which plasmodia may be demonstrated in the blood of an in- dividual in whom no definite clinical symptoms of the disease are ob- served. "The term should not be confined to those instances in which no symptoms of malaria have ever been present, for if the parasites be present in the blood in recurrent cases, between the attacks the disease is as truly latent as it may be before the initial one" (Craig). Remarks. — In a statistical analysis of 1653 cases, Craig* found 424 (25 per cent.) to be latent infections, and of these, 307 occurred in American soldiers or civilians, whereas 115 were in Filipinos. Variety of Organism. — Among these 424 cases, the tertian parasite was present in 110; the quartan parasite, in 8; the tertian estivo-autumnal parasite, in 272; the quotidian estivo-autumnal parasite, in 25; combined tertian and tertian estivo-autumnal parasites, in 7; combined tertian and quotidian estivo-autumnal parasites, in 2. In 307 cases studied in Ameri- cans the tertian organism was found 81 times; the estivo-autumnal tertian, 199; the quotidian estivo-autumnal, 21; and combined infections, 6. I/atent Infection in Children Natives of the Philippine Islands. — Craig examined the blood of 180 cases, and found that 87 (48.3 per cent.) showed the presence of plasmodia. The Plasmodium vivax was present in 34; the Plasmodium malariae, in 6 ; Plasmodium falci- parum tertianum, in 44; the Plasmodium falciparum quotidianum, in 4; combined infections were found in 3 cases. * Jour, of Infectious Diseases, vol. iv, No. 1, January 1, 1907, p. 100. TRYPANOSOMIASIS (kALA-AZAR). 957 "The infections in children diminished in number with advancing age; thus, between the ages of one month and five years, among 40 children, 79 per cent, were infected; between five and ten years, 37 per cent.; and be- tween ten and fifteen years, 24.5 per cent" (Craig). The researches of Craig confirm the observations of Koch, Stephens, Christopher, James and other observers, all of whom found that the younger the child, the more susceptible is it to malarial infection. Family Infection. — Several members of the same family are com- monly found to be infected, a feature that further supports the fact that the transmission of malarial infection is likely to be limited, a finding that is borne out by the accompanying table by Craig: Family. Number op Members. Nttmber In-' FECTED, Variety. 1 4 2 1 es:ivo-autumnal; 1 tertian. 2 3 2 2 estivo-autumnal. 3 4 2 1 estivo-autumnal; 1 tertian. 4 5 4 2 estivo-autumnal; 1 tertian; 1 quartan. 5 4 2 2 estivo-autumnal. 6 3 2 2 estivo-autumnal. 7 4 3 2 estivo-autumnal; 1 tertian. 8 3 2 1 estivo-autumnal; 1 tertian. 9 3 2 2 tertian. 10 6 4 2 estivo-autumnal; 2 tertian. TRYPANOSOMIASIS (KALA-AZAR). Pathologic Definition. — An acute infectious disease caused by the Trypanosoma gambiense. In this connection a variety of severe anemia occurring in Assam, associated with pyrexia and enlargement of the spleen and liver, has been shown to be due to a variety of trypanosomiasis in which only immature forms of the parasite (Leishman-Donovan bodies) have been found in the fluid obtained by splenic puncture. The trypanosomes are found to invade the blood-stream, connective structures of all organs, the reticular tissue of the lymph-nodes and spleen, and the substance of the brain. Clinical Remarks. — Trypanosomiasis begins as a febrile affection, with enlargement of the superficial lymph-nodes and the presence of a dif- fuse erythema. The fever is of the continued type, and varies in degree in different cases. After a week or more the temperature falls, and there is a period of apyrexia of indefinite duration. The periods of pyrexia and apyrexia alternate irregularly, and in time the patients become wasted, anemic, and mentally deficient. During the first febrile paroxysm the skin presents irregular areas of erythema, associated with edema of the under- lying connective tissue. The enlarged lymph-nodes are tender, but they seldom go on to pus formation. Headache, neuralgic pains, rapid pulse, cardiac weakness, painful local swellings, enlargement of the spleen and liver, and orchitis are among the symptoms that have been observed. After a period of several years, during which these alternating attacks of fever and apyretic intervals have been observed, the patient gradu- ally becomes lethargic, and the terminal stage of the infection, known as the sleeping sickness, begins. The weakness, wasting, and anemia now increase, the patient becomes indifferent to his surroundings, and is in- capable of exertion. His gait is shuffling. His mental processes become very sluggish, and localized edemas appear. He presents fibrillary twitch- ings of the muscles of the face and tongue, and tremors of the hands and legs 968 ANIMAL PARASITIC DISEASES. develop. He takes to bed or sleeps on the ground. At first he can be aroused to take his meals, but this soon becomes impossible, and death occurs either in convulsions or in coma, or is dependent on some intercur- rent disease, such as dysentery and pneumonia. Bxciting Factor. — Trypanosoma gambiense is transmitted from man to man by the tsetse fly, glossina palpalis, and possibly also transmitted by other insects. Protozoology. — Trypanosoma gambiense is an animal parasite, be- longing to the genus protozoa; order, flagellata. It has a spindle-shaped cytoplasmic body, having a nucleus (macronucleus) and a centrosome (micronucleus). The latter is situated at the posterior end of the body of the parasite. From the centrosome a flagellum arches over the dorsum of the cytoplasmic body, to project beyond the anterior end of the parasite as a free flagellum. The cytoplasm of the organism is prolonged from the dorsum of the body to the flagellum to form the undulating membrane. The cutaneous manifestations of trypanosomiasis may consist mainly of localized areas of erythema, or there may be a peculiar blotching over the extremities and upon the face and trunk. Nervous S3rmptoms. — Restlessness and mental dullness are present, and when the parasite infects the meningeal fluid, the patient becomes dull and sleepy. Cheyne-Stokes respiration develops late. Fig. 336.— Tbtpanosoma lewisi Stained with a 2 Per cent. Aqueous Solution of Methtlene- BLUE (Boston). Circulatory Phenomena.— The chief circulatory manifestation of the disease consists of thrombosis of the vessels of the extremities. The ocular manifestations consist of pallor and mottling of the fundus. _ I/aboratory Diagnosis.— The trypanosoma gambiense is detected m the peripheral blood of the infected person only with difficulty, even dur- ing the height of the paroxysms. Puncture of the enlarged lymph-nodes or injection of the blood of the suspected patient into monkeys or white rats will, however, clear up the- diagnosis. The lymph-node puncture is per- formed as follows: The skin over the enlarged organ is washed with soap and water, followed by sterile water, and a 1 : 1000 mercury bichlorid dressing is put on the skin for an hour. Then a sterile hypodermic needle attached to a syringe is plunged into the organ, and after being moved backward and for- ward a few times, so as to loosen the contents, the piston is pulled out and a FILARIASIS. 959 few drops of the contained fluid are withdrawn. This fluid is then examined — as fresh specimens and as stained smears. Inoculations of the blood are made by puncturing a vein — usually the median cephalic — of the suspected patient, after the usual aseptic prepara- tion. Next 10 c.c. of blood are withdrawn, and 5 c.c. are injected into each of two monkeys, or white rats may be employed for the inoculation. Ex- amination of the peripheral blood of the inoculated animals will show the presence of trypanosoma gambiense within about one week after the inocu- lation. Blood studies in cases of human trypanosomiasis show a marked chlor- anemia and a leukopenia. The differential leukocyte count shows an in- crease of the large mononuclear leukocytes. NEMATODES. FILARIASIS. Pathologic Definition. — A condition due to the presence of the embryos of filaria bancrofti (filaria noctm-na) or of filaria loa (filaria diurna) in the circulating blood, which is believed to result finally in obstruction to the lymph-channels, with the development of elephantiasis, obstruction to the lymphatics of the kidney and rectum, and, rarely, cutaneous abscesses are formed. Bxciting and Contributing Causes. — The exciting cause of filariasis is the filaria bancrofti or other species of the genus Filaria. Man becomes infected by the bites of infected mosquitos, usually of the genus Culex. Filariasis is a disease of the tropics and of subtropical regions. In the United States several cases of filariasis have occurred in a small section of country in North Carolina. A few cases have also been reported from Illinois, and we have studied a case of filariasis in a patient who had never lived south of New Jersey. Principal Complaint. — The patient may harbor filaria embryos in his blood for a long time and yet be in perfect health. The development of symptoms is thought by many writers to be dependent upon injury to the adult worm and the consequent blocking of the lymphatic vessels with im- properly developed embryos. Upon injury to the adult worm the first symptoms to appear are attacks of fever that somewhat resemble mal- aria, and are known bs filarial fever. The patient may complain of mental depression, anemia, weakness, and fatigue upon slight exertion. In some instances there is intense itching of the skin, as was seen in a case studied in Philadelphia. After several attacks of filarial fever separated by intervals of apyrexia, elephantiasis (Figs. 337, 338) begins to develop. The patient usually complains of inability to move the affected parts or of discomfort caused by scrotal and labial hypertrophy. Roughness and scaling of the skin of the lower extremities appear early. Physical Signs. — ^Inspection.— There may be general pallor, due to secondary anemia. When elephantiasis develops, the skin of the af- fected part presents a peculiar rough, scaling, and wrinkled appearance, not unlike the skin of the elephant, hence its name. As the result of this enlargement movements of the limbs are but slightly restricted. One or both limbs, the scrotum, or the vulvae may be involved. (See Figs. 337 and 338.) Palpation confirms inspection as regards those portions of the body show- ing elephantiasis. 960 ANIMAL PARASITIC DISEASES. I^aboratory Diagnosis. — There are three types of filaria embryos: (1) Those found in the peripheral blood during the night (filaria nocturna) ; (2) those found during the day (filaria diurna) ; and (3) those continually present. In four cases studied in Philadelphia the filaria could be de- tected at practically any time during the twenty-four hours, but in one of these cases filarial were abundant in the blood in but two days of each week. The method for detecting filaria embryos in the living blood is practically identical with the method described for the detection of the malarial parasites. (See p. 950.) The embryos are easily discerned under a |-inch objective, and when the parasites are very active, this degree of magnification is most desirable. In studying organisms that are })ut slightly motile, a ^ or a i-inch objective is entirely satisfactory (Fig. 339). Fig. 337. — Lateral ^'IEW of Case of Ele- phantiasis OF THE Labia Majora. Light area corresponds to opening of the vagina. (Patient studied and photographed by Dr. B. B. L'ssher, Jamaica, W, I.) Fig. 338. — Anterior View of Case of Ele- phantiasis OF THE LaBI.A. ^L^JORA. Patient studied and photographed by Dr. B. B. LTssher, Jamaica, W. I. The hemoglobin and the red blood-corpuscles do not undergo marked changes unless some other cause for the secondary anemia is present. This last statement may not hold true, however, for advanced cases of filariasis. In slides smeared thickly with blood containing the filaria embryos the hemoglobin should be dissolved with distilled water, and then stained for twenty minutes with warm Delafield's hematoxylin. The urine often contains red blood-cells, hemoglobin, and filaria em- bryos in cases of chyluria. The urine is milky in appearance, and contains numerous particles of fat (chyle) . When the quantity of chyle entering the urinary tract is extremely large, the urine may give off the odor of the food SCHISTOSOMUM HAEMATOBIUM. 961 Fig. 339. — Filaria Sanguinis Hominib (Boston). Lining filaria in blood from case at Pennsylvania Hospital. Sketch forty-eight hours after blood was taken. taken. The filaria embryos found in the urine are non-motile. In 132 cases of chylous ascites col- lected from the literature by one of us, there were but three instances in which this condition was dependent upon the filaria. Summary of Diag- nosis. — A historj' of having resided in the tropics or in districts in which the filaria are known to infest man is of great value in formulating a diagnosis. The presence of elephantiasis and the de- tection of the parasite (Fig. 339) in the circulating blood or in the urine furnish con- clusive evidence of the ex- istence of filariasis. In all cases of hematuria and chyl- uria the question of possible infection with the filaria should be entertained. Diflferential Diagno- sis. — Filariasis is to be distinguished from obstruction to the lymphatic channels following surgical operations upon the abdomen, the inguinal region, and the thighs; but here the history usually serves to distinguish traumatic elephantiasis. Chyl- uria is occasionally seen after surgical opera- tions upon either the bladder or the pelvic viscera. In one instance we have seen chyl- uria follow puerperal sepsis. Intermittent attacks of fever may make a microscopic ex- amination of the blood necessary in order to distinguish between trypanosomiasis and fila- riasis. SCHISTOSOMUM HAEMATOBIUM (BiLHARZIA HaEMATOBIA; BlOOD-FLUKE). This is a trematode furnished with two sucking disks. The male is shorter and thicker than the female, the former being 4 to 15 mm. (I to -f in.) long, and the latter, about 20 mm. (f in.) in length. It is found in Egypt, Cape Colony, and other parts of Africa. Its presence in the blood gives rise to the following symptoms: hematuria, with stinging and burning of the urethra and pain during micturition. The ova of the parasites are found in the urine. 61 Fig. 340. — Male and Female Speci- mens OF THE Human Blood- fluke (SCHISTOSOMUM HAEMATO- BIUM) Enlarged. X 12 (after Looss). 962 ANIMAL PARASITIC DISEASES The adult parasites (Fig. 340) inhabit the veins of the portal system. Their ova, however, seldom enter the general circulation, but are found in the veins of the rectum and of the bladder. When the ova escape from the veins ulceration of the mucous surfaces ensues, and the organisms are Fig. 341.' — Schistosomum H^matobium (Bilharz). 1-4, Various stages in development of embr;v'o: 5, empty shell; 6, surviving embryo (after Brock); 7, ova in urmary sediment (Boston). found enmeshed in blood-clots in the urine (Fig. 341) or the feces. (See Hematuria, p. 956.) Mode of Detection of the Parasite. — Transfer a portion of the thick urinary sediment to a glass slide, apply a cover-glass, and examine under a two-thirds inch objective. If large blood-clots are present, these AMEBIC DYSENTERY. 963 should be broken up or compressed gently between the slide and cover-glass to release the ova from the clotted material. The ova cannot be detected unless the smear of the sediment be comparatively thin, so that each in- dividual cell will stand out prominentl}^ in the field. A high-power ^-inch objective may be employed for the study of individual ova, but ordinarily there is no advantage in employing this degree of magnification. Anemia may follow hemorrhage from the bladder, which is generally persistent, and may continue for a period of several years. Eosinophilia has been detected soon after infection. INTESTINAL ANIMAL PARASITES AND THEIR OVA. AMEBIC DYSENTERY. Pathologic Definition. — An acute infectious disease caused by entamoeba histolytica, and characterized by the presence of multiple ulcers in the colon, which show a tendency to coalesce and to produce communi- cating sinuses in the submucous tissue and amebic abscess of the liver. Fig. 342. — Entamoeba Histolytica (Kruse and Pasquale). a and b, Amebee as seen in the fresh stools, showing blunt ameboid processes of ectoplasm. The endoplasm of a shows a nucleus, three red corpuscles, and numerous vacuoles; that of h, numerous red corpuscles and a few vacuoles: c, an ameba as seen in a fixed film preparation, showing a small rounded nucleus; X 600. Kxciting and Predisposing Factors. — The exciting cause is the entamoeba histolytica (Stiles). Among the predisposing factors are climate, the disease being seen more commonly in the tropics than in temperate and more northern districts. Age and Sex. — Adults seem to be afflicted oftener than children, and males more frequently than females. Amebic dysentery has long been re- garded throughout India, China, Formosa, and the Philippine Islands as extremely fatal, and the disease is also encountered along the Mediterranean Sea and Nile River. One of ns has studied a case where the patient had resided in Philadelphia and Atlantic City for ten years before his illness. The feces showed many amebse. Feeding Experiments. — Amebic dysentery may be induced in the lower animals (cats) by injecting the living entamoeba histolytica into the rectum. Craig* produced typical dysentery in 66 per cent, of cases in which kittens were fed 5 c.c. of feces that contained motile entamebae mixed with "Jour, of Infectious Diseases, June 4, 1908, p. 324. 964 ANIMAL PARASITIC DISEASES. milk. Amebffi were found present in the feces in each instance, and the autopsy findings were those characteristic of this type of dysentery. Incubation Period. — In Craig's experiments upon kittens the shortest period of incubation was seven days, the longest eleven days, and the majority of the animals developed diarrhea with blood-stained stools by the eighth day. The period of incubation is somewhat longer when living entamebffi are injected into the rectum. Principal Complaint. — The disease develops insidiously, with a mild diarrhea that continues for a period of from four to ten days, following which a variable degree of constipation occurs, lasting a somewha.t longer time. There is always a succession of attacks of diarrhea alternating with periods of constipation. Chnically speaking, the disease assumes a chronic nature from the time the patient observes the first symptoms. With the progress of the disease there is gradual loss of strength and of flesh, and the skin assumes a yellow hue. In advanced cases the patient may be unable to leave his bed, and in the majority of instances he complains of the general symptoms of anemia, e. g., dyspnea, palpitation, vertigo, ringing in the ears, anorexia, and occasional attacks of nausea. The mind is, as a rule, clear, and when marked nervous symptoms occur, they are to be regarded as of serious import. Thermic Features. — In the acute stage of the disease there is usually a marked febrile reaction, but as the condition becomes chronic the temperature is likely to fall to the normal or below. Physical Signs. — Inspection. — The skin is yellow, the cheeks are sunken, the expression is anxious, the tongue is dry and pale, and there are evidences of emaciation. Palpation. — The muscles are soft and flabby, and the skin is loose and dry. As the disease progresses the skin becomes cool and clammy. In ad- vanced cases there may be edema of the ankles. The pulse is at first of about normal frequency, but later becomes more rapid, weak, and dicrotic. Auscultation. — The heart-sounds are weak and fetal in character (late), a condition that is probably dependent upon an associated myocarditis. lyaboratory Diagnosis. — During the attacks of diarrhea the stools contain shreds of mucus, blood, pus, and occasionally sloughs from the mu- cous surface of the colon. When studied under the microscope, — ^-inch oil immersion objective,— the gelatinous mucoid substance present in the stool will show the presence of many amebse (Fig. 342). The hematologic findings are those of profound anemia, the hemoglobin and red blood-cells showing great loss. In the stained blood the red cells ^re found to be markedly degenerated, and to resemble in many respects the changes known to pernicious anemia. Eosinophilia has occasionally been pbserved. Illustrative Case of Amebic Dysentery. — C. H., aged twenty-one years; height, 5 feet lOi inches; usual weight, 165 pounds; present weight, 128 pounds. Family History. — Father living at the age of forty-six; mother in apparent health at forty-tw^o; three younger brothers and a sister all in good health. Previous History. — The patient had the diseases of childhood, including diph- theria at the age of nine years, which condition was complicated by otitis media. He was treated six years ago for influenza, and two years later had an attack of tonsillitis that went on to peritonsillar abscess. Six months ago he had malaria, and two months ago an acute attack of dysentery. Social History. — The patient is single, a bookkeeper by occupation. At the outbreak of the Spanish- American War he enlisted in the United States Army, and was sent to the Philippine Islands, where he remained for seven months. While there he AMEBIC DYSENTERY. 965 suffered from malaria and from dysentery, and upon returning to the United States he found he was unable to resume his usual vocation. Present Illness. — Following a ten days' stay in the hospital in Manila for what he described as an acute attack of dysentery, he had two similar, though much milder, attacks during the voyage from Manila to San Francisco. An interval of approximately seven to fourteen days occurred between the attacks of dysentery, during which time constipation was present. After returning to the United States he suffered from con- stipation, which was obstinate at times. When first seen he was so weak as to be scarcely able to walk about the room. The appetite was poor, and he complained of indigestion and of extreme shortness of breath following exertion. He was annoyed by ringing in the ears and by occasional attacks of cardiac palpitation. He slept well and did not display any well-marked nervous symptoms. It was not until three months after he had reached this country that a dull, boring pain developed in the region of the liver, which later became intense. Upon one occasion he suffered from paroxysmal pain that was followed by the general symptoms of shock, from which he rallied a few hours later. Upon reaching Ainerica he had a more or less chronic cough, which became grad- ually worse until the rupture of an amebic abscess into the lung took place, following which the cough became persistent, being frequently accompanied by bloody expectora- tion. The temperature ranged between 97.3° and 99.6° F., and at no time was there high fever. Physical Examination. — General. — ^The skin presented a cachectic appearance, and hung in folds, as the result of emaciation. Upon careful questioning it was learned that the patient had lost 40 pounds within the past six months. Local Examination. — Inspection. — The conjunctivae appeared to be slightly jaundiced, the hair poorly nourished, and the abdomen scaphoid. For a few days preceding the attack of paroxysmal pain in the region of the liver there appeared to be limited expansion at the base of the right chest. The apex impulse was rapid, and, following exertion, there was some pulsation over the greater portion of the precordial region. The tongue was heavily coated, and the mucous membrane of the mouth appeared to be unusually dry. Palpation. — Firm pressure over the region of the liver produced a duU pain that radiated along the right border of the sternum. The pulse was weak, the beats number- ing 100 to 110 a minute. Percussion. — ^The inferior area of liver dullness was limited to the right costal mar- gin, whereas the superior boundary of hepatic dullness was at the lower border of the fourth rib, in the nipple-line. ' Aiiscvltation. — The heart-sounds were clear, although not strong, and when the stethoscope was placed over the base of the organ, a soft systolic murmur was audible, but this murmur was not transmitted along the route where true organic murmurs are usually heard. Over the base of the right lung anteriorly numerous, fine, crackling rdles were heard, and after the attack of paroxysmal pain, many coarse bubbling rftles were audible in this region. Laboratory Findings. — During his stay in the hospital at Manila the feces contained considerable blood, and amebse were also present. No examination of the feces was made during the attacks, which occurred while traveling from the Philippines to the United States, and which were separated by an interval of approximately two weeks. After reaching this country the feces were examined repeatedly, but at no time was it possible to demonstrate the presence of amebae. Following the paroxysmal pain at the base of the right chest he expectorated several ounces of blood-streaked, mucopurulent material, a microscopic analysis of which showed it to contain active amebse, red blood-cells, leukocytes, and shreds of partially necrotic tissue. The urine was high colored, had a specific gravity of 1.016, and gave a decided reaction for indican. The patient's sputum continued to show amebae for a period of about seven months, since which time it has not been examined. When first seen the blood showed: hemoglobin, 64 per cent.; red blood-cells, 2,110,000. The leukocytes were not estimated before rupture of the abscess, but while studying smeared blood a differential leukocyte count showed 6.2 per cent: of eosinophile cells. Four months following the rupture of the abscess into the lung the red ceUs numbered 4,200,000; hemoglobin, 82 per cent.; leukocytes, 8700. Course of the Disease. — The condition doubtless began with the original attack of dysentery while in the Philippine Islands, and the fact that amebae were not found in the stools ten weeks later suggests that the intestinal process had possibly subsided by that time. The patient presented the further evidence that while in the hospital he was given repeated rectal injections of a quart of water which, the attendant said, contained 966 ANIMAL PABASITIC DISEASES. quinia. The profound anemia from which he was suffering disappeared gradually after the rupture of the amebic abscess of the liver with the escape of its contents through the lung, although hematinics and highly nutritious foods were administered at the same time. The patient was restored to apparent health within the course of approximately two years. Summary of Diagnosis. — Given a patient who has resided in the tropics and who presents the typical clinical history, e. g., repeated attacks of dysentery alternating with constipation, progressive anemia, and marked emaciation, and the diagnosis becomes quite clear. It may be substantiated, however, by the detection of amebffi in the feces. The presence of anemia and of eosinophilia is of some value in formulating a diagnosis. Differential Diagrnosis. — Amebic dysentery is to be. distinguished from chronic dysentery. In the latter the degree of emaciation and of prostration is but slight, the quantity of material dejected at each stool is large, and the ameba is not found in the feces. Duration and Clinical Course. — Uncomplicated cases that tend toward a favorable termination go on to recovery in about ten weeks. The course of the disease may be greatly curtailed by treatment. It must be remembered that the tendency is always toward repeated relapses, and that a relapse may occur when the patient is apparently cured. In relapsing cases convalescence is protracted over a long period, and the anemia and emacia- tion continue. The mortality rate in certain epidemics has been found to range between 70 and 80 per cent., whereas in others it may fall to from 10 to 15 per cent. " In sporadic cases the mortality rate in temperate climates is not over 5 or 6 per cent" (Anders). Complications. — Among the complications that occur in amebic dysentery are peritonitis, pyemia, malaria, hepatic abscess, bronchopneu- monia, and hepatopulmonary abscess. Hemorrhage from the bowel has been reported. Hepatic Abscess. — This complication may develop at any stage of the disease. In subacute cases it is prone to occur in from the fourth to the twelfth week. The abscess often occupies the convex surface of the liver, near the coronary ligament. In these cases the lung is also likely to be- come involved. Abscess of the liver is dealt with in the section devoted to Hepatic Diseases, but it is important to note here that hepatic symptoms may occur in cases in which, on account of the mildness of the attack, the local intestinal disturbance may have escaped observation. Hepatopulmonary Abscess. — The character of the expectoration points conclusively to the nature of the lung complication. A history of a dry, hacking cough, with the sudden expectoration of a large quantity of gela- tinous or mucoid and bloody material, is suggestive of hepatopulmonary abscess. In typical cases the expectorated material is of a brown or light chocolate color. The sputum may be bile-stained, and when studied microscopically under a |-inch objective, it often shows liver-cells, bile-pigment, and crystals. The amebse are readily seen with the |-inch objective, but the J gives better magnification. _ The first expectoration from an amebic abscess does not contain bacteria unless the abscess has become infected secondarily. After the patient has been expectorating the contents of the liver abscess cavity for a time, secondary infection occurs, and then the expectorated material will also be rich in pyogenic bacteria. With the increase in the number of bacteria in the sputum the number of amebse present is reduced. In a patient seen at the Medico-Chirurgical clinic (Philadelphia) amebae were pres- CESTODES. 967 This patient is at ent in the sputum for a period of nearly nine months, present in perfect health. FLAGELLATA. "Members of the group flagellata or mastigophora are characterized by the fact that each organism displays from one to eight fiagella. These fla- gella, by their active movements, render the animal capable of locomotion" (Fig. 343) . Infection with these worms is common in temperate climates, as well as in the tropics. BALANTIDIUM COLI. This is an oval organism that measures about 1 mm. in its greatest diam- eter. It differs from the flagellata in that its entire body is covered with Fig. 343. 1,2, 3, 4, 5, 10, and 11, Various forms of Cercomonas intestinalis (after Leuckart and Lamb): 6, 7, 8, and 9, various forms of trichomonas (after Scanzoni and Kolliker and Dock); 12, encysted form, and 13, adult form, of Megastoma entericum (Cercomonas) (after Grassi and Schewialcoff). fine cilia, which are thickest about the mouth of the parasite, and thinly distributed over the remainder of the body. The balantidium coli has a pale nucleus, and from two to four distinct vacuoles (Fig. 345). Within the body of the parasite small particles of starch may be seen, and at times droplets of fat are detected. Clinical Significance. — Infection of man with the balantidium coU is believed to have its origin in the dejecta of swine. In all, 89 cases of persistent diarrhea due to this parasite were reported in 1904. The balan- tidium coli has been recovered from the feces in persons suffering from this infection, and at a time when other intestinal parasites were also present. CESTODES. TAPE-WORMS. These parasites inhabit the small intestine, where they give rise to con- siderable irritation, which results in the development of a variable amount 968 ANIMAL PARASITIC DISEASES. of intestinal catarrh. As the result of this condition, body depletion, toxemia, nei-vous manifestations, and progressive anemia may follow. Parasitic tape-worms in man include species iDelonging to the family Tjeniids and to the family Bothriocephaloidse. There are eight species that are known to be parasitic for man. The segments (proglottides) of the tape-worm vary greatly in size (Fig. 347). The longer the tape- worm, — that is, the further it is from the head, — the larger is the segment. Passing from the largest segment, it will be found that each segment is smaUer until the neighbor- hood of the head of the parasite is reached, where the segments appear to the naked eye as a slightly flattened thread. The segments of the tape-worm are of a yellowish-white or bluish-white color. Fig 344. — Eggs of T.enia Saginata (Mosler and Peiper). 345. — Balanti- DTUM {PaRAM(E- cium) coli (Eich- horst). TAENIA SAGINATA (BEEF TAPE-WORM). This worm is four or five meters long. The head is pigmented (Fig. 346), and the segments are long and fat (Fig. 347). The head is supplied with four powerful sucking cups, but has no rostellum or crown of hooldets. The uterus in the ripe segment is finely branched, and these segments are capable of indevendent movement. The eggs are characteristic (Fig. 344). TAENIA SOLIUM (PORK TAPE-WORM). The parasite consists of a number of segments and a single head (Fig. 350). When the segments are intro- duced into the stomach of an animal they undergo partial digestion by the an- imal's juices, the ova liber- ating their young in the in- testinal canal ; these young immediately find their way through the intestiiaal wall into the body-tissues of the animal, which now be- comes their intermediary host. In the animal's tis- sues the young tape-worm develops only as far as the head, becomes encysted, and remains quiescent here until the flesh of the ani- mal containing such cyst is ingested by a second animal, possibly man. In the stomach or the duo- denum of the second animal the cyst is digested and the head of the tape- worm liberated. The liberated head then fastens itself to the mucous mem- brane of the intestine, and here rapidly develops its characteristic segments Fig. 346. — Head of T.enia Saginata (Mosler and Peiper). Fig. 347. — Matuhe Seg- ments OF T.EXi.A Sa- ginata. (Fig. 349): CESTODES. 969 34S. — Eggs of T^nia Solium. Fig. 349. — Mature Segments o f T.ENiA Solium. Lije Cycle. — When the segments of the mature tape-worm are introduced into the human stomach, cystic formation in the body-tissues follows, and the parasite is then known as the cysticercus. A fact to be iDorne in mind is that persons having matured segments of any form of tape-worm in their intestinal canal may, as the result of violent retching or vomiting, re- gurgitate some of the segments into the stom- ach, where, suspended in an acid medium, the ova are liberated and develop into scolices and then go on to form cysticerci. Autoinfection with the beef tape-worm is by no means uncommon, and a knowledge of the symptoms to which it gives rise is of great clinical value. Principal Complaint. — As a result of infection with any form of tape-worm there is an abnormal ap- petite, and a peculiar parched condition of the throat and mouth is present. A variable degree of mental hebetude, constipation alternating with diarrhea, and the passing of segments of the parasites (Fig. 349) from the rectum are observed. If the parasite has been harbored for months or even j'ears, a high-grade anemia is present, and this anemia may, in some instances, closely resemble one of the es- sential blood diseases. Persons infected with cestodes become extremely nervous and irrital^le. Physical Signs. — Inspection. — The skin is pale, often of a lemon- yellow or greenish hue, and the conjunctivffi generally show small, milk- white areas, due to deposits of fat. The abdomen is, as a rule, scaphoid in shape. I/aboratory Diagnosis. — The detection of segments (proglottides, Fig. 349) or of ova in the feces is the only positive evidence of infection with a cestode. Ova. — The ova of the tsenia saginata (Fig. 348) closely resemble those of the taenia solium. The slight difference in size is no guide to the diagnosis unless measurements are taken. The ova escape with the feces. DIBOTHRIOCEPHALUS LATUS (FISH WORM). Description. — A form of worm common in all countries iDordering upon the Baltic Sea, in the vicinity of Lake Geneva, and in Holland. This parasite may attain a length of from one to five meters, the average size found being two meters, or aljout seven feet, in length. Proglottides. — The mature proglottides do not escape from the rectum singly, but the segments are, as a rule, passed in large numbers, one foot or more of the worm being passed at a time. The individual segment is very thin at a point near the head. The segments graduall}^ increase Fig. .350. — Head of T.«n'ia So- lium (Mosler and Peiper). 970 ANIMAL PARASITIC DISEASES. m size, the largest being those situated farthest from the head. The small segments appear to be greater in length than in breadth, whereas the medium-sized ones are almost square. In the center of each segment is a dark or slightly bluish spot, indicating the position of the genital pore. Head. — The head is 2 or 3 mm. long by about 1 mm. broad. It is per- fectly ovoid in contour, and closely resembles the expanded portion and handle of a spoon. It has two suckers, resembling slits, on the lateral margin of the head. To the naked eye the head of this worm corresponds in size to that of a small pin. It may be of a light-gray or pearl-white color, and is sometimes opales- cent. Ova. — In fully matured segments the body of the uterus is seen to be so packed with ova that the center of the segment protrudes slightly. The detection of ova in the stool of man is of great diagnostic value. These ova are elliptic or ovoid in con- tour, and, as a rule, are of a muddy-white, brownish-white, or brown color. They vary in length from 0.06 to 0.07 mm., their width being usually equivalent to about one-half their length. With a one-sixth or a one- eighth inch objective a faint hyaline band may be seen at one end of the ovum, outlin- ing an apparent lid. HYMENOLEPIS NANA. This is a parasite occasionally encountered in the intestinal canal of man, but for more commonly seen in the intestine of the lower animals. It measures from 10 to 15 mm. in length. Geographic Distribution. — The parasite is common in Italy, Egypt, and along the shores of the Mediterranean Sea. Dead- erick found it to be quite common in the State of Arkansas, he having detected the ova of this parasite 8 times in 40 specimens of feces examined. Description. — Proglottides and Ova. — The proglottides of the hymenolepis nana may be clearly seen in the accompanying illustration (Fig. 351). The ova are numerous and slightly opalescent oval bodies, enveloped in a distinct membrane. Head. — The head of the parasite differs markedly from the heads of other tape-worms previously described, being more or less pear-shaped, and displaying four suckers and a club-shaped rostellum (Fig. 351). It con- tains from 24 to .'^O booklets, which are arranged in a single row to form a crown at the anterior portion of the head, instead of being inverted, as is shown in the illustration (Fig. 351). Fig. 351. — Hymenolepis Nana FRO.M Intestine of a Cat (Boston) 1, Head and neck (obj, B and L. two-thirds); 2, head and neck (natural size); 3, largest segments (natural size). CESTODES. 971 HYMENOLEPIS DIMINUTA. This parasite was first described by Leidy, and in 1900 Packard reported the ninth case of infection in man. The parasite varies in length between 25 and 60 mm. The head is pro- vided with four quite well-marked sucking cups. The ova resemble those of the taenia solium (Fig. 348). TAENIA MARGINATA. This parasite resembles in certain respects both the beef and the pork tape-worms, and has occasionally been known to infest the intestinal canal of man. DIPYLIDIUM CANINUM. Description. — The dipyhdium caninum, or dog tape-worm (Figs. 353 and 354), belongs to a family of intestinal parasites rarely encountered in man, but commonly attacking the cat and the dog. Its segments, which are elhptic, elongated, tape-like bodies, are not easUy confused with those of other intestinal parasites. The lar- val stage of this worm develops in Fig. 352. A, Egg packet of Dipylidium caninum: B, egg of same — sLx-hooked embryo (after Stiles); C, Cryptocystis tricodectia, as found in tiie flea (after LeuckartJ. Fig. 3.3.3. — Head of Dipylidium C-aninum (Stiles). Sliowing four rows of rose-tliorn liooks on the rostelluni and four unarmed suckers. lice and in fleas (Fig. 352). Stiles states that the dipylidium caninum is one of the smaller tape-worms, but should be looked upon as a pathogenic para- site, as it sometimes burrows into the intestinal mucosa. The head of the para.site shows four sucking cups and a rostellum, sur- rounded by four rows of booklets. Ova. — The ovum of dipylidium caninum differs markedly from that of any form of tenia known to infest man. " In the genus T^nia we find a thick, striated inner shell (embryophore), while in dipylidium the inner shell is thin" (Stiles). But few ova are found in the feces of persons infected with this parasite. 972 ANIMAL PARASITIC DISEASES. TAENIA MADAGASCARIENSIS (Grenet). Description. — A form of tape-worm found to infest persons residing on the eastern coast of Africa. It may attain a considerable length, its segments reaching a maximum number of 600. £3 A distinguishing feature of taenia Madagaseariensis is that its segments are trapezoid, its rostellum being surrounded with a double row of booklets, and the sucking-cups being well defined. CESTODES. 973 Under this name another type of tape-worm has recently been reported from eastern Africa. A single case has been reported. ~ ^' I TAENIA ECHINOCOCCUS. This parasite is another species of dog tape-worm, commonljr found in members of the canine family, and rarely in the intestine of man. In man the larval stage of the taenia echinococcus ap- pears in the form of hydatid cysts. (See also Animal Parasites of Liver, p. 980.) Description. — ^The taenia echinococcus is about one-fourth inch in length, and is composed of four seg- ments. The cephalic extremity, which is prolonged to form a well-marked net, is capped by a pointed rostellum. In the center of the head are four well-marked sucking cups (Fig. 355). The rostellum is surrounded by a double row of hooks, numbering between 30 and 40. The last segment, when sexually matured, is as long as the three anterior segments; it is provided with papillae at the margin of the proglottis, below the central line. The uterus is packed with ova. General Remarks. — A hydatid cyst is an em- bryo tape-worm. It consists of a vesicle in which there is a scolex with four sucking discs and six hooklets, cir- cularly arranged. After a time the scolex degenerates, the hooklets are shed, the cyst increases in size, and con- tains a clear fluid in which the hooklets and some cells may be found. The wall of the cyst is composed of fibrous tissue that gradually becomes dense. Clinically, echinococcus disease is of great impor- tance because it is a type of infection found wherever man is brought in contact with the dog or the wolf. Infection with this parasite is common in Russia, Finland, Iceland, and Australia. Sites of Development. — The echinococcus cyst develops in any part of the human tissues, the fa- vorite site, however, being the liver. We have seen echinococcus cysts in the liver and in the lung at post- mortem nine times, and in one case 19 of these cysts were found in the brain. Summary of Diagnosis. — The diagnosis is based entirely on the recovery of fluid from the tumor and the detection therein of hooklets of the echinococcus. Diflferential Diagnosis. — Among the conditions that may be confused with hydatid of the liver are: distention of the gall-bladder, hydronephrosis, syphilis, carcinoma, and amebic abscess of the liver WTl Fia. 355.^T.ENiA Ech- inococcus, En- larged (after Hel- ler). Above, at the right, echinococcua of natural size. 56.— Head of Echinococcus (Mo^ler and Peiper). , Head protruded; h, head drawn in. 974 ANIMAL PARASITIC DISEASES. The following tables, modified from Anders, outline the distinctive differences between hydatid disease of the liver and disease of the gall-bladder and of the Iddney: Hydatid Cyst. Dilatation of the Gall-bladder. 1. Previous history negative, except for 1. A history of having passed biliary cal- the companionship of dogs. culi is often obtained. 2. Pain and jaundice absent. 2. Attacks of biliary colic followed by jaundice either .are present or enter into the previous history. 3. Enlargement in any direction is depen- 3. Enlargement is always in one direc- dent upon the location of the cysts. tion — downward and posteriorly. 4. Tumor is firmly fixed to the liver or 4. The tumor is somewhat movable. other viscera. 5. Aspiration recovers fluid containing 5. Aspiration recovers bile-stained fluid. Charcot-Leyden crystals and hook- lets of echiiiococcus. Hydatid Cyst. Hydronephrosis. 1. The history is negative. 1. There is a history of renal calculi or of vesical inflammation. 2. There is no pain. 2. There may be severe pain. 3. The tumor is most prominent over the 3. The tumor is most prominent in the hepatic area, and is associated with flanks and iliac fossae. If it extends enlargement of the liver. to the right hypochondriac region, it does not move with the liver. 4. The duration is indefinite, and the tu- 4. The duration is short; a large amount mor is permanent. of urine may be passed and the tumor disappear; termination in uremia is common. 5. Aspiration recovers cyst fluid, etc. 5. Aspiration recovers urine. TREHATODES OR FLUKES. Trematodes are parasitic for man in nearly all parts of the tropics and in many of the subtropical regions. Fasdola hepatica is a parasite of sheep which is occasionally found in man if he has been closely associated with these animals. Paragonimus Westermanii (see p. 988), Schistosomum hcematobium (see p. 961), Fasciolopsis Buski, and Opisthorchis sinensis are frequently found in man in certain parts of the world. These parasites, when present in the intestinal tract or the liver, produce diarrheal attacks, the feces being found to contain blood, mucus, and pus. Abdominal pain and distention, anemia, and cirrhosis of the liver with ascites are important symptoms of infection with these parasites. The ova of the trematodes vary in size, but are characterized by the presence of a lid or operculum, with the exception of those of schistosomum hsematobium, which are furnished with a spine. INTESTINAL NEMATODES. ROUND-WORMS. Ascaris I/Umbricoides. — The common round-worm is from four to twelve inches in length, the females being somewhat longer than the males. They are of a reddish-white or milk-white color and bear a more or less close resemblance to common earth-worms. They inhabit chiefly the small INTESTINAL NEMATODES. 975 Fig. 357. — Ascaris, Oxturis, and Trichocephalus 1, 2, and a, Ascaris lumbricoides: 1, Male; 2, female; a, ova. 3, 4, 5, h, h' , b", Ascaris canis: 3, ilale; 4, female; 5, head of female (magnified); b, ovum; 6', ova, showing segmentation; b", ova showing embryo (Kobbold). 6, 7, 8, and c, Oxyuris vermicularis: 6, Male and female (natural size); 7, male; 8, female (magnified); c, ova (Boston) fobj. B. and L. one-sixth). 9 and d, Trichocephalus dispar: 9, Female (magnified); d, ova (obj. Queen one-sixth) (Boston). 976 ANIMAL PARASITIC DISEASES intestines, but frequently migrate to the stomach, large intestine, or even to the gall-bladder. Several parasites may be present in the intestine at one time, and in exceptional instances many hundreds may be found. They gain entrance into the system by means of their ova, which are swallowed with the food; the envelopes surrounding the ova are dissolved by the gastric juice, and the embryos are thus set free. Principal Complaint. — The symptoms produced by the presence of round-worms cannot be clearly distinguished from those due to gastro- intestinal catarrh, with which the ascarides are so commonly associated. The first sign to draw attention to the disorder is the passage of a round- worm by the rectum. The presence of one or two worms rarely gives rise to any symptoms unless they pass into the stomach or bile-duct. When, however, large numbers exist, they may give rise to colicky pains, coming on especially at night; diarrhea, vomiting, and symptoms of intestinal obstruction have also been observed. Nervous Symptoms. — There are general nervousness, picking of the cloth- ing and of the face, etc., and in children convulsions are by no means un- common. In rare instances worms have found their way into the peritoneal cavity, and have been discharged through the abdominal wall, together with the contents of an abscess. Anemia develops early and is of the secondary type. A differential leukocyte count is of service in making a diagnosis of infection of the in- testine with the various parasites, such infection showing, as a rule, an abnormally high percentage of eosinophiles. Laboratory Diagnosis. — The ascaris lumbricoides is readily detected in the feces (Fig. 357). Ova. — The ova of the ascaris lumbricoides are easily found in the feces. They are of a yellowish-brown color (Fig. 357), and vary in size, being from 0.06 to 0.07 mm. in diameter. Oxyuris Vermicularis. — (Thread-worm.) — This parasite inhabits the lower bowel — the cecum, colon, sigmoid flexure, and rectum — and the vagina. A diseased condition of the mucous membrane and sluggish bowels favor their development. To the naked eye they appear as short bits of white thread. Under a low magnification the females, which are the most numerous, wUl be seen to taper at each end; their uterine ducts are filled with numerous ova (Fig. 357), some of which contain embryos. Predisposing and Exciting Factors. — These parasites gain entrance into the system by means of their ova, which are ingested with the food, or perhaps more frequently by the ova adhering to the fingers of those already affected; they are thus conveyed directly or indirectly to others. Principal Complaint. — The symptoms are vague, and the diagnosis is usually made by finding the parasites in the stools of the child. The most common symptom is an irritation and itching at the anus or at the vulva. In girls, when vaginal infection exists, there is a discharge of mucus and blood from the vagina. ANKYLOSTOMIASIS (Uncinariasis , Hook-worm Disease). Pathologic Definition. — A disease caused by the presence of a nematode worm in the intestinal canal, and characterized by a severe secon- dary anemia, catarrhal enteritis, and secondary fatty degeneration of the viscera. ANKYLOSTOMIASIS . 977 Predisposing and Exciting Factors.— This disease was known before the Christian era. Of recent years, and particularly since 1898 in the United States, the disease has assumed great importance, because of its presence in Porto Rico and in the southern States. Two parasites are known to be responsible for the disease: that form seen in Europe, Asia, and Africa is caused by Ankylostoma duodenale; that seen in the western hemisphere is caused by a worm, necator americanus (Fig. 358). Age. — Children are chiefly affected, but adults may also harbor the parasite. Occupation is an important predisposing factor. The infection is known to be transmitted by soil pollution. The ova of the parasite are deposited on the ground with human feces, where they develop into larvae, particularly in moist, sandy soil. The larvae gain entrance to the tissues of the human host by burrowing through the skin, upon which they have been deposited with the rpud containing them. Consequently, any occupation in which a person is likely to get mud containing lar\'as on his hands or feet is one that predisposes to the infec- tion. Hence it is seen most often in miners, brick-mak- ers, farmers, civil engineers engaged in operations in an infected region, laborers, etc. In Porto Rico females af- ected with the hookworm were found to have con- tracted the infection by working in their rose-gar- dens. The larvae, passing through the skin, produce a pustular dermatitis known in Porto Rico as mazamorra, and in the southern United States as ground itch. Principal Com- plaint. — The chief symp- tom of uncinariasis is a marked anemia, the characteristics of which will be described under Labora- tory Diagnosis. There is a history of progressive weakness, nervousness, loss of weight, anorexia, per\^erted appetite, etc. In children infected before puberty physical development is retarded and mental evolution is delayed; the pubic hair fails to appear, the genitals remain infantile, and in girls menstruation is delayed. The symptoms of anemia are prominent: pallor of the skin and mucous membranes, headache, palpitation of the heart, dyspnea on exertion, vertigo, drowsiness, and localized edemas. Constipa- tion, alternating with attacks of diarrhea, is a common symptom. Digestive disturbances are not marked or common; catarrhal stomatitis, salivation, flatulence, heartburn, nausea without vomiting, pain and tenderness in the epigastrium are among the symptoms more frequently observed. Physical Signs. — Inspection. — The skin is ashy gray and often pig- mented; the conjunctivEe and lips are extremely pale; the tongue is flabby and heavily coated. The body shows evidences of emaciation, although 62 Fig. 358.— Uncinaria Americana (Boston). 1, Female, natural size; 2, head; 3, tail; 4, ova. 978 ANIMAL PARASITIC DISEASES. the face is usually full, and in advanced cases there is edema beneath the eyes. According to Ashford, this edema may so distort the face as to make recognition impossible. Edema of the hands and feet and abdominal distention due to ascites are seen late in the disease. The impulse of the apex-beat is indistinct. Palpation reveals the presence of edema and fluid in the peritoneal cavity. The pulse is weak, irregular, and compressible. Percussion is negative, unless there is effusion into the serous sacs, e. g., peritoneum, pericardium, and pleurse. The liver and spleen are not usually enlarged. Auscultation. — The heart-sounds are rapid and weak, and soft (hemic) murmurs are heard over the base of the organ. I^aboratory Diagnosis. — The total length of the female worm, necator americanus, varies between 9 and 11 mm., whereas the male worm is from 7 to 9 mm. in length. The tapering form of the neck and head, which is slightly turned, is shown in Fig. 358. The female worm tapers grad- ually, terminating posteriorly in a slightlv rounded point (Fig. 358). 'The tail of the male parasite displays a bursa from which two spicules pro- ject. Detection of the Ova in the Feces. — The ova of ne- cator americanus are found in the feces. They measure be- tween 0.064 and 0.075 mm. in length by 0.036 to 0.04 mm. in breadth. They are always deposited with seg- mentation begun, so that they are fiUed with two, four, or more segmentation spheres. They have a thin, transparent, clear white shell. The embryo may at times be seen in the shell. The de- tection of the ova in the feces is positive evidence of infection with the hook- worm. The Blood. — The anemia of ankylostomiasis is a secondary anemia of high grade. The percentage of hemoglobm is markedly reduced — often from 30 to 50 per cent. The red Ijlood-cells are also greatly diminished in number, and show the changes of degeneration, e. g., poikilocytosis, varia- tion in size, unequal distribution of the hemoglobin, granular degeneration and polychromatophilia, and the presence of normoblasts and megaloblasts. _ In uncomplicated cases of uncinariasis the leukoc3rtes are usually normal m number, eosinophilia is common, and myelocytes are sometimes present. Summary of Diagnosis.— The clinical history is in no way typical of infection with the necator nor is the additional fact that the patient has resided m the tropics of special importance. A positive diagnosis is attained only by finding the ova or the adult parasite in the feces. The presence of eosinophilia is of great value in making a diagnosis of Fig. 359. — Secttion of Adult Uncinaria (Anktlostoma Uterus Containing Ova (Boston). ECHINOCOCCIC DISEASE. 979 intestinal parasites, but is not pathognomonic of hook-worm infection. The high grade of anemia and the edema of the face and ankles are suggestive of uncinariasis. Differential Diagnosis. — Uncinariasis may be mistaken for leukemia, pernicious anemia, and chronic plumbism. In each of these, however, the clinical history will be found to be vastly different, and the detection of the parasite in tlie feces will furnish positive differential evidence. The hematologic findings are of service, since leukocytosis is characteristic of leukemia and fairly constant in chronic plumbism. In chronic lead intoxication the urine gives a reaction for lead. Clinical Course and Duration. — When judicious treatment is instituted early, the disease runs a favorable course, practically aU cases going on to recovery within a period of from two to six months. In cases of long- standing infection, and in the presence of profound anemia, the prognosis is guardedly favorable. In those in whom general edema is present there is a great tendency for complications to de- velop — e. g., bronchopneumonia. It has been estimated that infection by the hook-worm is accountable for more than 20 per cent, of aU deaths occurring in Porto Rico. TRICHURIS TRICmURIA. p,g 360.-Trichocephalu8 Dispas (Hel- Description. — This parasite is a t? ^ t, ^ 7't,„i „•,«^ fii.„ .^ . .. r m • 1 1 T 1 ^' Female; o, male (natural size). (Also member of a family of 1 nchotrachelidse, known as trichuria trichiuna.) which inhabit the cecum in man. It wiU be found to vary between 40 and 50 mm. in length (Fig. 360). Ova. — The ovum is of about the same size as the egg of the uncinaria, and measures about 50 to 54 microns in length by 21 to 23 microns in breadth. These ova are distinctly barrel-shaped, and present a light-colored plug at each pole. They are red brown or yellowish in color (Fig. 357) . Clinical Significance. — Trichuris trichiuria is a common intestinal parasite. It is usually productive of no symptoms. STRONGYLOIDES INTESTINALIS. This parasite is commonly found in the feces of persons residing in tropical and subtropical countries. In recent years it has been found by A. J. Smith, Claude A. Smith, Daland, Woldert, and Thayer in the States border- ing on the Gulf of Mexico. TRICHINIASIS. Remarks. — Embryos of the trichina spiralis may appear in the intes- tine and escape with the feces during infection with that parasite. The adult parasite may also be found during the initial diarrhea. (See Trich- iniasis, p. 982.) ANIMAL PARASITES OF THE LIVER. ECHINOCOCCIC DISEASE. Pathologic Definition. — An affection of the liver characterized by the formation of a multilocular cyst containing a limpid fluid in which booklets of the encysted scolex of taenia echinococcus are found. 980 ANIMAL PARASITIC DISEASES. Principal Complaint. — The majority of cases of echinococcus disease of the Uver are discovered at autopsy, the symptoms being vague except in those cases in which the cysts reach a large size. Generally speak- ing, the only symptoms of echinococcus cysts are caused by pressure upon the bile-ducts or upon adjacent structures. Marked pressure upon the portal vein and the bile-duct may be followed by the development of ascites and jaundice. Occasionally there is a distinct history of the tumor having dis- appeared suddenly, the patient having passed by the rectum a large quantity of peculiar looking material at the time of its disappearance. It is doubtless this form of cyst that ruptures into the colon, nature in this way effecting a cure. When an echinococcus cyst becomes infected with pathogenic l^acteria the symptoms described under Hepatic Abscess appear. (See p. 587.) When the cyst occupies the superior surface of the liver and forces the diaphragm well up against the lungs, coughing results. Spontaneous rupture through the diaphragm may occur, and in such cases the patients expectorate the contents of the cyst and a cure is effected. Physical Signs. — Beyond revealing the fact that the cyst is unusually large, inspection is negative. Palpation may be of great value when the cyst is large and exhibits fluctuation. By making deep palpation over one por- tion of the cyst and percussing over an- other the palpating hand occasionally de- tects a peculiar thrill (hydatid thrill), which many writers regard as pathogno- monic of the disease. Splenic enlargement is quite commonly associated with hy- datid disease. Percussion, as previously stated, wUl elicit the "hydatid thrill," or fremitus, and also confirms the findings of palpation as to the size of the spleen and the liver. Movable dullness shows the presence of ascites. Auscultation. — Upon placing the stethoscope over one portion of the cyst and percussing over a distant area, a peculiar short, sharply defined, booming sound will be obtained (Santoni). I/aboratory Diagnosis. — Aspiration of the cyst usually results in the recovery of a fluid that contains the booklets and scolices of the tsenia echinococcus (Fig. 361). In those cases rupturing through the diaphragm and communicating with a bronchus, hooklets are found in the sputum. We have detected both scolices and hooklets of the taenia echinococcus in the dejecta of two patients in the Philadelphia Hospital after a cyst had prob- ably ruptured into the colon. In a third case hooklets of the taenia echino- coccus were found in the urine, and within forty-eight hours the degree of hepatic enlargement was decidedly reduced. In the latter case it was believed that the hepatic cyst had probably ruptured into the pelvis of the right kidney. These cases went on to recovery, and the laboratory findings were the only positive evidences displayed. Stimmary of Diagnosis. — The diagnosis is based largely upon the presence of hepatic enlargement without tenderness, pain, or fever. The Fig. 361. 1, Scolex of TaTiia echinococcus, showing crown of hooklets: 2, scolex and detached hookleta (obj. B. and L. one- aixth) (Boston). LIVER FLUKES. 981 detection of the so-called hydatid fremitus is also of value. Aspiration of the cyst and the finding of hooklets in the cyst fluid constitute the only conclusive evidence unless either hooklets or scolices of the taenia echino- coccus are found in the sputum, urine, and feces. The cysts may rupture externally, when the discharge will be found to contain cyst products. The presence of shreds of cyst membrane also furnishes conclusive evidence as to the nature of the disease. Differential Diagnosis. — Hydatid disease of the liver must be distinguished from dilatation of the gall-bladder, from which condition it is readily differentiated by the fact that jaundice is more common in gall- bladder disease. The history is also of great importance in differentiating these two conditions, since previous hepatic disease is common in enlarge- ment of the gall-bladder. Again, dilatation of the gall-bladder is always dis- covered at one anatomic point, and extends below the surface of the liver, whereas a hydatid cyst is more nearly oval in contour, and usually develops at a point near the center of the right or the left hepatic lobe. Cysts are more common upon the superior surface of the liver. The distinctive features between hydatid cysts of the liver and hydro- nephrosis are shown in the accompanying table: Hydatid Cyst. Hydronephrosis. 1. The history is negative. 1. There is a history of renal calculus or of vesical disease. 2. Pain is absent. 2. Pain is common when the tmnor is large. 3. The tumor is more prominent over the 3. The tumor is most prominent in the hepatic area, and is associated with flank and the iliac fossa. If it ex- enlargement of the Uver. tends to the right hypochondriac re- gion, it does not move with the liver. 4. There is no history of the patient hav- 4. There is a history of the voiding of a ing voided a large quantity of urine large quantity of urine followed by with disappearance of the tumor. disappearance of the tumor. 5. Auscultatory percussion shows the tu- 6. The tumor is not attached to the liver. mor to be connected with the liver. 6. The duration is indefinite, and uremia 6. Uremia is a common termination. is absent. In rare cases an echinococcus cyst may resemble clinically a unilateral pleural effusion of long standing, but the distinction is made clear by examination of the aspirated fluid. (See Laboratory Diagnosis, p. 980.) Other Cysts of the I/iver. — Other cysts may develop in the liver, but seldom attain sufficient size to be of clinical importance, and there is no means of recognizing them unless they press upon the bile-passages or ad- jacent vessels. Clinically speaking, cysts of the liver are rare, Lipmann's analyses of the literature showing but 16 cases, 3 of which were retention cysts, 9 cystic adenomata, and 1 a chylous cyst. LIVER FLUKES. General Remarks. — ^The ordinary liver fluke (fasciola hepatica) inhabits the hepatic ducts in man, and is also quite commonly seen in sheep, deer, swine, and the bovines. The ova of the parasite collect in the bile-ducts, and, together with the parasites, may cause a marked dilatation along certain portions of their course. When there is an acute inflamma- tion of the lining membrane of these expanded ducts, the patient is likely to become jaundiced. 982 ANIMAL PARASITIC DISEASES. Among other types of trematodes (flukes) occasionally encountered in man are dicrocoelium lanceatum, fasciolopsis Busld, and opisthorchis sinensis. Diagnosis.— This is based on the detection of the ova of the particular Uver fluke in question in the feces. NEMATODES (Round-worms). Round-worms may enter the common bile-duct and cause obstruction, giving rise to acute obstructive jaundice. Such cases are rare. AMEBIC ABSCESS OF THE LIVER. Pathologic Definition. — A condition excited by the entamoeba histolytica, and secondary to amebic dysentery. It is characterized by ex- tensive destruction of the hepatic tissue, with the formation of pus. General Remarks. — Amebic abscess may develop at any time during the course of amebic dysentery, but is most likely to appear after the disease has become chronic. Residence in the tropics and a previous attack of dysentery are among the predisposing factors. There is progressive emaciation, together with a high grade of anemia, although the blood-findings are not characteristic. The recovery of amebae from the stools points strongly toward the existence of hepatic abscess, when there is questionable enlargement of the liver. In those abscesses developing on the superior surface of the liver there is likely to be cough, and the abscess may rupture into a bronchus. ANIMAL PARASITES OF THE MUSCLES. TRICHINIASIS. Pathologic Definition. — A disease caused by infection of the intes- tinal tract with the trichinella spiralis. It is characterized by the deposit of embryos of the trichinella in the muscles and by eosinophilia. Remarks. — Trichiniasis is primarily a disease of the rat. Sources of the Trichinella. — The parasite was first found in pork — the usual source of transmission to man. The swine become infected by eating diseased rats, trichinous meats, or human dejecta containing embryos of the trichinae. About 2 per cent, of hogs are found to be trichinous. Man is infected by eating raw or partially cooked meat containing the encysted larvae of the trichinae (Fig. 364). Principal Complaint. — ^There is usually a history of having eaten raw or partially cooked pork or other meats, followed in from two to five days by anorexia, nausea, vomiting, and cramp-like pains in the abdomen. The patient always suffers from headache and insomnia. If the amount eaten has been large, vomiting and diarrhea are severe. Following the acute intestinal symptoms the patient appears to improve slightly for a period of from ten to fifteen days, when the embryos begin to migrate, and a class of symptoms appear that are in many instances misleading. There may be a series of chills, chilly sensations, or a distinct rigor, followed within a few hours by fever ranging between 100° and 104° F. Within two or three days after the chill, distressing polymyositis appears. Practically all the muscles are stiff. There is a variable degree of muscular spasm, and the muscles of the calf and of the frontal region are extremely tender. There is intense soreness at the base of the chest, and agonizing pain upon deep inspiration — a TRICHINIASIS. 983 symptom due probably to the presence of great numbers of larval trichinae in the fibers of the diaphragm. Dyspnea is at times extreme. The muscles of mastication are sore, and the patient is unable to open his mouth, and even swallowing may give rise to pain. Thermic Features. — The temperature usually falls to near the normal I. 362. — Trichinella Spiralis (Larvae) from He.\d or Right Gastrocnemius Muscle; Seventh Week of Disease (Boston). Fig. 363.— Trichinella Spiralis (Larv«) from Outer Head of Left Gastrocnemius Mus- cle; Twenty-first Day after Symptoms (Boston). within from six to fourteen days. The pulse, as a rule, is increased in pro- portion to the degree of fever. Physical Signs. — Inspection. — The occipitofrontalis and the jaw muscles are swollen, and the calf muscles and those of the arms are similarly affected, the greatest degree of swell- ing taking place near the tendinous insertion of the muscles. There is swelling of the frontal region and of the eyelid and face. The conjunct! vse are greatly congested, and minute hemorrhages beneath the conjunctiva are not unusual. The tendon reflexes are diminished or absent. Urticaria, herpes, and pruritus are present. The pupils are dilated. Palpation. — Firm pressure exerted over any group of muscles gives rise to pain. The tendon-reflexes are lessened or abolished. I^aboratory Diagnosis.— There are but three points of special interest in the laboratory diagnosis — (1) The detection of the adult or embryo trich- inae in the dejecta during the initial attack of diarrhea; (2) the discovery of the embryos in the patient's muscle tissue in from twelve to twenty days after the initial diarrhea (Figs. 362 and 363); and (3) blood findings (p. 984). Methods for Detection. — The skin should be cleansed thoroughly near the tendinous insertion of one of the calf muscles, and the skin and fascia Fig. 364.— Encapsulated Trichina from Muscle One Year after Infection (Boston). 984 ANIMAL PARASITIC DISEASES. then divided down to the muscle-sheath; the sheath is next incised, and a small portion of the muscle removed. This removed tissue should be placed in water and a portion of it teased thoroughly, placed upon a slide, and studied under a f inch objective 'when, if larval trichinae are present, they will be detected among the muscle-fibers. Several months after the initial symptoms the larvae are found to be encysted (Fig. 364). Persons infected with trichinella spiralis display a high degree of eosino- phiha — from 20 to 40 per cent. ; the total number of leukocytes may, how- ever, remaianear the normal. The blood findings are: (o) eosinophiUa, and (6) the detection of the embryo-trichineUi, in the peripheral blood. Herrick and Janeway first demonstrated embryos of the trichinella spirahs in the circulating blood, and their observations have been con- firmed by a number of writers, including A. H. Lamb. Embryos are present in the circulating blood a few days after the onset of symptoms. Experi- mentally, embryos are found to enter the blood in from eight to twenty-five days after infection. The embryo is cylindric, refractile, and curved, with both ends rounded, one extremity being slightly tapered and surrounded by a hyaline capsule. Detection. — Dilute the blood with ten times its volume of three (3) per cent, solution of acetic acid. Shake well, and after the sediment forms lift a portion of it into a pipet for examination. Place on a slide, cover with a thin glass, and examine imder a one-sixth (J) objective. At times it may be well to close down the diaphragm, since these highly refractile bodies are often best seen under a rather feeble illumiaation. Summary of Diagftiosis. — ^A history of having eaten raw or partially cooked meat should always be regarded as of importance when coupled with the general symptoms of muscular rheumatism. Edema over the muscles, and particularly over the frontal region, is of great diagnostic value. A girdle pain foUowiag an attack of gastro-intestinal catarrh, accompanied by diarrhea and vomiting, should give rise to the suspicion of infection with the trichinella spiralis. The diagnosis is substantiated by the detection of the larval trichinae in the muscle tissue (Fig. 363) and blood. Differential Diag'nosis. — The accompanying table shows the dis- tinctive features between acute trichiniasis, acute articular rheumatism, and acute muscular rheumatism: TABLE SHOWING THE POINTS OF DIFFERENTIATION BETWEEN ACUTE TRICHINIASIS, ACUTE ARTICULAR RHEUMATISM, AND ACUTE POLYMYOSITIS. AcDTE Trichiniasis. Acute Articular Rhett- Acute Polymyositis. MATISM. 1. There is a history of 1. History of previous at- 1. History of exposure to having eaten raw or tacks. cold and wet. partially cooked meats (pork). 2. Preceded eight to four- 2. Gastro-intestinal symp- 2. Gastro-intestinal symp- teen days by gastro- toms absent. toms absent, intestinal disturbances, diarrhea, nausea, vom- iting, and cramps. 3. Edema of the forehead 3. Edema absent. 3. Edema absent. and face seen early. 4. Swelling of muscles near 4. Muscles not swollen. 4. Swelling of body of tendinous insertions oc- muscles appears early, curs late. PARASITES OP THE BLADDER AND KIDNEY. 985 «tCUTE TrICHINIASIS 5. Tenderness over the body of the muscles and near their tendin- ous insertions. 6. Joints not swollen. 7. Effusion into the ser- ous sacs of the larger joints absent. 8. Dyspnea pronounced, and girdle pain upon deep inspiration. 9. Eosinophilia develops with the muscular symptoms (4 to 8 per cent, or higher). Em- bryos found in blood. 10. Detection of adult trichinella in the de- jecta during the initial attack of diarrhea. 11. Larval trichina present in the muscle tissues. 12. Conjunctivitis. Acute Articular Rheu- matism. 5. Tenderness over the ar- ticular surface of the long bones, and may in- volve the small joints. 6. Joints swolleri, red, and tender. 7. Effusion into the serous sacs of the larger joints and fluctuation a com- mon sign. 8. Dyspnea not marked, and no girdle pain. 9. Eosinophilia not con- stant and seldom high. Acute Polymyositis. 5. Tenderness over the body of the muscles. 6. Joints not swollen. 7. Effusion absent. 8. A sense of soreness over the chest. 9. Eosinophilia absent, as a rule. 10. No trichina in the de- 10. Feces negative, jecta. Constipation present early. 11. Muscle tissue normal. 12. Rare. 11. Muscle tissue normal. 12. Unusual. Clinical Course and Duration. — Frederick A. Packard, in an analysis of 357 reported cases, found the mortality rate to be 44.07 per cent. Cases terminating favorably go on to recovery ia from three to six months. An early diarrhea is said by some writers to be a favorable symptom, whereas others regard it as evidence of serious intestinal irritation, and as a sign that the patient has ingested a large amount of infected meat. Cysticercus. — The cysticercus represents one developmental stage in the l3e-cycle of the tape-worm (see Taenia solium, p. 968). It is found in the muscles and viscera. PARASITES OF THE BLADDER AND KIDNEY. Among the animal parasites that infect the urinary tract are the sctis- tosomum hsematobium, which may be recognized by the presence of its ova in the urine. Schistosomiasis has been further considered in detail on p. 961. The ova are always found in the urinary sediment and in the small blood-clots. They vary in size from 135 to 160 microns in length, and from 55 to 66 microns in breadth. The extremity of each ovum is provided with a spine (Fig. 341). Ova of oxyuris and ascaris are occasionally seen in the urinary sedi- ment. Ova of the trichuris trichiuria and the adult rhabditis pellio are rarely seen in human urine, and cases have been reported in which the proglottides of dibothrioceplialus have been found in the bladder. Bcfiinococcus Cyst of the Kidney. — Infection of the kidney with the taenia echinococcus is rare in the United States, though quite common in Scandinavia, Greenland, and Iceland. The tumor develops somewhat slowly, but displays aU the physical signs characteristic of other growths of the kidney. In one case studied at the Philadelphia Hospital the cyst rup- 986 ANIMAL PARASITIC DISEASES. tured into the pelvis and the patient voided a large amount of bloody urine that contained booklets of the tsenia ecbinococcus. Bustrongylus. — Rarely, indeed, ova of eustrongylus gigas are found in the urine, three such cases having come under our observation. PARASITIC DISEASES OF THE LUNGS. ECHINOCOCCUS DISEASE. General Remarks. — Ecbinococcus disease of the lung is due to in- fection with the embryo of an animal parasite, the taenia ecbinococcus. The condition is frequently encountered in Australia, Iceland, and Russia. Hyda- tid cyst of the lung may be either primary or secondary, but in the majority of cases hydatid disease of the liver or of other viscera is also present. The statistics collected by authors in different portions of the world vary widely as to the frequency of involvement of the lung in this disease. Thomas, in an analysis of the reports of 1897 cases of ecbinococcus disease collected from practically all parts of the world, found the lung to be the site of disease in 11.59 per cent., whereas the cases collected in Australia showed pulmonary involvement in 16.56 per cent. Hosier and Peiper assert that secondary ecbinococcus disease of the lung frequently results from perforation of the diaphragm by a hydatid cyst of the liver, in consequence of which the hepatic cyst communicates with the pleural sacs or directly with the lung as the result of adhesions existing between the visceral and diaphragmatic pleurae. Bxciting and Predisposing Factors. — Infection with the ecbino- coccus follows the ingestion of the ova of the adult parasite, which is known to infest the intestinal canal of dogs. The most common predisposing factor is intimate association with dogs, the disease being common in Iceland and other countries in which these animals occupy the same quarters as their masters. Principal Complaint. — Frankel distinguishes three clinical stages of the disease: First Stage. — In this the symptoms are vague, but are suggestive of pulmonary congestion. Emaciation and fever are, as a rule, absent, the only symptom of clinical importance being the repeated attacks of hemopty- sis. The quantity of blood expectorated at one time is small, the sputum being merely tinged or blood-streaked. Delgrange declares that hemorrhage from the lung is seldom absent altogether during the initial stage of pulmon- ary ecbinococcus disease. Repeated attacks of acute pleurisy are prone to occur, and moderate effusion into the pleura is not uncommon, although such liquid is absorbed within the course of a few weeks. In cases in which the pleura is attacked dyspnea and cough may be annoying. Second Stage. — This is marked by the appearance of definite physical signs referable to pulmonary disease. Inspection.— li the cysts are numerous, dyspnea is extreme. If a large cyst is present, there may be local bulging of the chest-wall or displacement of the heart. Palpation may show that the tactile fremitus is diminished over the affected areas, whereas in those cases in which the pleura is involved or in which the cyst is surrounded by a dense fibrous capsule, the tactile fremitus may be increased. ECHINOCOCCUS DISEASE. 987 The peraission-note is impaired. As a rule, the breath-sounds over the affected area are feeble, but, on the other hand, they may be exaggerated, depending upon the location of the cyst, the area of congestion surrounding it, and the presence of involvement of the pleura. Impairment may be detected over any portion of the lung, but by outlining the dull area in echinococcus disease this will often be found to be curvilinear, the con- vexity of the curve being directed upward. During this stage pleural effusion is by no means uncommon, and when present, the sjTnptoms of this condition (p. 142) will also appear. Pain in the side, cough, dyspnea, together with dullness and crepitant rales, should suggest echinococcus disease, particularly when the patient has previously displayed the symptoms of the first stage of this malady. Late during this stage the general symptoms suggestive of chronic de- structive changes in the lung make their appearance, and, indeed, at this time the general cHnical picture may simulate closely that of pulmonary tuberculosis (p. 803). Third Stage. — ^This is marked by and succeeds rupture of the cyst or cysts, and the symptoms following such rupture vary directly with the direc- tion in which the contents of the cyst are discharged; e. g., in those cases in which the cyst ruptures into a bronchus, this may be ascribed to paroxysmal coughing, heavy lifting, or violence to the thorax. Cough is, as a rule, present during the stage of rupture, irrespective of whether or not the cyst communicates with a bronchus. Following rupture into the bronchus there is copious expectoration of a clear fluid or semifluid material that is found microscopically to contain hooldets, scohces, and often fragments of cyst membrane (Fig. 361), all of which are characteristic products of the taenia echinococcus. Secondary infection of the cyst may have taken place, when the material expectorated will be purulent in character. Pulmonary hemor- rhage may be profuse at the time of rupture. Rupture into the pleural cavity may be accompanied by a mild expres- sion of shock, following which pneumothorax frequently occurs, although the cyst contents may escape into the pleural cavity without evincing the usual symptoms; on the other hand, the symptoms and signs of pleural effu- sion may be present. Dieulafoy has called attention to the development of urticaria prior to rupture of the cyst, and artificial evacuation of the cyst may also be followed by this cutaneous manifestation. X-Ray Diagnosis. — In 1907 Levy-Dom and Zadak reported their findings in a case of pulmonary echinococcus disease in which a distinct oval, black shadow was seen in the left lung, and another lighter shadow in the middle portion of the right lung. Summary of Diagnosis. — The diagnosis is based solely on the de- tection of the products of the echinococcus cyst in the sputum or in the fluid obtained by aspiration. Clinical Course. — ^Months and sometimes years are necessary for the cyst to develop to a size sufficient to produce physical signs. The chron- icity of the disease depends largely upon the number of cysts present, and to some extent upon their location. Surgical interference not only modifies the course of the disease, but is said by Luffier to effect a cure in 90 per cent, of all cases. Spontaneous rupture into a bronchus is, as a rule, followed by recovery, although the illness is somewhat protracted. (See Diseases of the Lung, Collection of Sputum, p. 82.) 988 ANIMAL PARASITIC DISEASES. AMEBIC ABSCESS. Pathologic Definition. — A disease of the lung secondary to ame- bic abscess of the liver, caused by the entamoeba histolytica, and charac- terized by destruction of the pulmonary tissue with pus-formation. Principal Complaint. — ^There is usually a history of having resided in the tropics, and of having suffered from an attack of dysentery, the clinical course of which corresponded closely to that described under Amebic Dysen- tery (p. 964). Primary amebic abscess of the lung is extremely rare, the condition usually complicating amebic abscess of the liver (p. 982). Summary of Diagnosis. — The diagnosis is based entirely upon the detection of the entamoeba histolytica in the sputum. In a case under our observation the sputum was frequently tinged with blood, and amebae were present over a period of several months. PARAGONIMIASIS (Endemic Hemoptysis). Pathologic Definition. — A chronic disease of the lung caused by a trematode worm, paragonimus Westermani, which produces cavities in the lung tissue, in which there is a characteristic exudate containing the ova of the fluke. Geographic Distribution. — Thus far almost all cases of paragon- imiasis have been reported from Japan, Korea, the Philippine Islands, Formosa, and China. The disease has been transported to the United States, although but few cases are on record. A peculiar disease characterized by bloody sputum and pulmonary hemorrhage has been detected in various por- tions of the United States among cats, dogs, and hogs, and the transmission of this disease to North America is doubtless explained by the great numbers of emigrants from the far east that settle in all sections of this country. Bxciting and Predisposing Factors. — The disease is caused by the presence of the lung fluke, paragonimus Westermani. Residence in Formosa, Japan, China, Korea, and certain of the East India Islands is the most potent predisposing factor. Principal Complaint.— Cough is the most annoying symptom, being present during almost the entire course of the disease, and is usually most urgent upon rising after a night's sleep. Paroxysms of coughing are not unusual, and are frequently accompanied by the expectoration of a rusty brown, bloody-looking sputum that resembles anchovy sauce in ap- pearance. When the patient clears his throat he is often able to eject a small quantity of this somewhat characteristic sputum. As a rule, there are repeated attacks of hemoptysis; these are slight at first, but as the disease progresses, profuse hemorrhage may follow. The patient states that upon slight exertion, even that of walking hurriedly, this bloody-looking fluid may be expectorated. Extreme weakness is present, and the general symp- toms referable to secondary anemia appear, being dependent for their inten- sity upon the amount of lung destruction that has taken place. I/aboratory Diagnosis. — The sputum is usually quite profuse, es- pecially after violent coughing; it is dark brown in color, and, as a rule, con- tains no blood, the color being due to the ova that are present. Free red blood-corpuscles may at times be found. Filaria. — The literature contains records of the embryo filaria bancrofti having been found in the bloody sputum. DEACTJNCULUS MEDINENSIS. CUTANEOUS PARASITES. 989 DRACUNCULUS HEDINENSIS (GUINEA-'WORM). Remarks. — Dracontiasis, or guinea-worm disease, is a tropical affection caused by the dracunculus medinensis. The adult parasite inhaljits the connective tissue, and belongs to the class of nematodes (Fig. 365). It is found on the western coast of Africa, India, Brazil, and Arabia. The adult Fig. 365. A, Embryo of guinea-worm (Dracunculus medinensis) ; i?, adult female guinea-worm (Boston, after Briatow). female worm is cylindric in form, al:)Out 26 inches in length, and -^ inch in diameter; it is of a milky color, and has smooth surfaces, with a tapering tail that is bent abruptly near its tip. The head is provided with a tri- angular mouth surrounded by six papillse. The uterus extends nearly from the head to the taU, and is filled with embryos. Predisposing Factors. — Man is probably infected by drinking water containing a small crustacean known as cyclops, which acts as the intermediary host. 990 ANIMAL PARASITIC DISEASES. The Embryo. — The embryo (Fig. 365) is nearly one-half inch in length, and its alimentary canal is readily distinguishable. The impregnated female works her way through the intracellular connective tissue for a period of from nine to twelve months, and when fully matured, burrows toward the legs, just above one of the malleoli; and she then migrates toward the sur- face of the skin, where a small vesicle is produced, which finally ruptures. The head of the worm, near which the uterus is located, is now in a position from which the embryos may be discharged. Symptoms of guinea-worm disease do not develop until the parasite is fully matured, when a vesicle or abscess appears at the site where the parasite comes in relation with the skin. There may be localized swelling, a feeling of tension, sensitiveness, and red- ness, and in many instances the worm may be felt beneath the skin. Develop- ing from the abscess is a more or less extensive ulcer, from which a portion of the adult parasite may protrude. Detection. — The milky discharge from the ulcer, when examined mi- croscopically, will be found to contain a number of embryos (Fig. 365). Summary of Diagnosis. — ^The finding of the embryo of the parasite in the discharge from cutaneous ulcers is positive evidence of the existence of this disease. PSOROSPERMIASIS. Psorosperms belong to that order of protozoa known as sporozoa. A common form occurs in the muscles of swine (sarcocystis Miescheri). Internal Psorospermiasis. — In man hepatic disease similar to that found in the rabbit is produced by the coccidium oviforme. The tumors formed by the coccidia may be palpable, and the liver may be quite tender. Chilliness, fever, malaise, stupor, and coma have been observed. In the intestinal variety of internal psorospermiasis nausea, vomiting, diarrhea, and the typhoid state may be seen. Involvement of the kidneys has given rise to hematuria. External Psorospermiasis. — Cutaneous psorospermiasis, one vari- ety of which was formerly termed keratosis follicularis, is characterized by the presence of lesions that at first are hard, crusty, and papular, later becoming confluent, situated on the face and lumbo-abdominal and inguinal regions. These growths contaia either parasitic sporozoa or, as suggested by Montgomery, Darier, and others, parasites that belong to the blastomyces. PARASITES OF THE EYE. CYSTICERCUS. This form of the tape-worm has been known to invade the orbit. FILARIA. The adult filaria loa has been recovered from the conjunctiva of man, as well as from the eye of the horse. MYIASIS. This disease is an infection of the human tissue with the larvae of certain dipterous insects. If these larvae are found in the skin or in the mucous membrane of a cavity communicating with the surface of the body, such as the nose, the external auditory canal, or the vagina, it is known as external PARASITIC DISEASE OF THE BRAIN. 991 myiasis. If the larvae are passed with the feces, the condition is termed internal myiasis. In the United States compsomyia macellaria, the screw- worm, is the most important of these parasites, although cases of infection with the larvse of dermatobia noxialis are on record, and Swan* reported a case of infection with the larvse of lucilia serricata, and a case of infection with the larvae of lucilia ccesar, which occurred in Philadelphia. Clinical Features. — The larvae are known to burrow through the tissues, destroying the mucous membrane, the muscles, and the cartilages. They may invade the serous sacs and the bones, producing extensive lesions. They have been recovered from the eye and the conjunctivae. George Gray has reported five instances in which the larvae of the screw-worm were found in human beings. He states that the parasite is common in domestic animals, and that it is widely distributed throughout America. PARASinC DISEASE OF THE BRAIN. Cysticerci are occasionally found within the substance of the brain and the ventricles, a case having been reported by J. Hendrie Lloyd. (See section on Nervous Diseases.) The Plasmodium of malaria may be found to plug the smaller blood- vessels of the brain. * Jour, of Tropical Medicine and Hygiene, January 1, 1910. CONSTITUTIONAL DISEASES. DIABETES HELLITUS. General Remarks. — A disease of metabolism characterized by atrophy of the islands of Langerhans, fatty infiltration of the liver, or organic changes in the brain, with abnormal carbohydrate digestion. The syndrome necessary to produce typical diabetes is composed oi: (1) Intense thirst; (2) polyuria with glycosuria; (3) progressive emaciation and weakness; and (4) an inordinate appetite. When the urinary phenom- ena constitute the chief symptoms presented by the patient, the condition is known as glycosuria. Clinical Types. — (1) Infantile Diabetes. — Diabetes of the new- bom and diabetes occurring during the first decade of life is, as a rule, hered- itary, although traumatism and acute infectious maladies have been re- garded as potent factors in the production of this affection. Infantile diabetes is a rare condition, but we have studied the urine of 11 cases of diabetes mellitus occurring in children under ten years of age. (2) Pancreatic Diabetes. — In this type of the affection other evidences of pancreatic disease are commonly present. This variety may differ from other forms of diabetes in that, in quite a large percentage of cases, polyuria and intense thirst are absent or but feebly manifest. Pancreatic diabetes runs a more chronic course than infantile diabetes, but the two varieties are equally fatal. (3) Phosphatic diabetes is a condition in which many of the general symp- toms of diabetes are present, and, in addition, there is a decided increase in the elimination of phosphates. This increase has been known to reach a maximum of nine grams excreted during the twenty-four hours. ' When phosphates are present in abundance, glucose is often absent from the urine, but following a decrease in the phosphates, glucose appears in the urine; the alternation of phosphaturia with glycosuria constitutes the cardinal symptom of this malady. (4) Alimentary Glycosuria. — This is a form dependent upon the too liberal imbibition of carbohydrates, together with the inability to digest such substances. (5) Transitory Glycosuria. — This type of glycosuria is oftenest encoun- tered after a breakfast that has been rich in carbohydrates. In certain low- grade conditions transitory glycosuria is not unusual, and for convenience of description these have been classified under the following subheadings: (a) Toxic; (6) puerperal; (c) digestive; (d) intermittent glycosuria of arthritis; (e) cerebral glycosuria. Toxic glycosuria is the term applied to the appearance of glucose in the urine after the administration of such toxic substances as hydrochloric acid, sulphuric acid, mercury, strychnin, glycerin, alcohol, nitrobenzol, lead, arsenic, phosphorus, potassium iodid, caffein, thyroid extract, tuberculin, pancreatin, phloridzin, diuretin, carbon monoxid, and morphin. Analgesics 992 DIABETES MELLITUS. 993 and anesthetics also possess the power of exciting transitory glycosuria, and several instances are recorded in which glycosuria has followed the adminis- tration of chloral,! chloroform, and amyl nitrite. Several observers found small quantities of glucose in the urine after ether anesthesia, and Andral reports a case of true diabetes developing after ether narcosis. Pathologic transitory glycosuria (toxic) is best exemplified by the gly- cosuria of cerebrospinal meningitis; it is also seen, though less commonly, in relapsing fever, typhoid fever, cholera, and diphtheria, in the advanced stages of pulmonary tuberculosis, rickets, and gastritis. During the course of certain acute infections, viz., scarlatina, measles, smallpox, malaria, and whooping-cough, glycosuria is occasionally encountered, and it has been known to follow such chronic conditions as interstitial nephritis, gall-stone, asthma, and syphilis. Glycosuria developing during the course of another malady is often re- ferred to as functional glycosuria. Digestive glycosuria is recognized by its disappearance after the with- drawal of carbohydrates from the diet and the correction of digestive dis- orders. Intermittent glycosuria of arthritis should possibly be included with hereditary glycosuria of the young or with that of gouty and obese adults. (6) Cerebral Glycosuria. — A condition in which the presence of glucose in the urine is dependent upon a pathologic state of the central nervous system. Von Jaksch has found glycosuria in hysteric women and in cases of phosphorus-poisoning in which autopsy disclosed the presence of fatty degeneration of the liver. We have found glucose in the urine during the febrile stage of cerebrospinal meningitis, aiid glycosuria has been known to develop during the course of neuritis. Transitory glycosuria occurs in disseminated sclerosis, epilepsy, neuralgias, neuroses, psychoses, exoph- thalmic goiter, myxedema, after prolonged mental strain, sudden emotions, anxiety, and in certain forms of insanity. (7) Traumatic glycosuria not infrequently follows severe injury to the head, chest, abdomen, or extremities; but in this case the presence of glucose in the urine is, as a rule, of short duration or intermittent in nature. (8) The so-called puerperal glycosuria is usually due to the absorption of lactose from the mammary gland. It may make its appearance at any time throughout the course of gestation or during the puerperium. We have studied more than 50 cases of puerperal glycosuria, and in many of these the condition did not exist prior to conception; in others a history of intermittent glycosuria was obtained. In more than 25 per cent, of the cases the patients were Hebrews, but in none did the amount of glucose present exceed 2 per cent. Predisposing' and Bxciting Factors. — (a) Age and heredity figure prominently as etiologic factors of diabetes. Heredity is generally conceded to be the most potent predisposing influence, two, three, and in one instance five members of the same family having suffered from the disease. Heredity is said to figure prominently in the diabetes of children. The majority of all cases of diabetes occur between the thirty-fifth and sixtieth years; the malady is rarely seen before the tenth year, although it has occasionally been observed in children under one year of age. (b) Sex. — Males are more frequently affected than females, except in the diabetes of children, in which sex does not appear to exercise any appreciable influence. (c) Season. — The greatest number of cases are seen in March, July, and 63 994 CONSTITUTIONAL DISEASES. November, but since diabetes is usually chronic in nature, but little impor- tance can be attached to season as a predisposing factor. (d) Race exerts a decided influence in the production of diabetes, the disease being extremely rare in the negro and particularly common in the Caucasian. (e) Nationality also figures in the production of diabetes. Hebrews are more often afflicted than Gentiles, a fact thought to be due not so much to the habits and customs of the Jewish people as to their intermarriages. (/) Station. — Diabetes is a disease of the well to-do members of society; in our service at the Philadelphia General Hospital and in various medical clinics in Philadelphia it is rarely encountered, whereas in private practice a large number of cases are seen. (g) Nervous Influences. — Sudden shock, such as the loss of friends, or severe financial reverses are not infrequently followed by the onset of dia- betes; prolonged mental strain, study, and combined mental and physical overwork are also potent factors in its causation. (h) Occupation plays a small part in the etiology of diabetes, although the disease is somewhat more common in clerks than in those who do strenu- ous muscular work. Obesity, gout, rheumatism, syphilis, and pregnancy (puerperal diabetes) have aU been named as etiologic factors. (i) Incidence. — Diabetes is said to affect the residents of cities more often than those living in the country. This is possibly due to the fact that little attention is paid to urinalysis in the rural districts. Hare's statistics show that diabetes is increasing in America; and there is statistical evidence to show that in India and in France the percentage of cases of diabetes is progressively increasing. (f) Contagion is believed by a few to exert an etiologic influence in dia- betes, and according to Senator's analysis of 770 cases, in 9 both husband and wife suffered from this malady. Shram' s statistics, covering 5000 cases, further supports the theory of contagion. Among the exciting factors are: (1) Pancreatic disease; (2) hepatic disease; (3) disease of the brain or nervous system (sclerosis, tumors, cysts, lesions of the fourth ventricle or of the spinal cord) ; and (4) traumatism — e. g., trauma to the spine, loins, and abdomen, injury to the head and ex- tremities. Special Clinical Types. — For convenience of description and to avoid confusion the disease will be considered under the heads of acute Dia- betes Mellitus, Chronic Diabetes Mellitus, and Glycosuria, the three varieties presenting one common leading symptom, namely, the appearance of glucose in the urine. Acute Diabetes Mellitus. — Instances in which diabetes may be said to run an acute course are extremely uncommon, yet it is not unusual to see cases in which the various symptoms of the disease follow one another in rapid succession. In such cases emaciation, progressive weakness, a high percentage of glucose in the urine, and the presence of acetone and diacetic acid in the fluid all develop within a few months, a fatal termination occurring in less than one year. 'To be accurate, this group of cases should be con- sidered as subacute, but when compared with the chronic types of the malady, which may continue over a period of from three to thirty years, this variety may be regarded as acute. Chronic Diabetes Mellitus. — The onset is insidious, and the patient is often unaware of his condition until it is discovered as the result of urinalysis. Among tB8* early symptoms there may be dyspnea or gastritis, or the DIABETES MELLITUS. 995 patient may complain of being constantly tired, and exhibit some mental hebetude. Following these symptoms the knees may seem to bend too far backward or the clothing lie as a weight upon the shoulders. Later more pronounced and characteristic symptoms of the malady appear, but these, as a rule, foUow one another slowly, an interval of from three to six months elapsing between the appearance of the different characteristic features to be described further on. Diabetes follovnng shock, traumatism, or extreme grief and anxiety may begin abruptly, and pursue a somewhat acute course for several nionths, when all the manifestations of the disease become chronic in nature, and the patient may live for several years. In this tj^je of diabetes glycosuria may occur at intervals, particularly after a meal rich in carbohydrates. This sjonptom is almost always intermittent in character for a period of months or even years. Polyuria, ravenous appetite, intense thirst, and gradual pro- gressive wealmess, with marked nervous symptoms, constitute the initial symptoms that suggest true diabetes. Glycosuria. — ^Under this head are included those cases in which glyco- suria is the only symptom, the other characteristic manifestations of diabetes mellitus being absent. In the majority of cases of simple glycosuria, there- fore, polyuria, emaciation, progressive weakness, and nervous symptoms are not present. Glycosuria is seldom continuous, but, instead, runs a remittent or an intermittent course. Again, glycosuria is commonly dependent upon dietetic errors, overexertion, either physical or mental, or the presence of some acute or chronic infection. Glycosuria may occur as the result of faulty digestion, either gastric or intestinal, or from faulty metabolism of a questionable nature, which is not essentially associated with appreciable disease of the pancreas, liver, or brain. In glycosuria the cutaneous symptoms, intense thirst, and ocular mani- festations common to diabetes mellitus are lacking. The condition is readily amenable to treatment, in which respect simple glycosuria differs markedly from diabetes mellitus. Principal Complaint. — The patient may complain of general malaise and weakness, or state that he is tired after a night's rest. His clothing appears to be too heavy for comfort, and he is frequently unable to wear an overcoat. There are soreness and weakness of the calf muscles. A history of having taken on flesh during the past few months or years is often obtained, and the patient attributes his shortness of breath and exhaustion to the increase in. weight. The appetite may at first be unaffected, but as the disease progresses it becomes ravenous, and there is a craving for sugars and carbohydrates. Occasionally, however, the appetite may remain normal throughout the entire course of the disease. After diabetes has progressed for an indefinite period thirst develops, and increases with the progress of the disease. The greater the amount of glucose in the blood, the more intense is the thirst, until, in advanced cases, it is not unusual for the patient to drink several gallons of water during the twenty-four hours. Cases have been observed, however, in which all the other cardinal symptoms of diabetes were present except the intense thirst and polyuria. Oral Symptoms. — The tongue is large and dry, even in the early stages of diabetes, and as the disease progresses this dryness becomes more and more marked, until, in the later stages, the tongue is parched, fissured, and of a bright-red color. In some cases it is coated, and the lips are dry^d fissured, 996 CONSTITUTIONAL DISEASES. the gums swollen and edematous, and, rarely, a bloody exudate escapes from the bases of the teeth. The secretion of the mouth is commonly acid in reaction, and when the saliva is subjected to chemical analysis, it will be found to contain glucose. Stomatitis develops during the course of advanced diabetes, when the gums recede from the teeth, the teeth decay and become loose, and small ulcers form along the margins of the gums and on the cheeks. Infection of the buccal mucous membrane by the thrush fungus and other extensive ulcera- tions of the mucous surface occasionally develop. Digestive Symptoms. — Considering the quantity of food ingested, the digestive function is almost normal early during the course of diabetes, but later, after the patient has become extremely emaciated and weakened, less food is taken, and the digestion becomes impaired. The bowels may move regularly or there may be constipation or diarrhea; the latter condition lasts for but a short period, and is followed by constipa- tion. In those cases in which the diabetes is due to disease of the pancreas or to obstruction to the escape of bile into the intestines, the stools may con- tain fat. Cutaneous Manifestations. — The skin is apparently normal to the touch early during the course of diabetes and before polyuria has developed, but after the disease is well advanced, the skin becomes dry and rough, and sweat- ing is absent, even in the groins and axillce. In advanced diabetes the pa- tient is extremely pale, and at times a slight lemon tint is observed. Boils and abscesses of the skin are a prominent feature of well-established diabetes. Itching of the skin, particularly at night, is present in about 60 per cent, of all cases. In fact, itching of the scalp and of the skin over the calf muscles may be among the earliest symptoms of diabetes. Eczema of diabetic origin is one of the most annoying manifestations of this affection; it usually develops about the genitalia, but may affect any portion of the body. In a case studied at the Philadelphia Hospital the entire body was involved in the eczematous process. The hair becomes dry and lusterless, and in nearly all cases tends to fall out after the other symptoms of diabetes become well marked. The nails become thickened and homy, or extremely brittle, and their surfaces are marked by furrows and ridges. In a case seen by us onychia with shedding of the nails occurred. Owing to the extreme emaciation the bony skeleton becomes especially prominent. Gangrene of the feet, particularly of the toes, is a serious cutaneous symptom, and is due to general arteriosclerosis. Pruritus vulvae in the female and balanitis in the male constitute trouble- some symptoms, and are probably due to the irritating properties of the diabetic urine. Abscesses of the vulva often cause intense suffering. Ocular Phenomena. — The conjunctivse are pale and often show peculiar yellowish spots — deposits of fat. The margins of the eyelids are commonly reddened and covered with small scales. Abscesses and boils of the eye- lids are distressing, and faiUng vision, retinal hemorrhages, and cataract all occur during the later stages of diabetes. Aural Symptoms. — Among these may be mentioned otitis media, otalgia, tinnitus aurium, and, rarely, mastoid disease. Respiratory Symptoms. — Pulmonary complications do not occupy a prominent place in the general symptomatology of this affection. Pul- monary tuberculosis is a common termination of diabetes, but among the cases studied by us it was not of frequent occurrence. Pulmonary gangrene is an occasional finding. Both lobar and lobular pneumonia have been DIABETES MELLITUS. 997 known to complicate diabetes. Dyspnea is often present, and is dependent either upon pulmonary disorder or upon general wealmess with cardiac failure. The mucous membrane of the nose and pharynx is dry, and the patient's voice is somewhat husky. Rhinitis is uncommon. Abscesses of the nose are of frequent occurrence, and we have seen several cases in which abscess of the nose preceded the onset of diabetic coma. Ciradatory Peculiarities. — In advanced diabetes the circulatory tension is, as a rule, high, and the arteries are wiry and atheromatous. The frequency of the heart's action is not increased unless the patient is unusually weak, and in fact during the early stages of arteriosclerosis the pulse may be found to vary between 40 and 70 beats a minute. Sexual Weakness. — Impotence and a premature menopause may be among the earliest symptoms of diabetes, and should always be regarded as sugges- tive of this malady. Diabetic women rarely conceive. The disease often develops during the period of gestation, and in such instances is likely to continue after dehvery. It has been asserted that premature delivery is to be expected, but there is little evidence to show that instrumental interrup- tion of pregnancy materially benefits the sufferer. Intense itching of the vulva, with shooting pains in the clitoris, is a most troublesome symptom. In the male, hypersensitiveness of the glans penis may-be present in advanced diabetes. Muscular cramps occur in a large proportion of all cases of confirmed diabetes, and these are most likely to affect the muscles of the calf of the leg. Cramp iu the region of the stomach (gastric crises) may occur at any time during the day, the ingestion of certain foods being held responsible for the gastric pain. In one of our patients intestinal cramp was excited by the eating of an orange or the drinking of orange-juice, and a much less severe paia followed the ingestion of tomatoes. Nervous Symptoms. — Peripheral neuritis may develop during the course of diabetes, and is accompanied by numbness and tingling of the extremities, and such trophic disturbances as perforating ulcer and thickening or even shedding of the naUs. Neuralgia is a prominent symptom, and may affect the lower extremities, loias, back, face, or arms. Diabetic tabes exhibits many of the features characteristic of ataxia; thus the knee-jerks are diminished or absent, as is shown by Williamson's series of 50 cases of diabetes, among whom 25 showed this sign. Lancinating pains, paralysis of the extensor muscles of the feet, and the ataxic gait are observed, and paraplegia has also been encountered. Temperament. — ^The patient is extremely irritable, and is unduly affected by trivial causes. Hysteric outbreaks and hypochondriasis are seen to occur during any stage of the disease. The mentality may be unusually active at times, the power of concentration of mental forces being abnormally in- creased, but following such period there is a corresponding stage of mental hebetude. Coma. — Diabetic coma develops only at the terminal stage of this affec- tion in about half the cases. It is almost invariably fatal. We have found coma to occur earlier during the course in young patients and in those in whom emaciation and prostration were rapid and progressive. The pre- cursors of coma are: Afruityodorof the breath and of the urine; a reduction in the amount of glucose excreted; a diminution in the quantity of urine voided during the twenty-four hours; an increased reaction for acetone and for diacetic acid in the urine; the appearance of /?-oxybutyric acid in the 998 CONSTITUTIONAL DISEASES. urine; the occurrence of a chill or of a series of chilly sensations; intense headache, dimness of vision, and neuralgic pains in various parts of the body. For convenience of study we have classified diabetic coma under five heads, as modified by Anders: (1) Abortive coma, which tends to run a short course and terminates in recovery; in this class of cases there is a special tendency for repeated at- tacks of coma to occur, one of which ends fatally. (2) A group in which diabetic coma follows violent exercise with extreme exhaustion and circulatory collapse. To this group the largest number of cases belong. This form of coma is, as a rule, fatal, lasting for from a few hours to four days. (3) Cases in which headache and the other signs of severe autointoxica- tion are followed by coma, a fatal issue ensuing within a few hours. (4) Coma developing abruptly during the course of an acute inflammatory process, such as abscess, tonsillitis, gastritis, etc. In this type of coma the circulatory, respiratory, and febrile symptoms may be prominent, but bear no direct relation to the degree of coma, which continues for from one to five days, ending fatally. (5) Coma developing in aged persons during the course of such chronic conditions as eczema and gangrene. Thermic Features. — The temperature may be normal throughout the course of diabetes. Not uncommonly, however, the temperature fluctuates between 99° and 100° or even 101° F. in cases in which there is no positive evidence of the existence of an acute inflammatory process. An elevation of temperature the result of a complicating acute infection resembles more or less closely that peculiar to the existing condition. In many cases of diabetes a subnormal temperature is present, particularly during the morning hours. I/aboratory Diagnosis. — One of the early symptoms of diabetes is the presence of glucose in the urine. (See Tests, p. 653.) Numerous writers have maintained that glucose is found in normal urine. It is our opinion that normal urine does not contain glucose in sufficient quantity to reduce Fehling's solution, and that a urine that will give a positive reaction for glucose with that solution is a pathologic one. Undoubtedly, normal urine contains a carbohydrate substance, but, we believe, no glucose. The quantity of urine voided during the twenty-four hours is, as a rule, above the normal (50 ounces), and as much as from 200 to 500 ounces may be excreted. The specific gravity is high, varying between 1.025 and 1.050, although we have detected small amounts of glucose in urines of low specific gravity — 1.010 and even 1.006. The reaction of diabetic urine is acid; it is of normal color, free from sediment, emits a sweetish odor, and upon shaking displays a heavy white froth that remains for some time. Chemically, the urine is found to contain glucose in variable amounts, a typical case showing from 1 to 3 per cent, of glucose. Early in the disease, however, there is merely a trace of glucose — too small a quantity to be es- timated; in other cases the glucose may exceed 5 per cent. As a rule, the percentage of glucose present in the urine in a given cases of diabetes or of glycosuria will be found to fluctuate in direct proportion to the amount of carbohydrates ingested; thus, we have seen the percentage of glucose fall from 4.5 to 1 per cent, after the withdrawal of carbohydrates from the diet. Occasionally a specimen of urine will be found to contain both albumin and glucose. The amount of colloidal coefficient is high, exceeding 1.79. DIABETES MBLLITUS. 999 The detection of fat in the feces is highly suggestive of pancreatic dia- betes. A microscopic study of the urine should always be made. Evidences of nephritis are uncommon in diabetes, but when the disease has reached an ad- vanced stage, marked nephritis may be present, and even before the terminal renal lesion develops, casts may be found in the urine. Blood. — There is a secondary anemia, and a differential count shows an increase in the lymphocytes to 40 or even 70 per cent. In eczema and inflammatory conditions of the skin (boUs, abscesses) cocci, bacilli, and fungi may be detected in the secretions from these lesions, but these are probably but another proof of the lowered resistance of the patient. Illustrative Case of Diabetes Mellitus. — P. R., male, aged thirty-four years; apparent age, forty years. Height, 5 feet 8 inches; weight, 170 pounds. Since the age of thirty he has taken on weight somewhat rapidly, going from 150 to 170 pounds. Family History. — Father living and healthy at the age of fifty-six years; mother died at forty-five after having suffered from diabetes for several years. One maternal uncle, now fifty years of age, has periodic attacks of glycosuria. A brother of eighteen and one of twenty-six are reported as being in good health. Previous History. — In addition to the usual diseases of childhood, he had diph- theria at the age of twelve. From this time until after the age of thirty he does not re- call having consulted a physician, except, perhaps, for an acute cold. Social History. — Married four years ago; one child living and in good health. A business man by occupation, and has undergone heavy financial strain during the past two years. Present Illness. — For some months past he has noticed that his appetite was abnormally increased, and while he has not observed a special fondness for sweets, he admits taking a large amount of starchy food. During the past year there has been inordinate tlnrst, although no accurate estimate of the quantity of liquid taken during the day could be ascertained. He has been annoyed at night by itching of the skin and of the rectum and genitalia. Six weeks ago an abscess developed on the buttocks, and since then four smaller abscesses have appeared. The patient tires easily on moderate exercise, and states that even the weight of his coat on his shoulders is distressing. Pain. — There is a sMght stiffness and soreness of the joints, particularly of the ankles and knees, most marked on arising after a night's sleep or after sitting for some time. Nervous Phenomena. — He becomes exhausted after mental strain, and has observed that he has been unable to cope with financial problems that ordinarily caused him no annoyance. He sleeps fairly well during the night, but on certain days the mind is not clear and he becomes drowsy, such mental hebetude not being relieved by sleep. Physical Examination. — General. — The patient is well nourished; the skin and mucous membranes display an unusual color, and the cheeks are slightly flushed. The skin is dry, and there is slight scaling upon the arms and limbs, and eczema of the genitalia and inner surface of the thighs. The hair has lost its luster, and is sparsely distributed over the scalp, although the patient states that his hair was unusually heavy two years ago. At times the mind is remarkably clear, although he tires easily after moderate exertion; mental dullness and irritability are present. Palpation. — The skin is dry and somewhat rough. Laboratory Diagnosis. — The quantity of urine voided during the twenty-four hours varied between 90 and 120 ounces was clear, did not show a sediment upon standing, emited a sweetish odor, and had a specific gravity of 1.035. Chemically, it gave a reaction for glucose, of which 2 per cent, was present. Course of the Disease. — Following medication and the observance of a re- stricted diet the quantity of glucose excreted was reduced by about one-half, but de- spite this reduction the patient continued to lose weight until two years later, when he weighed 128 pounds. Weakness was progressive, and at the age of thirty-eight he was unable to foUow his usual vocation. At this time an ophthalmoscopic examination was made and retinal changes were found. His condition progressed from bad to worse and terminated in diabetic coma and death within the course of five years. Summary of Diagnosis. — The syndrome necessary to the diagnosis of diabetes mellitus includes intense thirst, polyuria with glycosuria, pro- 1000 CONSTITUTIONAL DISEASES. gressive weakness and emaciation, and polyphagia. If any one of these symptoms is absent in a given case, we are dealing with atypical diabetes or with alimentary glycosuria. For convenience of study diabetes and gly- cosuria have been considered together, although they may differ widely in their clinical manifestations, etiology, and prognosis. Course and Duration. — The conditions influencing the prognosis in diabetes are: (a) The-age of the patient; (&) the presence or absence of a history of traumatism to the trunk or cranium; (c) a history of heredity; (d) the mode of development, e. g., whether it occurred during gestation, after delivery, or following severe shock or mental strain; (e) overeating of all kinds of foods, particularly of starches and sugars. Again, the prognosis is influenced by environment, occupation (sedentary or active), and the patient's ability to carry out a proper course of treatment. Diabetes developing during the first year of life, and even before the tenth year, runs a rapid course, and usually terminates in death within from six months to two years. The younger the patient, as a rule, the more rapid and shorter is the course of diabetes. When the disease appears during the third, fourth, and fifth decade, it runs a more chronic course, and may continue over a period of from ten to thirty years. Diabetes following traumatism is seldom amenable to treatment and generally runs a rapid course. Hereditary diabetes developing early in life is of short duration, but if it develops later, it may be materially influenced by judicious treatment, although, as a rule, the prognosis in these cases is unfavorable. Diabetes developing during the course of pregnancy, soon after delivery, or following severe shock and mental strain may be either mUd or severe in character. We have seen cases belonging to this last class in which diabetes persisted for more than thirty years. In one instance, that of a woman now under observation, glycosuria developed during a period of gestation thirty- five years ago, and she is at present suffering from diabetes, and has had one attack of coma within the past year. When diabetes appears as the result of overeating and of insufficient exercise, sedentary habits, and the like, the correction of such habits is followed by a decided amelioration in all the symptoms, and the prognosis is favorable. DIABETES INSIPIDUS. Pathologic Definition. — A chronic disease without characteristic organic changes demonstrable at autopsy. In some cases h3^ertrophy of the kidneys has been seen; in others tumors of the floor of the fourth ventricle have been discovered. Predisposing and Exciting Causes- — (1) Heredity serves as the most potent predisposing factor, a statement that is borne out by the statistics of Weil, who found that in the 91 descendants of a certain family, 23 suffered from polyuria. The records of the descendants of a man living in northern Pennsylvania who was afflicted with diabetes insipidus showed that 18 cases of diabetes insipidus appeared in three generations. In the series of cases just referred to males and females seemed equally prone to transmit the disease, although not a single instance of polyuria in a female was found. It was the rule, however, for each female who married to bear one or more sons who suffered from diabetes insipidus, but in no instance did a son have more than one heir who displayed this malady. (2) Sex. — Males are afflicted more often than females. RACHITIS. 1001 (3) Age. — It is generally conceded that diabetes insipidus occurs most frequently in children and during early adult life, although we have en- countered several cases occurring in men from thirty to sixty years of age. (4) Temporary diabetes insipidus may follow extreme shock, as from fright, nervous strain, traumatism to the head, and, rarely, trauma of the trunk and extremities. It may also occur in acute infectious diseases, e. g., acute nephritis, influenza, etc. Lesions of the fourth ventricle are said to cause diabetes insipidus, and it has also been known to follow paralysis of the sixth nerve. The polyuria following hysteric attacks also belongs to this category. Principal Complaint. — Diabetes insipidus develops gradually with the growth of the child, so that the mother does not realize that the child is taking an abnormal quantity of liquids until it is two or more years old. If the malady follows traumatism or disease of the brain, it develops abruptly. The frequent passing of large quantities of urine is a constant symptom and is usually followed by intense thirst and the imbibition of a large quan- tity of water. The appetite is normal. The skin and mucous surfaces are generally drier than in health. Indigestion is frequently present, although it is by no means a constant finding. In one case seen by us the patient was able to take large quantities of intoxicants, particularly beer, without be- coming affected. I/aboratory Diagnosis. — The quantity of urine voided during the twenty-four hours is in direct proportion to the amount of fluid ingested, and will be found to fluctuate between 20 and 50 pints. Such urines are pale, of low specific gravity, — 1.001 to 1.006, — and show a low percentage of sohds, although the total amount of solids voided during the twenty-four hours may equal or exceed that of the normal. Rarely, traces of glucose are present, and inosite has been found. Albumin is usually absent. Stimmary of Diagfnosis. — ^The diagnosis is based upon the existence of polyuria without glycosuria, and the presence of intense thirst in a patient who is well nourished. Clinical Course. — The prognosis as to life is good, diabetes in- sipidus seldom, if ever, causing death. The application of judicious treat- ment is said to give relief in selected cases. RAOnXIS (RICKETS). Pathologic Definition. — A disease of metabolism that occurs dur- ing childhood, and that is characterized by developmental abnormalities of the bones and cartUages, with the production of physical deformities. Those portions of the bony skeleton most likely to be involved are the ends of the ribs and the long bones. An examination of the diseased long bones shows the presence of pronounced changes in the vicinity of the junction of the epiphyses with the diaphysis. A microscopic examination reveals the fact that there is an increased proliferation of the cartilage-cells, with a proportionately scanty fibroid matrix and imperfect calcification. Exciting and Predisposing Factors. — Rickets is seen to affect the new-bom, and is by no means a rare condition. Heredity may exert some influence, although this is doubtful when both the parent and the child have been exposed to unhygienic conditions. Malnutrition of the mother during the period of gestation and of lacta- tion, close confinement, and syphilis are predisposing factors. Locality. — Rickets is found to be more common in the large cities than 1002 CONSTITUTIONAL DISEASES. in rural districts. The disease is prevalent in Russia, Italy, Great Britain, and Germany. Race is not without influence, the African negro being especially prone to acquire this disease, and in America the half-breed is also highly susceptible. Social Station.— Rickets is especially common among children of the poorer classes, who are surrounded by an unfavorable environment. Oc- casionally rickets is seen among the well-to-do classes, but in this case the disease is usually the result of improper diet, insufficient sunlight, and im- perfect ventilation. Diet.— Rickets is in a great measure dependent upon improper feeding; Fig. 360.— Rickets (Potter, after Dr. W. L. Stowell). Note the size and shape of head, the rosary. Harrison's (groove, kyphosis, prominent belly, bowing of legs, and the enlargement of wrists. hence the disease is more common among artificially fed children than among breast-fed infants. Age. — Practically 75 per cent, of all cases develop the disease before the end of the second year, although rickets may first appear as late as from the sixth to the tenth year. Clinical Picture. — There is usually a clear histor\r of one or more of the predisposing factors previously outlined. The mother states that the child has been less playful than usual, and has suffered from gastro-intestinal disturbances for some weeks or possibly months before true rachitic symptoms developed. The child is at first restless and irritable, sleeps poorly, and in RACHITIS. 1003 some cases moderate fever may be present. The mother states that the child sweats profusely during sleep, the pillow being wet with perspiration while the remainder of the bed-linen coming in contact with the child's body is dry. Rachitic children generally push the covers from about their head and chest during sleep, and are consequently more or less exposed to cold. Marked tenderness is an early feature, and in selected instances may be localized over the bony surfaces; it is also found to affect the soft parts, and the child consequently prefers to rest rather than to be handled. The mother may very early observe that the child shows a lack of inclination to move his limbs, and whenever this condition prevails, a careful examination should be made for the possible existence of rickets or of scurvy. In chronic rickets months may elapse before definite bony deformities appear. Owing to malnutrition the muscles of the extremities become soft and flabby, and there may be an apparent sweUiug, or at times atrophy, of such muscles, which usually goes hand in hand with impairment of function — ^the so-called "rachitic" paralysis. Nervous Symptoms. — Rickets with marked deformity of the cranial bones is occasionally associated with laryngismus stridulus, and tetany of the upper extremities is also an occasional symptom. Epilepsy is quite common in rachitic children, and is probably dependent in part upon the degree of gastro-intestinal irritation present. Enlargement of the abdomen is a conspicuous feature, and is usually due to flatulence and, in selected cases, to enlargement of the liver and spleen. Chaiis:es in the Bony Skeleton. — Among the first bones to under- go changes are the cranial bones, the ribs, the radius, and the ulna. The cranium is large, this enlargement, however, being more apparent than real, and due to the diminished size of the facial bones. The sutures remain open, and the fontanels are large. Craniotabes is most frequently seen in infants vmder one year of age, and is due to pressure. It affects the surfaces on which the head of the child rests. It should be remembered that craniotabes is often a syphihtic manifestation. A rachitic head (Fig. 366) is generally of square outline, or it may present marked angularities, with an increase in the anteroposterior diameter and flattening at the top. Hyperostosis may result in prominence of the parietal and frontal eminences. The veins of the scalp are enlarged, and the hair is scanty. On auscultat- ing over the anterior fontanel, a systolic murmur may be audible. The teeth may not be erupted until late, and may decay during childhood, although occasionally they may be misshapen and yet show no tendency to decay. The ribs become beaded early, and swelling occurs at the junction of the ribs with the costal cartilages. The ribs are curved quite acutely at the lateral dorsal portion of the chest, and again curve in abruptly toward the sternum. Harrison's curve consists in a peculiar, furrow-like appearance, beginning at the anterior end of the eighth or ninth rib, and extending toward the axilla. There may be a bulging of the sternum, producing the so-caUed "chicken-breast." Deformities at the junction of the diaphyses and epiphyses of the radii are among the early bone lesions of rickets, and both the radii and ulnae are commonly found to be deformed. The clavicles may be curved and the scapulae show marked thickening; in selected cases deformity of the vertebral column may be present. Deformity of the pelvis is also seen, and when rickets has occurred in a female child, an x-ray examination should be made 1004 CONSTITUTIONAL DISEASES. when the child reaches puberty, in order to ascertain whether any pelvic deformity exists. Swelling at the lower end of the tibise is also an early osseous change, and curving of the femora may be present. I^aboratory Diagnosis. — Secondary anemia is commonly present, and the hemoglobin may fall to from 60 to 70 per cent. Moderate leukocyto- sis may be present, but is not a constant feature. A differential count of the leukocytes may show an increase in the relative number of lymphocytes, a clinical finding that may be present in children suffering from malnutrition. X-Ray Diagnosis. — In typical cases the existence of rickets can be determined without the use of the x-rays, but in those cases in which mal- nutrition, gastro-intestinal symptoms, and profuse sweating of the head are prominent, deformity of the bones may be made out with the x-ray long be- fore such osseous change can be recognized by other methods of diagnosis. Summary of Diagnosis. — Early during the course of rickets, and be- fore bony changes are apparent, the features of greatest diagnostic importance are: (1) The general evidence of malnutrition, together with the progressive loss of weight and the presence of secondary anemia; (2) gastro-intestinal catarrh; (3) profuse sweating of the head during sleep; (4) the application of the x-ray to ascertain beginning deformity of the bones of the cranium, ribs, and tibise. After well-marked bony deformities have developed, the characteristic alterations in the bones of the head and chest at once become apparent. Clinical Course. — ^This is greatly modified by the application of judicious treatment, although in the average cases deformity of the skeleton continues to progress for a period of several months. Complications. — Children suffering from rickets exhibit a very low grade of vitality, and consequently are especially prone to develop broncho- pneumonia and the ordinary complications occurring in diseases of child- hood. MYELOMATA (Bence- Jones Albumosuria). Pathologic Definition. — A malady characterized by the formation of multiple new-growths (myelomata), chiefly of the flat bones, although in certain cases the long bones may also be the seat of myelomatous infiltration. Historic Note. — Since the publication, in 1847, of Bence-Jones' case of osteomalacia fragilitas rubra associated with albumosuria, 37 similar cases have been recorded in which neoplasms of the bones, regarded as probable myelomata, were disclosed at autopsy.* In 9 of the reported cases tumor growths were observed antemortem. Von Jaksch and Fitz have each reported albumosuria occurring in connection with myxedema (?), and Askanazy calls attention to a case of lymphatic leukemia in which the urine contained Bence-Jones albumose. Albumosuria may be produced in the dog by the administration of poisonous doses of pyridin. In 1902 we re- ported 3 cases of Bence-Jones albumosuria, in one of which there was bone deformity, and within the course of one year from the date of our report the other two cases died. In 1902 Boston described at length a rapid reaction for the detection of this form of albumose in the urine, f and in August, 1903, he reported a case of Bence-Jones albumosuria.! * Anders and Boston, address before the College of Physicians. PhiladelDhia June 4, 1902. *^ ' t Ibid., April, 1903. t Boston, Amer. Jour. Med. Sci., October, 1902. MYELOMATA. 1005 Predisposing and Exciting Factors.— Age.— From our analy- sis of the reported cases of questionable myelomata with albumosuria, we find that the youngest case reported was twenty-four years of age. The condition was also found in patients of thirty-two, thirty-three, thirty-six, and thirty-seven years respectively. Ten were between the age of forty and fifty, and 7 between sixty and seventy; in the remaining cases the age was not stated. Injury. — In 15 per cent, of cases there was a definite history of severe traumatism to the bony structure. Sex. — Of 35 reported cases, 80 per cent, of males were found to be af- fected. Syniptomatology. — Pain is an almost constant symptom, but a single exception to this being found among the reported cases. The pain is com- monly described as a bone pain, or as rheumatism, lumbago, or neuralgia. The patient usually states that the pain occurs without apparent cause, is severe, and is accompanied by an apparent " giving way" of a portion of the bony skeleton. At times the pain may be dull and continuous, and again it may be cramp-like, lancinating, and pass rapidly. Pressure over the affected bones, as well as exercise, aggravates the suffering. The pain is more common over the flat bones, although the extremities may share in this agonizing symptom. Cramps involving the lower extremities are fairly common, and toothache, falling of the teeth, and necrosis of the maxillary bones, with well- marked salivation are occasionally encountered. Pain may be increased by the act of deglutition. Neuralgia. — Facial neuralgia was present in 30 per cent, of the reported cases. Paralysis of the hj^oglossal nerves and of the motor portion of the trifacial nerve has been recorded. In one case there were numbness and tinghng of the feet and legs, and in one of our cases paralysis and twitching of the left side of the face occurred. Cephalalgia is mentioned as a prominent symptom in 70 per cent, of the cases. In 3 of our cases it was most trouble- some, and in another it occurred periodically. Painful micturition was present in one of our cases, and frequent urina- tion was mentioned in 4. of the reports furnished by the literature. Voice. — Changes in the voice were observed in 16.4 per cent, of the re- ported cases, whereas in 12.5 per cent, mention was made of an appreciable impairment of the auditory function. Ocular Phenomena. — Impairment of vision occurred in 4 cases fur- nished by the literature, and in 2 of our cases retinal changes, consisting of hemorrhage and colloid degeneration, were detected. Emaciation. — Progressive emaciation is an almost constant feature, and hand in hand with this go anemia, prostration, and such gastro-intestinal symptoms as nausea, vomiting, diarrhea, and constipation. Jaundice is occasionally observed. Glandular enlargement occurred in approximately 15 per cent, of all cases. I^aboratory Diagnosis. — In 4 cases coming under our observa- tion the leukocytes fluctuated between 16,000 and 40,000 per c.mm.; the hemoglobin varied between 55 and 70 per cent., and the red cells numbered between 3,000,000 and 3,700,000 per c.mm. In 3 cases in which a differen- tial blood count was made the eosinophilic cells were diminished in number or absent. When Bence-Jones albumosuria is coexistent with myelomata, the quantity of urine voided during the twenty-four hours is likely to exceed the IQQQ CONSTITUTIONAL DISEASES. normal. The specific gravity has been found to range between 1.004 and 1.040. In many of the cases recorded in the literature, and in 2 under our own observation, the urine was of the consistence of syrup. Chocolate or coffee-colored urine has been described by various writers, and in other cases the urine was said to be transparent and of low specific gravity. In applying the ordinary test for serum-albumin, a positive reaction is obtained when Bence-Jones albumose is present, and, indeed, it is customary to find both serum-albumin and albumose present in the same specimen. Casts may be present, and are ordinarily of the amyloid or hyaline varieties. Deformities.— In an analysis of the reports of cases furnished by the literature we find that bony deformities existed in 67 per cent. Fractures were common (25 per cent, of cases), and often occurred from slight causes. Summary of Diagnosis. — The diagnosis is based largely upon the clinical history, which usually includes pain, either neuralgic or boring in character, tenderness over the bony structures, emaciation, and prostration. A history of traumatism to the bones, together with pain at the site of injury and deformity, is of great clinical value, whereas a tendency toward frac- tures must also be considered. The detection of albumose in a urine of the consistence of syrup or of a coffee color makes the diagnosis fairly positive. Complications and Duration. — In our analysis of 35 reported cases pneumonia figured as a complication in 12.5 per cent. The condition usually terminates in death within the course of two years, although one case has been recorded in which the condition existed for eight years. GOUT. Pathologic Definition. — A disease of metabolism, characterized by arthritic changes, including the deposit of sodium urate in the cartilages, the ligaments, and the synovial membranes. At first the deposited sub- stance is fluid in character, but contains small masses of crystalline substance that later become hard. Secondary inflammatory changes result in fibrous overgrowth, which is accompanied by a variable degree of deformity and flexure at certain joints. Acute ulceration may foUow, and gouty tophi be extruded. Gouty deposits have been found in the cartilages of the ears, nose, and larynx. Inflammatory changes generally take place in the kidneys, and stony deposits may be found within the kidney substance, which, in turn, lead to a variable degree of destruction of the organ. The kidney of chronic inter- stitial nephritis (see p. 674) is present in gout, and arteriosclerosis with myocardial changes may also be present. Varieties. — (1) Acute gout; (2) retrocedent gout; (3) chronic gout; and (4) irregular gout. Predisposing Factors.— (1) Age. — Primary attacks occur most frequently during middle life. They are rare before puberty, although ex- ceptionally they may be seen to occur even in childhood; after puberty, however, they become more frequent, this frequency decreasing rapidly after the fiftieth year is reached. (2) Heredity. — ^The cases that develop quite early in life often show a striking hereditary taint, and it has been asserted that 50 per cent, of all cases of gout are directly traceable to a hereditary tendency. (3) Sex. — The arthritic form is less frequent in women than in men, whereas in chronic gout women are more often attacked. (4) Alcohol is among the chief predisposing influences. GOUT. 1007 (5) Diet. — Overeating and insufficient exercise doubtless constitute the most potent factor in the production of gout. (6) Social State.— The majority of cases occur among members of the upper stratum of society, but there is also a well-defined form, known as "poor man's gout," that is due in part to the excessive use of alcoholic beverages. (7) Lead. — ^We have seen a large number of cases that were clinically fairly typical of gout in which the patient had been employed ia the handling of lead for from six to twenty years. (8) Traumatismi is a rare predisposing factor. Symptomatology.— Clinical Picture of Acute Gout.— The onset is that of a more or less typical acute arthritis, and is at times preceded by prodromal symptoms that vary greatly with the individual cases. SHght muscular cramps and pains, dyspepsia, mental irritabihty, inability to sleep, and depression of spirits may antedate an attack of acute gout, following which there may be a period of reUef just prior to the outbreak of an acute attack. AUack. — ^This generally develops during the morning hours, and the patient may be awakened by severe pain in the region of the great toe. Pain soon becomes agonizing, and is described as though the toe were held in a vise. Within the course of a few hours the joint becomes swollen and tender, is unusually hot to the touch, and for some distance from the joint the skin pits upon firm pressure. Within the course of a few hours the suffering generally abates, the fever falls, and the patient becomes bathed in per- spiration. After a mQd attack of gout the patient may go about his usual work. One or two days after an initial attack there is a variable degree of enlargement of the joint, the edema returns, and the paroxysm recurs during the night or early morning hours. The number of paroxysms wiU vary greatly for a period of from six to eight days, although after the first forty-eight hours they are likely to be less severe. By the end of the first week the joint has usually returned to the normal size, and the patient suf- fers no inconvenience. Acute gout returns at varying intervals, the longest of which occurs between the first and the second attack. A single joint may be affected, although after repeated attacks other joints commonly become involved. Thermic Features. — ^With the onset of the paroxysm the temperature rises to from 101° to 103° F. Retrocedent Gout. — ^This is a sudden transmission of the arthritic symptoms to some internal organ, and during a paroxysm the joint-inflammation may quickly disappear and intense pain develop in the region of the stomach. Faintness, nausea, vomiting, and diarrhea are now common. The pulse be- comes rapid, weak, and at times compressible. Precordial pain, dyspnea, pal- pitation, and mental anxiety are occasionally referred to as suppressive gout. Nervous Manifestations. — Severe cerebral symptoms are occasionally observed, and are most often dependent upon uremia. Clinical Features of Chronic Gout. — This clinical type is secondary to the acute variety. The transition is gradual, the intervals between the at- tacks are short, whereas the attacks themselves grow milder and milder, but are of longer duration. Local inflammation subsides, and in long-standing cases disappears entirely. There is a tendency for the disease to involve other joints, and while at first corresponding joints are attacked, later there is gouty involvement of the other joints of the feet, and eventually the articu- lations of the hands and wrists are attacked. \ 1 , 1008 CONSTITUTIONAL DISEASES. Deformity ensues as the result of an accumulation of chalky deposits in and about the articular surfaces. The skin covering the chalky deposits may undergo ulceration, and the calcareous material be discharged. Associated Conditions. — Among these are chronic nephritis, general arterio- sclerosis, cardiac hypertrophy, myocarditis, valvular heart disease, and chronic catarrh of the gastro-intestinal tract. Irregular Gout. — Under this head should be included those cases in which some of the symptoms of gout exist, with or without the presence of gouty deposits around the articular surfaces of certain joints. In irregular gout there is usually a history of a hereditary tendency to develop the disease, although this form of gout may be acquired. Clinical Manifestations. — Pains are generally localized to the muscles, but may occur in any portion of the body, and are acute and lan- cinating in character. Certain groups of muscles are particularly prone to be affected, as, e. g., the muscles of the neck, of the lumbar region, and of the thighs. Gastro-intestinal Disturbances. — These resemble closely those seen in typical cases of lithemia. Colic, accompanied by diarrhea, is an occa- sional feature. During the course of irregular gout the patient may also suffer from parotitis, bronchitis, tonsiUitis, and catarrh of the laryngeal mucous membrane. Nervous Manifestations. — Cephalalgia, facial neural^a, sciatica, a burning sensation of the skin, tingling of the extremities, pain in the hands and feet, and intense itching are among the less common nervous manifesta- tions of this type of the disease. In selected cases eczema may occur. Gouty neuritis is occasionally seen, and in practically all cases the tempera- ment becomes extremely irritable as the disease progresses. I/aboratory Diagnosis. — The urine is of high color, high specific gravity, often scanty, and on standing uric acid is deposited. These features are not, however, peculiar to gout alone. In many cases uric acid is in ex- cess only at intervals, whereas at other times it may be diminished in quan- tity. Following the administration of atophan, Tuelzer found the uric acid in the urine increased. A heavy reddish precipitation in the urine of gouty subjects, following the use of atophan, is of diagnostic value when accom- panied by amelioration of annoying symptoms. Glycosuria may develop at any time during the course of chronic gout. Albuntiinuria may be present, and oxaluria is also an occasional finding. Ocular Manifestations. — ^Tophi in the cornea, and rarely in the eyelids, as well as conjunctivitis, keratitis, iritis, hemorrhagic retinitis, and glau- coma may accompany the other manifestations of gout. Auditory Phenomena. — Impairment of the auditory sense may be observed within a few months after birth, and rarely occurs in long-stand- ing cases. Diagnosis and DiflFerential Diagnosis. — Gout is diagnosed chiefly from the clinical history, which includes one or more of the conditions known to predispose to this disease. The onset of the initial attack, and its tendency to return at intervals and to spread to other joints, are characteris- tic of gout. The presence of mild fever at the onset of each attack and the development of distinct nodular masses in the vicinity of the articular sur- faces go far to support the diagnosis. Disturbances of the gastro-intestinal tract are also of some value in formulating the diagnosis. Gout is tb be distinguished from chronic rheumatism, although the fact that the former disease displays a special predilection to attack the small joints (great toe), whereas chronic rheumatism commonly involves the larger OBESITY. 1009 joints, must be borne in mind. The characteristic onset of each attack of gout is but mildly evidenced during the course of chronic rheumatism. Acute Articular Rheumatism. — This form of rheumatism may re- semble closely an attack of gout, from which it is distinguished by the general clinical picture of articular rheumatism, including not only joint involve- ment, but also a tendency toward the development of endocarditis. Clinical Course. — The primary attack usually lasts for from eight to fourteen days, and the condition is likely to recur within a few weeks, months, or years. Gout is characterized by repeated exacerbations of pain in one of the small joints. The course of any cUnical type of gout is decidedly modified by treatment, which varies greatly in different cases. LITHEMIA. Remarks. — This condition is believed to be due to disturbed cellular metaboHsm, and is characterized chemically by the presence of an excess of uric acid in the blood, which in turn gives rise to certain symptoms referable to the circulatory, gastro-intestinal, and nervous systems. Stockton con- tends that lithemia is a variety of gastro-intestinal autointoxication, and it is generally conceded that heredity and alcoholism contribute largely to- ward the development of lithemia. Males are more often attacked than females. Clinical Picture. — This resembles closely that previously described under Irregular Gout, and for a description of the circulatory, respiratory, in- tegumentary, and nervous manifestations of lithemia the reader is referred to p. 1008. Gastro-intestinal Phenomena. — The appetite varies — at times it is voracious, and at others it is impaired or perverted. The tongue is coated, there is a metallic taste in the mouth, and the various forms of indigestion are common. Pyrosis, gastric oppression, and at times nausea and vomiting are conspicuous symptoms. Flatulence is somewhat common, and inter- mittent attacks of diarrhea, often accompanied by unusually foul-smelling discharges, are seen. Moderate hemorrhage from the rectum and hemor- rhoids are encountered in typical cases. At times the patient complains of unusual tenderness along the border of the liver, and, indeed, this organ may be felt well below the costal margin. OBESITY (PoLYSARCiA Adiposa, Lipomatosis UNrvERSALis). Pathologic Definition. — A disease of metabolism, characterized by the deposit of an abnormal amount of fat in the areolar tissue of the body. Not only is the adipose tissue greatly increased in localities in which it is normally found, but the various internal organs and tissues that are nor- mally quite free from fat may show decided fatty infiltration. The condition is often accompanied by hypertrophy and dilatation of the heart. (See p. 299.) Fatty changes may also be present in the arterial system, and endarteritis with sclerosis and varicose veins are often encountered. His- tologically, the fat-globules will be found to vary in different forms of obesity, the globules being larger in the plethoric variety of the disease than in the anemic or hydremic form. Predisposing and Exciting Factors.— Among the chief pre- disposing factors are heredity, cHmate, habit, occupation, temperament, age, and sex. Among 543 cases that came under our care in which the family 64 1010 CONSTITUTIONAL DISEASES. history was noted, heredity was distinctly traceable in 60.7 per cent. Gout either occurred in association with the condition or was present among the antecedents in 43.2 per cent, of these cases, and the same was true of rheu- matism in 35.5 per cent. In 10 the condition dated from longer or shorter periods of enforced rest, as following accidents, and infectious diseases, such as typhoid fever (in 4.7 per cent.). In 16.2 per cent, of the cases the disease dated from childbirth, and in 4.8 per cent, of 437 females it followed marnage. Climate. — Obesity is more frequent among the inhabitants of hot, moist climates, and of low countries in the temperate and arctic regions. Hence it is commonly observed among Orientals, Dutchmen, South Pacific Islanders, southern Itahans, and certain Africans. Social Condition. — Sedentary habits and occupations constitute a common predisposing factor. A sluggish temperament also favors the ac- cumulation of an abnormal amount of fat. Age and Sex. — Most cases occur in persons of advanced middle life, i. e., between forty and fifty years of age, but hereditary obesity often dates from infancy and early childhood; in women it may appear at puberty, and be- tween the thirtieth and fortieth years. Women seem to be more prone to corpulence than men. Congenital monstrosities (idiots, cretins, acephali) and hemiplegics are frequently found to be excessively fat, as are also those suffering from anemia. Exciting Factors. — An important exciting factor in the production of obesity is the ingestion of fat-building foods and the excessive use of alcohoHc beverages, all of which tend to favor the accumulation of fat, irrespective of the amount of exercise taken. Clinical Picture. — The patient may complain of inconvenience and of discomfort on walking or on working. As the viscera become involved, subjective symptoms develop. An early and annoying symptom is dyspnea upon exertion, due to a weak heart and to interference with respiration by heavy chest-walls and the upward crowded diaphragm. In plethoric subjects the face and mucous membranes are red and congested, whereas in anemic subjects the skin is pale, the muscles are flabby and weak, the pulse is small and compressible, and dyspnea, palpitation, weariness, drowsiness, and Vertigo are present. In plethoric corpulent subjects the muscles are firm and strong, and the pulse and heart-beats are vigorous; late in the disease, however, the pulse becomes weak and irregular, and finally tachycardia may be seen. " Muscxilar power may diminish, and irregular fat masses (in the anemic variety) in the subcutaneous tissue are seen." Gastric catarrh and gastrectasia, inordinate thirst, and bulimia may be observed. Constipation may be followed by chronic diarrhea. Sexual Peculiarities. — Sexual desire is diminished, and azoospermia is not rare. Corpulent women often suffer from uterine displacement and pro- lapse, and amenorrhea, sterility, endometritis, and leukorrhea are observed. Cutaneous Phenomena. — The skin is often irritated (intertrigo) by the excessive sweating and by the friction of cutaneous surfaces in the folds of fat, as under the breast, in the abdominal and inguinal regions, and around the scrotum and labia. This may be followed by eczema, painful excoria- tions, pruritus, acne rosacea, and alopecia. Physical Signs. — The liver is commonly found to be enlarged, but owing to the presence of excessive fat and thickness of the abdominal wall this finding is best obtained by means of auscultatory percussion. The intensity of the heart-sounds is dependent directly upon the degree of cardiac hypertrophy or of degeneration of the heart muscle presented by ADIPOSIS TUBEROSA SIMPLEX. 1011 each individual case. The signs of fatty heart are often obtained upon physical examination. I/aboratory Diagfuosis. — In the anemic variety the condition is due to chlorosis; in the plethoric form the red cells will be found to fluctuate between 6,000,000 and 9,000,000 per c.mm., and the hemoglobin will com- monly exceed 110 per cent. The urine may be normal, although at times polyuria and again oliguria may be present. As a rule, the urine is rich in urates and uric acid. Diagnosis and Differential Diagnosis. — The existence of asso- ciated conditions, complications, and sequelae should be carefully ascertained. In myxedema the skin is thick and inelastic, and the physiognomy is much altered, the lips, tongue, nostrils, and mouth being thickened by infil- tration. Obesity is also to be distinguished from adiposis dolorosa. (See p. 1154.) Complications. — Hernia, cardiac asthma, bronchitis, pulmonary con- gestion, edema, arteriosclerosis, albuminuria, glycosuria, anginal attacks, cerebral hemorrhage, and coma have all been observed. ADIPOSIS TUBEROSA SIMPLEX. This condition resembles adiposis dolorosa (Dercum's disease) clinically, but differs from the latter in that it is apparently dependent upon general obesity, with which it has been thus far invariably found to be associated. "Circumscribed fat masses appear in the subcutaneous tissues; they form distinct, moderately dense, slightly movable, somewhat flattened tumors, ranging in size from a bean to that of a hen's egg. Their number varies all the way from one-half dozen to two dozen or more. These moder- ately firm fat-nodules are not distributed over the entire body, but in some cases are confined to the extremities, particularly the lower, and in others to the abdomen. The tumor masses show no tendency to fuse together, and are not elevated above the surrounding surface; they are sensitive to the touch, and may be the seat of pain, which varies in intensity within rather wide extremes, being moderately severe and distressing in rare cases and trivial or even absent in the majority of instances. The lymphatic glands are not involved, and the skin remains soft, flexible, and non-adherent. The mental processes are normally active, and also the muscles; asthenia is not present, and there is no more indisposition to physical exertion than is observed in cases of obesity, as a rule. The knee-jerks are present, and the cutaneous sensibility is unaltered, in some cases at least. The mammae and abdominal panniculus adiposis may be overhanging or pendulous, but not in all cases. It is an uncommon condition, since it was noted in only 4 out of a total of 324 cases." * From the nodular variety of adiposis dolorosa, the condition under discussion distinguishes itself by the absence of any psychic disturbance and asthenia out of proportion to the polysarcia, and more particularly the complete disappearance of the fat masses as the result of treatment directed to the extreme obesity. Lipomas, by their painlessness, soft, doughy, semi-fluctuating- consistence, their more globular shape, as evidenced by the slight though distinct elevation above the surrounding surface and more or less lobulated character, may be also excluded. Moreover, these tumor-like subcutaneous growths are not dependent on associated general obesity, and are not amenable to medicinal, dietetic, and regiminal treatment. * American Journal of Medical Sciences, March, 1908, by James M. Anders, M.D- DISEASES OF THE NERVOUS SYSTEM. By T. H. Weisenburg, M.D. General Considerations. In making a diagnosis of any organic nervous disease, each symptom should not only be appreciated but also interpreted as being associated with a definite lesion of a certain part of the nervous system. To do so it is necessary to have an accurate knowledge of its anatomy, physiology, and pathology. This is not so difficult if certain general principles are observed. The nervous system consists of the brain, the spinal cord and the sympa- thetic system of plexuses, and the nerves connecting with the peripheral parts of the body and the internal organs. The brain is the principal part of this system, and in it are represented the so-called centers for every possible voluntary and involuntary movement, consciousness, and thought. The spinal cord is the pathway for fibers coming from the brain, and in it are nerve-cells which represent every part of the body, with the exception of the internal organs, which are similarly represented in the sympathetic plexuses (Fig. 367). The brain consists of two lateral hemispheres, connected by a band of white fibers called the corpus callosum; of a system of ganglia which are in the center and between the hemispheres, this including the caudate nucleus, optic thalamus, and lenticular nucleus; and of the cerebellum, consisting of two lateral hemispheres and a central part or the vermis. Within the brain are a system of communicating cavities or ventricles which are in continuation with the central cavity of the spinal cord. These are the two lateral ventricles, occupying parts of the lateral hemispheres; the third ventricle, situated between the optic thalami; and the fourth, which is between the cerebellum and the medulla oblongata, communicating below with the central canal of the spinal cord and above with the third ventricle by means of the aqueduct of Sylvius. These cavities in life are filled with fluid. The brain is intimately surrounded by the pia, which dips between the convolutions and into the fissures, accompanying the vessels into the interior. Surrounding the pia is the dura arachnoid, which envelops all parts of the brain and subdivides the cranial cavity into two parts — ^that which includes the cerebrum proper, or the two lateral hemispheres, and the posterior part, which covers the cerebellum and is called the tentorium cerebelli. 'Anatomically the brain consists of a system of convolutions and fissures arranged in a definite manner for a given purpose. The outer part of the convolution is called the cortex, it being from | to | of an inch in thickness, and consists of a system of nerve-cells arranged in layers. From these nerve-cells arise nerve-fibers. Those which go into the internal capsule are called the projection fibers and are concerned with motor, sensory, 1012 GENERAL CONDITIONS. 1013 and special functions, while the fibers ^yhich connect one part of the brain with another are called the association fibers, and are concerned with the correlation of function of the different parts of the brain. As a result of investigation definite functions have been assigned to different parts of the cortex, these being motor, sensory, and special. The general underlying principle is that in the cortex are^'epresented, as, for instance, in the motor, movement, and any irritation of a motor center will produce movement of the related part, in the opposite side of the body, while destruction will cause loss of that movement. The same principle is true of the other portions of the cortex. Not much is known of the function of the so-called central ganglia; that is, of the caudate and lenticu- lar nuclei and the optic thalamus. The two cerebral hemispheres are in (Opercular prrtion of inferic r frc ntal gj rua Operculum Precentr I s ilcu-^ \iiteri r f enf r il ff^ ru f er tia! -^ultu Frontal pcile Triangular portion of infer frontal gyru Anterior honz i limb of lateral cerebral fissure Anterior asceniing limh of lateral cerebral fi urt. Lateral cereVjral fissure lemporal i rle Superior frrntal g\ rus Superior temporal sulcus /' Middle temporal gyrus , Middle temporal sulcus Postenrr central gyrus Interi arietal sulcus Supramarginal p.\ rus Interparietal ulcus Angular i}^^^ gyrus ■(fj Superior \i parietal r^— - lobule ' i\^ Inferior parietal lobule Parieto- occipital fissure Lateral occijiital sulcus i Fig. 367 Side Occipital pole Transverse occipital sulcus Superior temporal sulcus Posterior limb of lateral (Sylvian) fissure Inferior temporal gyrus -The Fissures and CoxvoLrTioNs of the Cerebral Cortex as seen from the Left The Cerebellum and Braix-stem have been Removed i.Sobotta and McMurrich). intimate connection with the cereliellum, which is the great coordinating center of all vohmtary and involuntaiy movements. Motor Symptoms: Method of Obtaining Them and Their Interpretation. — Every part of the body has a nuclear representation in the nervous system. By that is meant that every muscle-fiber is in relation with cells which are located in the anterior horns of the spinal cord throughout its whole extent, and in the so-called nuclei of the different cranial nerves from the third to the twelfth inclusive, in the crus, pons, and medulla, these parts being really the upward continuation of the spinal cord. Thus, for instance, if there is a destruction of the nerve-cells in the facial nuclei in the pons, there will be loss of function in the muscles of the face; and if there is a disturbance of the cells in the anterior portions of the spinal cord in the lumbar region, there will be alteration of function in the corresponding muscles of the leg (Fig. 368). 1014 DISEASES OF THE NERVOUS SYSTEM. In other words, there are two great forms of representation in the ner- vous system: That in the cortex, wliich is concerned purely with motion; while in the spinal cord and its prolongation, including in this the crus, pons, and medulla, are represented not motion, but the innervation of the individual muscle-fibers. There must necessarily be a connection between these two systems, and this is effected by means of the motor tracts. These have their origin in the motor centers in the cortex. From here they go through the anterior part of the posterior limb of the internal capsule, and those fibers which are concerned with the movements of the opposite side of the body below the head go through the crus, pons, cross over in the medulla, and then are transmitted by means of the crossed pj^ramidal tracts into the spinal cord. Some of these fillers do not tlecussate in the medulla, but descend on the same side of the cord in the direct pyramidal Fig. 368.' — Diagram showing Course of Motor Fibers (Pickett). tract. From here these fibers go to the cells in the anterior horn. For example, the nerve-fibers which come from the nerve-cells in the leg center first go through the internal capsule, then the crus, pons, cross over in the medulla, then go through the crossed pyramidal tract all the way down the cord to the lumbar segment, and then join the cells in the anterior horn, while the fibers in association with the arm only go as far as the cells in the anterior horn of the cervical part of the cord. Correspondingly, the motor fibers which come from the face center go through the internal capsule and leave the motor tracts in the upper part- of the pons because the facial nuclei are in the lower part of the pons, while those fibers which are in rela- tion with the muscles of the eyeball begin to leave the motor columns just below the internal capsule and above the crus because the oculomotor nuclei are in the crus and pons. UPPER AND LOWER MOTOR NEURONS OR SYSTEMS. 1015 THE trPPER AND LOWER MOTOR NEURONS OR SYSTEMS. The upper part of the motor system, that is, the cortical cehs and the fibers coming from them to the nuclei of the motor cranial nerves in the crus, pons, and medulla, or to the cells in the anterior horns of the spinal cord, but not including them, is called the upper motor neuron or system, and by the lower motor neuron or system is meant the nuclei of the motor cranial nei'ves or of the cells of the anterior horn of the spinal cord antl the fibers coming from them, this including the motor peripheral or cranial nen^es as far as their ending in the periphery. We see, then, that each neuron or system, so called, has its own center or nerve-cell and a fiber con- tinuation. A normal relation between the upper and lower motor neurons or sys- Fia. 369.- -Method of Obtaining Bicepr Re- flex. Fig. .370. — Method of Obtaining the Triceps Reflex. tems is necessary in the performance of any movement, for while the im- pulse originates in the upper neuron, its performance is the result of the action of the lower, and if there is a lesion in either there necessarily results a disturbance of this relation or tone. Thus, in a lesion of the upper neuron there will he overaction of the lower, and vice versa. This overaction on the part of the lower motor neuron is manifested by an exaggeration of the tendon reflexes and spasticity or stiffness in movement, and on the part of the upper by a flaccidity or loss of tone and abolition of reflexes. In other words, in a lesion in the upper motor neuron there will be spastic- ity and increase in the tendon reflexes, while in a lesion of the lower, flac- cidity and loss of the tendon reflexes. 1016 DISEASES OF THE NERVOUS SYSTEM. REFLEXES. It is, then, upon the normal relation or the tone between the upper and lower motor neurons or systems that the condition of the tendon reflexes will depend. Everj^ reflex has its physiologic arc, this ^ consisting of a sensory impulse, a center, and a motor response. The simplest example is the knee or patellar jerk, in which, after tapping the patellar tendon, the impulse is carried by the sensory nerves and posterior roots to the cells of the anterior horn in the second, third, and fourth lumbar segments, and from here the motor response is transmitted by the anterior roots and the peripheral motor nerves. If there is a lesion in any portion of this arc, there will be loss of the reflex, no matter what the contlition above in the spinal cord and brain. The first principle, then, in the attainment Fig. 371. — Method of Oet.\ining the Patel- lar Jerk. Fig. 372. — Method of Obtaining the Achilles Jerk. of any reflex is to have its arc intact and in normal condition. Should, however, there be a lesion in any portion of the upper motor neuron or system anywhere in its course, this disturbing the normal tone, there will result exaggeration of the reflexes because of loss of cerebral or what has often been called inhibitory influence. That every reflex has a cerebral influence is proved Isy the fact that if there is a complete transverse lesion, for instance, in one segment of the cervical cord, all the reflexes below are lost, even though the arcs are intact. Reflexes are of two kinds: First, deep or tendon; and second, super- ficial or skin. The usual tendon reflexes employed are: (a) In the Upper Limb : The biceps and triceps. UPPER AND LOWER MOTOR NEURONS OR SYSTEMS. 1017 The biceps reflex is obtained by having tiie patient flex the arm on the forearm, at right angles, with the thumb of one hand of the examiner on the biceps tendon. Striking the thumb with the percussion hammer will produce flexion of the forearm upon the arm (Fig. 369). The center of the reflex is in the fifth cervical segment. Triceps Reflex. — With the arm in the same position, if the triceps tendon is struck near its insertion in the elbow, extension of the forearm on the arm will result (Fig. 370). Spinal center is in the sixth and seventh cervical segments. (b) In the Lower Limb : The knee or patellar jerk is best obtained by crossing one leg over the other and striking the patellar tendon near its insertion. A forward movement of the leg will result (Fig. 371). Spinal center is in the second, third, and fourth lumbar. When the reflex is diminished, it may some- times be brought out by reinforce- ment. This is done by having the patient lock his hands and then pull them apart, the examiner striking the tendon at the time of the great- est effort. Achilles jerk is best obtained by having the patient kneel on a chair and then tapping the Achilles tendon near its insertion into the heel. A flexion of the foot on the leg will re.sult (Fig. 372). Spinal center is in the first sacral. Ankle and Patellar Clonus. — A clonus is obtained only when there is an exaggerated tonicity, and al- ways indicates a lesion of the motor or pyramidal tracts. Ankle clonus is obtained by first flexing the leg upon the thigh. With one hand held overthecalf of the leg, theother hold- ing the foot, a sudden flexion of the foot on the leg is made, this result- ing in to and fro movements which are regular in rhythm (Fig. 373). Patellar Clonus.— With the leg extended on the thigh the patella is grasped between the thumb and the forefinger and suddenly brought forward. Biceps and triceps clonus is sometimes olstained similarly to that of the ordinary reflexes. Rarely, ankle clonus and sometimes patellar clonus can be obtained in hysteria, but the movements are not regular and the rh}rthm is influenced by the will. Skin or Superficial Reflexes. — The abdominal or umbilicus reflex is obtained by stroking on one side of the al^domen, the umbilicus moving toward the side stroked. Spinal center is in the ninth, tenth, and eleventh thoracic segments. The cremasteric reflex is obtained by irritating the inner portion of the Fig 373.' — Method of Obtaining Ankle Clonus. 1018 DISEASES OF THE NERVOUS SYSTEM. upper thigh, this resulting in upward movement of the scrotum. Spinal center is in the first lumbar segment. r j.u f 4. Plantar reflex is obtained by irritating the plantar surface ot the toot, flexion of the toes resulting. Spinal center is m the second sacral. _ Babinski reflex is obtained by irritating the plantar surface extension of the toes resulting. Irritation is best produced with a match, which should first be drawn along the outer part of the foot and then across the sole. The important part of this reflex is the extension of the large toe, and the movements of the small toes may be disregarded. It is also advisable to first grasp the foot at the ankle so as to prevent any voluntary movement. This reflex is never obtained in a functional condition and is always indica- tive of a lesion of those motor fi- bers which are in relation with the leg. A lesion of the motor fibers in relation with the upper limb will not produce this reflex (Fig. 374). PARALYSIS. The nature of the paralysis will also differ in lesions of the two neu- rons or systems. In a lesion of the upper, the paralysis will be that of ^^mJ^-f A-- movement. For example, should M^* TKr ' ''' ^^'^'^^ ^^^ ^ lesion of the fibers in re- ^^""HP^l — . ^--"WMtad lation with the arm, there wiU be total loss of movement in the arm, while in a lesion of the lower neu- ron, the extent of the paralysis will depend upon the degree of involve- ment either of the nerve-cells or of the motor fibers innervating the arm. In the former there will be an exaggeration of tone, or spasticity, with increased reflexes; in the lat- ter loss of tone, or flaccidity, with loss of reflexes. Besides, in the lat- ter condition, as the cells of the anterior horn are trophic in func- tion, there will be atrophy of the muscles and electrical reactions of de- generation. Disturbances in vasomotor function occur in both. Fig. .374. — Method of Obtaining the Babinski Rkflex showing Extension of the Large Toe. SENSORY SYSTEM. The arrangement of the sensory fibers is more complex than that of the motor because of the great number and variety of sensations. The principle, however, is the same. There is still a great lack of definite knowl- edge regarding the course of the sensory fibers. It must be remembered that while motor impulses travel from the cortex, sensory impulses are transmitted to the cortex by means of the peripheral sensory nerves and the spinal cord. It is possible that in the cortex, sensation is represented simi- larly to that of motion, and that, just as in the motor area there is repre- sentation of motion, so in the sensory centers there is representation of the sensation concerned in the particular movement, and that there is a correla- SENSORY SYSTEM. 1019 tion of function between the two. In support of that theory is the fact that the cortical motor and sensory centers concerned in a particular move- ment are in apposition. Within a few years our views of the subdivisions of sensation have been considerably modified, chiefly through the work of Head, in association with Sherren and Rivers. Instead of the usually accepted subdivisions of touch, pain, and heat and cold, these authors have shown that common sensation is based upon three kinds of sensibility which are present and may be demonstrated in the peripheral system: " (1) A system corresponding to the group of impulses which they have ca,lled deep sensibility. The end-organs of this system respond to the stimulus of pressure and to the movement of joints, tendons, and muscles. Painful impulses can also arise within this system in consequence of injury of a joint or excessive pressure. This sensory mechanism is capable of responding in such a way that the patient appreciates both the locality of the stimulus and the direction of movement in any joint which lies within an area innervated solely by this system; and yet the integrity of deep sensibility carries with it no power of appreciating a stimulus, such as that of cotton-wool, even over hairy parts. Nor does it permit of the discrimina- tion of two compass-points applied simultaneously to the skin, even when widely separated. "The fibers which connect these sensory impulses run mainly with the muscular nerves, and are not destroyed by division of all the sensory nerves to the skin. " (2) The protopathic system, capable of responding to painful cutane- ous stimuh and to the more extremes of heat and cold. Its end-organs are grouped in points on the surface of the body, sensitive to one only of these stimuli. Their response is diffuse, and unaccompanied by any definite appreciation of the locality of the spot stimulated. " (3) The epicritic system. To the impulses of this system we owe the power of cutaneous localization, of discriminating two points, and of recog- nizing the finer grades of temperature, called cool and warm." These three forms of sensibility are transmitted from the periphery by means of the posterior roots into the spinal cord. Anatomically, the posterior roots are supposed to contain five different sets of fibers, each having a different termination (Fig. 375). One goes to the nerve-cells of the anterior horns of the same side and is supposed to subserve reflex functions. The second ends in the cells of Clarke's column, this consisting of a group of cells situated at the base of the posterior horns, running along the whole ex1;ent of the spinal cord, but principally from the first thoracic to the second lumbar. From these cells new fibers arise which run to the postero-lateral portion of the same side of the cord, forming the so-called direct cerebellar tract, lateral to the motor columns and behind the tract of Gowers. This tract maintains this position in the spinal cord and enters the cerebellum by means of the inferior cerebellar peduncle and is supposed to end in the superior vermis. The third set of fibers end in, the nerve-cells of the posterior horns on the same side. From here new fibers arise, most of which cross over in the gray and white commissure, forming the so-called Gowers' tract, situ- ated anterior to the direct cerebellar and outside of the lateral motor columns. These fibers ascend in the spinal cord and in the lateral portions of the medulla and pons, terminating in the lateral and ventral nuclei of 1020 DISEASES OF THE NERVOUS SYSTEM. the optic thalamus. From here a new set of fibers arise, these ending m the sensory cortex. Some of the fibers of Gowers' tract, however, are given off along their course and end in the superior vermis of the cerebellum and in collateral nerve-cells situated in the medulla. Gowers' tract also receives a number of fibers from the cells of the posterior horn on the same side. Not all the fibers arising from the cells in the posterior horns ascend in Gowers' column. A number cross over in the white commissure, forming the so-called anterior tract, situated in the anterior portion of the cord in front of the anterior horns. Their course is not accurately known, but some of the fibers ultimately reach the nuclei of the optic thalamus, and from here a new system is given off to the sensory cortex. Homolateral impuUcs underlying muscular Sensibilily — i.e. Sena 0/ passive position and of movement^ also of touch and pressure for a few segments. 7 H eterolateral Uncomcicrus a^erevt. Tmftulses underlying Muse. Coordination and reflex t body Cerebral peduncle"^ Pons Trigeminal /" nerve [l Temporal^ f^ iobe~'-N l^, Facial nerve Frontal pole Olfactory sulcus Olfactory bulb Olfactrrv tract Optic nerve )ptic chiasm I )lfictory trigone Tuber cinereum Maxillary nerve < )] hthalmic nerve Portio nninor of trigem. nerve Mandibular nerve \ Flocculus t cerebellum Cerebrllum Choroid plexus of ventricle IV Glo33opharygeal nerve Abducens nerve Vagus nerve' Hypoglossal nerve' Olive Pyramid ^Medulla oblongata Accessory nerve / /' Vermis of \ \ Tonsil of cerebellum Root filaments of cervical nerve' I / cerebellum \ Occipital pole Decussation of pyramids Spinal cord Fig. 386. — The Base of the Entire Brain, with the Pointb of Emergence of the Twelve Cere- bral Nkrvfs rPON THE Left (Sobotta and McMurrich). The entire semilunar ganglion has been retained. The hypophysis has been displaced slightly backward and compressed to expose the infundibulum. The Roman numerals indicate the number of the cerebral nerves. conjugate deviation of the eyes and head to the same side, besides flexion of the homolateral elbow, and that deeper excitation of the paracerebellar region will produce extension of the contralateral elbow, hyperextension of the neck and trunk, with powerful extension of the lower limbs. It is prol:>able that the cerebellum is concerned with the coordination of every vokmtary movement, whether this be of the limbs, eyes, or of those THE OPTIC NEKVE. 1035 muscles which are concerned in articulation, eating, or swallowing. It is characteristic of cerebellar incoordination that it is only apparent in volun- tary movements, and that it does not increase when the object is attained or when the eyes are shut, and that it is not dependent upon any disturb- ance of peripheral sensation. It has also been recently held that lesions of the cerebellum will produce weakness or paresis of the muscles of the trunk and limbs, but this is not a true weakness in the sense that it is not dependent upon the motor fibers. Besides, there may be present in the muscles a lack of tone, so that it would be possible to move the limbs like a flail. If the lesion is in the middle lobe or the vermis, the symptoms of incoordination are most marked, and wiU involve both parts of the body, while unilateral lesions will of course produce unilateral ataxia and atonia. Whatever symptoms are produced by lesions of the cerebellum or by those lesions which invade the cerebellum by pressure are dependent upon this disturbance of coordination. This is apparent in every movement, whether it be in the gait, station, in the movement of a limb or limbs, or of the eyes or of those muscles which are concerned in eating, talking, and swallowing. Other localizing symptoms will be discussed under the head of cerebellar tumors. The Cranial Nerves and Their Diseases. There are twelve pairs of cranial nerves. These are known either by special names or numerically. The first and second, or the olfactory and optic, should really be considered as parts of the brain proper and not as distinct cranial nerves (Fig. 386). THE OLFACTORY NERVE. The center for the olfactory nerve is not definitely known, but its function is concerned with smell, the loss of which (anosmia) is very frequent in fracture of the base of the skull. It is also lost in inflammatory conditions of the nose and turbinate bones and in any lesion which destroys the olfactory- nerves or bulbs. Irritative disturbances of smell (parosmia) are present in hysteria and other functional neuroses or may sometimes form the aura of an epileptic convulsion. THE OPTIC NERVE. The optic or second nerve is the nerve of vision. From the orbits, in their course backward, the optic nerves enter into and form the optic chiasm, and then the optic tract, and from here the visual fibers go to the primary optic centers, this constituting the anterior corpora quadrigemina, the external geniculate body, and the pulvinar or the posterior portion of the optic thalamus. From here the fibers pass through the extreme posterior portion of the posterior hmb of the internal capsule to the occipital lobe. It must be remembered that the visual fibers coming, for instance, from the right occipital lobe, innervate the right half of each retina or the temporal part on the same side, and the nasal on the other, and thereby supply vision to the left half of each visual field. A lesion interrupting the fibers coming from the right visual centers or the occipital lobe, for instance, either in the extreme posterior portion of the posterior limb of the internal capsule or in the so-called primary optic centers or in the optic tract, must give loss 1036 DISEASES OF THE NERVOUS SYSTEM. of half vision in both visual fields on the other side or left lateral homonymous hemianopsia. . i j.i j. r The decussation of the optic fibers takes place in the chiasm and that of the nasal fibers in the center. A lesion, therefore, m the center of the optic chiasm will cause loss of innervation to the nasal part of each retma, or bitempoi-al hemianopsia (Fig. 387). A lesion interrupting the fibers on either side of the optic chiasm, as, for instance, the right, will cause loss of innervation to the right temporal retina, and therefore loss of the nasal field of vision of the right eye. A bilateral lesion must give bilateral loss of vision of the nasal fields, or bmasal hemianopsia. A lesion destroying the whole optic chiasm, as, for instance, a tumor Fig. 387. — Diagram of Visual Paths (Starr). of the hypophysis, will cause loss of vision in both eyes. Destruction of either optic nerve will, of course, give l3lindne.ss in the correisponding eye. Choked Disc or Optic Neuritis. — Whenever there occurs increase in intracranial pressure, whether liecause of a brain tumor, trauma, or internal hydrocephalus, pressure will l^e exerted upon the optic chiasm and optic nerves. This is because pressure in any portion of the brain will result in a heightened tension in the lateral and third ventricles, the latter pressing directly upon the optic chiasm and optic nerves. In every choked disc there must be some inflammation of the optic nerve or optic neuritis, but in optic neuritis choked disc does not necessarily occur, for the latter is distinctly a pressure sj^mptom. When the optic nerve is pressed upon, there will be first a stasis of the vessels, this resulting THE OCULOMOTOR NERVE. 1037 in a swelling of the veins, it being so severe at times as to produce hemor- rhages. There will also be retardation of the arterial flow, this causing a diminution in the size of the arteries. Because of this stasis there will result an edema, it causing a swelling of the optic nerve-fibers or of the optic nerve-head. If the pressure is continued, the nerve-fibers will become diseased, this resulting in impairment of ^-ision. This is choked disc. If the pressure is continued for a long time there will necessarily result atrophy of the optic nerve-filjers. Optic Atrophy. — Optic atrophy maybe primary or secondary. When primary, it may be the result of an atrophic condition of the optic nerve, but it generally indicates a spinal cord disease, such as locomotor ataxia, Friedreich's ataxia, or any spinal cord cUsease in which the posterior columns are involved. Secondary optic atrophy is nearly always the result of an old choked disc or optic neuritis. Pupils and their Reactions. — The ciliary muscles react to two forms of stimulus: (1) light, (2) movement of the eyeballs. No mat- ter what the stimulation, the con- traction or dilatation of the pupil is performed by the same muscles, but the innervation differs. The or- dinary light stimulation is trans- mitted by means of the optic nerves to the oculomotor nucleus, and from here the impulse to the ciliary muscle is carried by the oculomotor nerve. This is the light reflex arc, and if there is any disturbance anywhere in the arc, there will he impairment or loss of the reaction of the pupil to light. The filjers which are concerned with the reaction of the pupil to movement, as, for instance, in con- vergence and divergence, and in upward, downward, and outward move- ments, have probably a .similar arc, with the addition that they are in con- nection with the nuclei of the muscles necessary to perform a certain ocular movement. THE OCULOMOTOR NERVE. The oculomotor or third nerve supplies all the muscles of the eyeball with the exception of the superior oblique and the external rectus. A total paralysis will cause drooping or ptosis of the upper lid, outward and downward deviation of the eye, with inability to move it in any but the outward and downward direction, and an enlarged pupil which does not react to any form of stimulation. Unilateral paralysis is nearly always due to basal syphilis (Fig. 388). It mu,st also be remembered that just at the exit point of the third nerve at the foot of the cerebral peduncle, the different fibers which make up the nerve are still separated, and it is possible for a basal .syphilitic lesion to involve only a few of the fibers. It is because of this that at times only a partial oculomotor paralysis will result from syphilis, Fig. 388. — Syphilitic Oculomotor Palsy. Drooping of the Left Upper Lid. 1038 DISEASES OF THE NERVOUS SYSTEM. such, for instance, as internal rectus palsy, drooping of the upper lid, or disturbance of the iridic reflexes. Fractures of the base of the skull, basal tumors, and aneurisms may rarely cause oculomotor palsy. The nuclei of the oculomotor nerves in the posterior portion of the crus are very close together, and a lesion or a hemorrhage in this area will nearly always cause bilateral oculomotor palsy. The disease causing such hemor- rhage is known as acute superior polioencephalitis (of Wernicke). It comes on acutely and is usually accompanied by fever and its attending symptoms, and the pathology consists in multiple hemorrhages and areas of inflamma- tion in the gray matter surrounding the aqueduct of Sylvius. The nuclei of the fourth and sixth cranial nerves may also be involved, and there will result what is known as complete bilateral ophthalmoplegia, or paralysis of all the muscles of the eyeball, causing inability to move the eyes in any direction. Areas of inflammation or hemorrhage sometimes involve the cranial nuclei in the lower portion of the pons and medulla, and we may have, in addition to the ophthalmoplegia, the symptoms of such involve- ment. Rarely the disease in the lower part of the pons or medulla is inde- pendent, when it is known as acute inferior polioencephalitis (of Wernicke). In such cases we have the symptoms of acute bulbar paralysis, with difficulty in talking, eating, and swallowing, and paralysis of the muscles innervated by the seventh, ninth, tenth, eleventh, and twelfth nerves. Ophthalmoplegia, or paralysis of all the muscles of the eyeball, may be internal, external, or complete. By internal ophthalmoplegia is meant paralysis of the ciliary muscles, this resulting in rigid pupils. By external ophthalmoplegia is meant paralysis of the external muscles of the eye. In complete ophthalmoplegia there is inability to move the eyeballs in any direction, drooping of the upper lid, and rigid pupils. Unilateral oph- thalmoplegia may result from a lesion in back of the eyeball, and com- monly occurs in cavernous sinus thrombosis, when there will be, in addition to the ophthalmoplegia, a protrusion of the eyebaU with stasis of the veins and edema of the lids. In nearly all cases of cavernous sinus thrombosis there will ultimately be bilateral involvement. Bilateral external ophthalmoplegia may be the terminal stage of an old polioencephalitis, may be part of a chronic degeneration of the motor cranial nuclei, as in progressive bulbar palsy, or may be an independent disease coming on in childhood or in early adult life with apparently no recognizable cause, when it is called chronic ophthalmoplegia. THE TROCHLEAR NERVE. Isolated paralysis of the trochlear or fourth nerve is an extremely rare condition and hardly ever occurs. It is generally found in association with palsies of the other ocular muscles. This nerve supplies the superior oblique muscle, which pulls the eye downward and outward. Basal syphilis is nearly always the cause of paralysis. THE ABDUCENS NERVE. The abducens or sixth nerve supplies the external rectus muscle, which pulls the eye outward (Fig. 386). Temporary or permanent paralysis is a very frequent and early symptom in basal syphilis and brain tumors. This nerve is probably more frequently diseased than any of the other ocular nerves. This is partially due to the fact that it has the longest course PLATE XVI is THE TRIGEMINUS NERVE. 1039 of any of the nerves in the base of the brain, and it is therefore more vul- nerable to pressure, trauma, or a lesion in any portion of the skull. Its involvement with other nerves has already been discussed. THE TRIGEMINUS NERVE. The trigeminus, or the fifth nerve, has both a sensory and a motor function,^ it being mostly sensory. The motor part suppHes the muscles of mastication. The sensory division supplies sensation for the face, eye, nose, palate, and pharynx, and also the anterior two-thirds of the tongue. In paralysis of the motor fiftii there will be inability to chew on the side of the paralysis, the contraction of the masseter and temporal muscles will be weak, and the jaw will deviate toward the affected side. Isolated paralysis of the motor fifth nerve never occurs, and when present may be one of the symptoms of chronic nuclear degeneration of the bulbar nerves. It may, of course, occur in pontile tumors, when there are, in addition, such other symptoms as paralysis of associated ocular movement and hemiplegia. When the result of a basal lesion, as syphilis, the sensory part of the nerve is involved in ad- dition, this causing disturb- ance of sensation in its dis- tribution. It is frequently temporarily paralyzed in early hemiplegia. In an irritating lesion of the sensory part of the fifth nerve there will be pain either in its whole distribu- tion or the subdivisions of the ner\re, that is, the su- praorbital, infraorbital, or mental. Tic douloureaux, or painful spasm of the fifth nerve, is due to many causes, but in the majority of instances no ascertainable factor can be found. Repeated examinations of the Gasserian ganglia have demonstrated occa- sionally diseases of the nerve-cells, but this is not constant, and the real cause is not known. The disease may involve at first or be always limited to one branch of the fifth nerve, usually to the supraorbital, when it is termed supraorbital neuralgia. As a rule, it begins with an occasional numbness in one of the divisions, this becoming more frequent and severe, the onset of the disease lasting sometimes over a numlier of years, to be followed by pain which involves two and lastly all of the branches. If the disease is limited to the supraorbital nerve, pain will be marked over the forehead and brow, and there will be pain in the eye, sometimes a sensation as of a foreign body. Occasionally the pains will be so sharp as to cause closure of the eye with flow of tears. Inflammation limited to the middle or infraorbital nerve (infraorbital neuralgia) will cause numloness or pain in Fig. 389. — Arteriosclerotic Palsy of Ocular Muscles, SHOWING Paralysis of Left External Rectus. 1040 DISEASES OF THE NERVOUS SYSTEM. the upper jaw and upper teeth, and sometimes in the tongue. If the disease is limited to the inferior or mental branch, the pain will be in the lower jaw, teeth, and tongue, it being aggravated by eating or talking. There will, besides, be pain on pressure over the nerves at their exits. If the disease involves all parts of the fifth nerve, the pain will come on spasmodically and cause the most excruciating pains over the whole side of the face, and associated with this contractions or spasms of the muscles. Accompanying this there will be flow of tears and pain on pressure over the exits of the nerve. At such times any irritation, no matter how slight, and talking or eating will luring on a fresh attack, and there may also be hj^peresthesia in the dis- tribution of the trigeminus. The prognosis in a well-marked case is poor, inasmuch as operative pro- cedure offers the only relief. In such case, whether the Gasserian ganglion FiQ. 390. — Left Facial Palsy showixg Ina- bility TO Wrinkle the Brow. Fig. 391. — Drooping of the Left Angle of the Mouth with Inability to Shut the Eye. be excised or the sensory root cut, relief of pain will he obtained, and there will be anesthesia in the distribution of the fifth nerve. It is important to remember that sensation after a short time will return, there being a return of deep sensation, and even superficial skin sensation to some extent. THE FACIAL NERVE. ^ The facial or seventh nerve supplies the muscles of the face. Its nucleus is in the lower and posterior portions of the pons, and the nerve in its course outward surrounds the nucleus of the sixth nerve. Its exit is just between the pons and medulla. Because of this anatomic relation, any gross lesion involving the seventh nucleus will nearly always involve the sixth, and vice versa. The usual form of facial palsy is that known as peripheral or Bell's palsy. Lesions causing this may be either in the pons, at the exit of the THE AUDITORY NERVE. 1041 nerve at the base of the brain, in the Fallopian canal, or in its extracranial course. Central facial palsy is that form of facial paralysis in which the lower part of the face only is paralyzed, and is the result of a lesion in any portion of the central facial fibers between the facial centers in the cortex and its nucleus in the pons, as, for instance, in a capsular hemiplegia. The reason for the escape of the upper portion of the face in such paralysis is because wrinkling the brow, in common with other bilateral functions, such as chewing, eating, and swallowing, has bilateral cortical innervation, and to cause paralysis of such functions there must be bilateral cerebral lesions. In a large majority of cases ordinary peripheral facial palsy is the result of a neuritis which may be of rheumatic origin or may follow a "cold." Rarely it is due to basal syphihs, tumors, fractures, etc. When resulting from a lesion in the pons, facial paralysis is generally accompanied by other symptoms, such as palsy of the sixth nerve, paralysis of associated ocular movement, or hemiplegia upon the other side. Abscess of the middle ear is a common cause as well as mastoid operations. When the lesion is in the Fallopian canal, we have, in addition to the usual symptoms, tem- porary disturbance of taste in the anterior two-thirds of the "tongue because of involvement of the chorda tympani which runs along with the seventh nerve in the Fallopian canal. The symptoms of peripheral paralysis of the facial nerve depend upon the degree of its involvement. When the paralysis is total, there is inability to wrinkle the brow, to shut the eye, to elevate the corner of the mouth, to whistle, or to pronounce labials properly (Fig. 390). Besides, there will be drooping of the lower lid and of the corner of the mouth, and the wrinkles on that side of the face will be smoothed out. Because of the drooping of the lower lid there will be widening of the palpebral fissure and excessive flow of tears because of the lack of proper conduction into the nasal cavity. Electrical reactions of degeneration will be found, their degree depending upon the extent of the neuritis. Sensory disturbances may be present at the onset, when the patient may complain of pain in the face, and there may also rarely be herpetic eruptions in the ear because of involvement of the geniculate ganglion. Most cases of peripheral facial paralysis recover provided the cause is an ordinary neuritis such as results from " colds" or rheumatism, and that prompt treatment is instituted. In those cases in which the nerve is cut, unless an anastomosis is performed recovery cannot be expected. Some- times, years after the occurrence of such paralysis, there may occur secondary contractures. THE AUDITORY NERVE. The auditory or eighth nerve has two divisions — the cochlear, which is the nerve of hearing, and the vestibular, which is concerned with equih- bration. The nucleus of the eighth nerve is in the posterior and lateral portion of the inferior part of the pons and the upper part of the medulla oblongata, and may be affected by vascular lesions or tumors of this area. As a rule, deafness is due to middle-ear involvement. Rarely the eighth nerve is involved at its exit in the cerebello-pontile angle by basal syphiUs or tumors. Disease of the vestibular portion of the eighth nerve is discussed under the heading of vertigo. 66 1042 DISEASES OF THE NERVOUS SYSTEM. THE GLOSSOPHARYNGEAL, THE PNEUMOGASTRIC, AND THE SPINAL ACCESSORY NERVES. The glossopharyngeal, the pneumogastric, and the spinal accessory, or the ninth, tenth, and eleventh nerves, have their nuclei in the posterior and lateral portions of tlae medulla, and their functions are intimatel}' concerned with one another, and a lesion in the nucleus of one will nearly always in- volve the other. The consequences of such lesions will not be discussed, because hemorrhages in this region will nearly always cause parah'sis of respiration and death. Chronic degenerative diseases, however, will often involve these nuclei, as in progressive bulbar palsy. It is only necessar)^ to add that the ninth nerve supplies taste sensation for the posterior third of the tongue and the muscles of the upper part of the pharynx. The tenth sup- plies the muscles of the pharynx, larynx, heart, lungs, and other viscera, and the eleventh nerve, besides being an accessory nerve to the tenth, sup- plies the sternomastoid and the ^ trapezius muscles, parah'sis of this causing inability to turn the head to the opposite side and drooping of the shoulder. THE HYPOGLOSSUS NERVE. The hypoglossus, or twelfth nerve, supplies the tongue. Its nucleus is in the posterior median portion of the medulla. It is one of the first nuclei to be in- volved in such degenerative un- clear diseases as bulbar palsy, when there will be fibrillary trem- ors, atrophy, and weakness of movement. Isolated paralysis of the twelfth nerve is very rare, but sometimes occurs as a result of basal syphilis, fractures of the base, or tumors in the posterior cranial fossa. Sometimes in hemiplegia temporary unilateral paralysis of the tongue may occur, and when the tongue is protruded it will be pro- jected to the side of the paralysis (Fig. 392) . Fig. 392.— Illustrating Atbopht of Right Side OF Tongue. DISEASES OF THE BRAIN. _ General Symptoms.— Certain general svmptoms may be present m any disease of the bram, the degree and number depending upon the nature, extent, and location of the lesion. They are headache, nausea vomiting, vertigo or dizziness, disturbances in motility, such as' tremors' convulsions, general or focal in type, partial or total paralj^sis, disorders of sensation and disturbances of vision or of the other special senses, and, lastly alterations in mentality. ' ' Headache, as a result of any cerebral lesion, is nearly always due either to an irritation of the dura or to an increase of intracranial pressure, which causes tension of the dura. The meninges are innervated by the sensory DISEASES OF THE BRAIN. 1043 portion of the fifth nerve, and disease, therefore, of this part must cause pain. At times the headache is localized to the place of direct irritation, but, as a rule, it is general. The pain is usually severe and constant and is difficult to relieve by medication, and vomiting does not lessen its intensity. The location and character of the headaches as they occur in tumors and other brain diseases will be discussed under their heading. The majority of headaches are, however, due to causes which are not a direct result of irritation of the dura, but are possibly caused by vascular changes. Under this are included the reflex headaches resulting from dis- turbances of the ocular, nasal, sinus, aural, buccal, pharyngeal, laryngeal, and visceral functions. In fact, there is no organ in the body disturbance of which has not been thought to be a possible cause for headache. A still greater variety of head pains are due to general disturbances, as syphilis, acute rheumatism, or diabetes, but the largest number of all occur in the so-called functional neuroses. It would be interesting to differentiate the various locations of headaches resulting from reflex and other causes, but this is impossible, for, as a matter of fact, the pains may occur in any portion of the head. The general characteristic of all neurasthenic and so-called functional headaches is that they are nearly always in the back part of the head and neck, or in the top of the head, and are described as a pressure sensation and sometimes as a band around the head. Headaches resulting from disturbance of the sensory portions of the fifth nerve or the Gasserian ganglion and from migraine will be discussed separately. The nausea and vomiting which are present in diseases of the brain are generally indicative of intracranial pressure, for they are not present unless such be the case. They are probably due to an irritation of the ninth and tenth nerves. The nausea may appear in the morning or at any time, and may be accompanied by vomiting, but the latter, as a rule, does not relieve the nausea or the accompanying headache. The vomiting is generally pro- jectile in character and comes on without warning. These symptoms are generally indicative of brain tumor. A greater amount of nausea and vomiting is present in cerebellar lesions because pressure is more direct upon the ninth and tenth nerves. Vertigo or dizziness is also considered a pressure symptom in diseases of the brain. The dizziness may be objective or subjective, i. e., the patient may either see objects move before him or may have a sensation that he moves himself. In cerebral tumors this symptom is not very common, but in cerebellar lesions vertigo appears very early and is very marked and persistent. It is probably due to pressure which is exerted on the vestibular division of the eighth nerve. M^nifere's Disease. — This is the name given to a symptom-complex the leading characteristic of which is vertigo accompanied by loud noises in the ear. The disease generally occurs in the latter end of life, and, as a rule, begins with noises in the ear accompanied by some dizziness. These first come on occasionally, and gradually the tinnitus increases, the noises sometimes resembling the shrieking of a whistle, and are accompanied by excessive vertigo, which, as a rule, terminates in nausea and vomiting. During the attacks the patient feels weak and is pale. At first the disease is unilateral, but ultimately there is bilateral involvement. Disturbance of hearing finally comes on, the deafness then becoming progressive. The tinnitus, vertigo, and deafness now become constant, sometimes preventing the patient from assuming an erect posture. Rarely when the deafness becomes complete the vertigo and tinnitus cease. It is supposed that this 1044 DISEASES OF THE NERVOUS SYSTEM. symptom-complex is due to a disease of the terminal filaments of the vesti- bular nerve in the labyrinth, and there may also be disease of the semi- circular canals. Disturbances in motility do not occur unless there is an involvement either of the cortical motor centers or of the fibers coming from them. Be- cause of the readiness with which motor symptoms are tletected they are more quickly appreciated than any of the other symptoms. They may consist of tremors, forced movements, convulsions, either general or focal, and partial or total paralysis. Tremors. — A tremor may be indicative of a general disease, such as paralysis agitans, when it is coarse, vil:>ratory, and lessens on effort. In disseminated sclerosis the movement is made worse on effort and is called an intention tremor. It also differs from that present in paralysis agitans in the fact that it is not vibratory and resembles more an irregular movement. A general tremor of the limbs may sometimes be present in old age, hysteria, and other functional neuroses. Fibrillary tremors are always indica- tive of a chronic degeneration or atro- f)hy of the cells in the anterior horns of the spinal cord or of the motor cranial nuclei in the medulla. The movements are fine and consist in a wave-like twitching of one or a number of muscle- fibers. Such other movements as are pres- ent in chorea, myokymia, and its sub- divisions will be discussed separately. Forced or Associated Movements. — By this is meant the forced movement of a healthy limb when the patient at- tempts to move the paralj^zed limb, as in hemiplegia. It is probable that this is due to the fact that one side of the cortex innervates both sides of the body. Athetosis. — It may be present in the face or in all of the limbs, or in any one of the limits, and is always indicative of a lesion in the motor columns or cortex, either at infancy or birth. The athetoid movement is slow, twisting, and constant (Fig. 393) . Convulsions. — These are spasmodic movements of a part of a hmb, of a whole limb, of one-half of the body or of the whole body, and may be ac- companied by loss or impairmemt of consciousness, "if the convulsive movement is limited to a part of a limb or one-half of the body, and if it always begins in the same muscles, it is called a focal or Jacksonian convul- sion, and is nearly always indicative of an irritative lesion in the motor cortex. In Jacksonian convulsions or epilepsy the spasms come on quickly and may last from a few seconds to several minutes, and are generally clonic in type, and, as a rule, are not accompanied by unconsciousness. It is of the utmost importance to see where a Jacksonian convulsion begins, what muscles or movements it involves, and their succession. Sup- posing, for instance, twitchings begin in the fingers of the right hand, and from here the movements extend into the muscles of the forearm' Fig. 393. — Athetoid Movements in the Face in a Case of Old Infantile Diplegia. EPILEPSY. 1045 arm, and shoulder, and then into the muscles of the face. This would be indicative of a lesion in the left motor cortex, probably extending from the hand to the face center, from the middle to the lower portion of the precentral convolution. Should, however, the convulsion involve the leg instead of the face, it would indicate that the lesion extends from the middle of the precentral convolution upward or to the leg center. These facts are of the utmost importance when surgical procedures are considered, for upon their correct observation will rest the probable seat of operation. General convulsions are nearly always indicative of epilepsy. EPILEPSY. Definition. — A chronic progressive disease, characterized by periodic loss or impairment of consciousness, with or without convulsions. There is no disease which has so many variations in its form, but in all the cardinal point of an epileptic attack is either impairment or loss of con- sciousness. When an attack is unusual it is either because the convulsions have been suppressed or were not present at all, that consciousness was only partially impaired or the attack consisted of so-called, psychic or mental manifestations known as epileptic equivalents. These will be described separately. It is supposedly more frequent in the male sex, although this is disputed by many. Race has no influence upon the frequency of the disease. Predisposing Factors. — There is no other disease in which he- redity plays so important a part. Epilepsy in one of the grandparents, but especially in the parents, will predispose the child toward epilepsy. Mental or brain diseases, and especially alcoholism or syphilis in the parents, are important predisposing factors. Children in whom epilepsy subsequently develops, and who have a neuro- pathic history, may have certain symptoms or so-called stigmata of degener- ation as an evidence of their inheritance. These stigmata may consist in microcephalic or macrocephalic heads, asymmetry in the head and face, and sometimes in deformity, irregular oi* poorly shaped teeth, poorly arched palates, irregular and asymmetrical ears, and at times poor sight and poor development of the limbs. Exciting Factors. — ^The pathology of epilepsy is not definitely known. By many it is thought to be a functional disease, and by others the result of cortical chemical changes, but it is probably the result of a mal- development of the whole brain, and especially of the motor portion. In support of this, recent microscopic evidence seems to show that the motor cortical cells are undeveloped. Given a child with a bad heredity, or one who was born with a weak motor cortex, it is possible for epilepsy to de- velop. In a large majority of cases the disease appears in infancy, and only rarely do the convulsions appear after the twentieth year. In the early cases it is possible that reflex convulsions, such as are caused by toxemic and gastric disturbances, may be the exciting factors. The convulsions may follow regularly thereafter or may be absent for a few years, and then re- appear about the age of puberty. Epilepsy, of course, may occur in any organic disease in which the motor cortex or the fibers are involved, as in hydrocephalus and tumors, and also following trauma. Varieties and Symptoms. — There are three chief types of attacks: First, major epilepsy, or grand mal; second, minor epilepsy, or petit mxil; and third, psychic epilepsy. 1046 DISEASES OF THE NERVOUS SYSTEM. Major epilepsy, or grand mal, may or may not be preceded by an aura. This may consist in a disturbance of any of the special senses, such as flashes of hght or temporary blurring of vision, a peculiar odor or taste, noises in the ear, or a feeUng of numbness ascending one of the limbs, as from the arm to the shoulder, or the foot to the abdomen and neck, or it may be referred to one of the viscera, as a sensation of numbness rising from the stomach to the throat. Sometimes it consists in a feeling of dizziness or of a sensation or of a fear that something is going to happen. Rarely there may be a so- called dreamy stage. An aura may last from a few seconds to a minute or longer, and, as a rule, is immediately followed in a typical attack by loss of consciousness, the patient falling to the ground, sometimes hurting himself. There may be a cry — the so-called epileptic cry. The body then becomes rigid in tonic contracture, the head may bend backward, the fingers are clenched, the face is blue and livid, the eyes may roll in any direction, and the teeth are clenched. Generally the patient bites his tongue and froths at the mouth. The tonic convulsion may last from a few seconds to several minutes, and is succeeded by clonic or intermittent movements, which may also last from a second to several minutes. Relaxation then follows, and the patient may rally from the attack immediately or may not do so for several hours or longer, feeling weak and exhausted afterward. Because of the con- traction of the abdominal walls on the bladder, there is usually some drib- bling of urine, and there may be excretion of feces. The above description is that of a typical attack of major or idiopathic epilepsy. There are, of course, variations, some attacks being more severe than others. An attack may consist in an aura, followed by the epileptic cry, but the tonic and clonic movements may be very slight, although there may follow just as severe a period of exhaustion as that which succeeds the more severe attack. . Sometimes the spasms may be very limited, such as movements of the jaw, smacking of the lips, or twitching of a limb, but the i important point is that in all of these incomplete attacks there is impairment or loss of consciousness, and nearly always there is a preceding aura and the I ^succeeding period of exhaustion which characterize the more severe attacks. By minor epilepsy, or petit mal, is meant a condition in which there is either a partial or an incomplete loss of consciousness and no appreciable or a mild convulsive movement. The milder forms consist only in an aura, followed by a slightly dazed feeling which may last a second or so, but in which there is no actual loss of consciousness. In the more severe attacks, besides the aura the patient will fall to the ground and the loss of conscious- ness is more complete, the patient feeling dazed for a moment or so. It can be easily recognized from this that there may be many varieties of petit mal, depending upon the presence of the different forms of aura and the extent of the impairment of consciousness. By psychic epilepsy is meant a condition in which certain mental symptoms take the place of the convulsion or spasm with loss of conscious- ness. By many these attacks are likened to the incomplete form of the minor epileptic attacks, as, for instance, when there is only an aura accompanied by loss or impairment of consciousness. It is probable that these so-called psychic attacks take the place of the spasm, and as such are known as epilep- tic equivalents. They resemble the mental conditions which sometimes occur before and after a spasm. By describing, then, the different forms of psychic epilepsy or epileptic equivalents we will be describing the mental conditions which occur before and after an epileptic attack. The commonest form is that in which the patient loses consciousness a EPILEPSY. 1047 moment or so and performs mild, automatic movements, such as unbutton- ing his clothes, or making use of some exclamation, ^nd then resuming his previous occupation or what he had been previously engaged in. The patient has no recollection of the occurrence. When the automatic movement is prolonged for some time, it is called epileptic ambulatory autovmtism. The patient may be in this condition for an hour or longer or for several days, and rarely weeks, and he may wander or travel over considerable distances and behave himself in an apparently orderly manner and after it is over have no recollection of what he has done. He may in the interim have had typical convulsive attacks. Ambulatory automatism sometimes occurs in hysteria, and the differential diagnosis will depend upon the history and the occurrence of other forms of epileptic attacks. Acute maniacal conditions sometimes take the place of epileptic attacks. They usually come on suddenly, with a feeling of irritability and exhibition of temper, and suddenly the patient becomes maniacal. These attacks sometimes take the form of homicide, suicide, or pyromania or the desire to burn objects. The attacks may last for an hour or longer or for some days, and may finally terminate in stupor, sometimes the patient dying as a result. Instead of acute mania there may be temporary delusional conditions which may last only a short time, or the patient may become stuporous or in a catatonic condition, or he may get into the so-called dreamy state, during which he has a feeling of unreality, especially regarding himself and objects surrounding him. Again, the attacks may take the form of paroxysmal laughing, and crying or of narcolepsy or periodic sleeping. Frequency of Attacks. — It is impossible in the beginning of this disease to foretell the frequency of the attacks. As a rule, epilepsy occurs periodic- ally, and in ancient times it was thought that it occurred nearly always once a month, at the time of the full moon. There is no question that in the majority of cases proper treatment will lessen the number of the spasms. The frequency of the attacks will to some extent depend upon the time of the onset and the type of the spasm. In those cases in which they come on in early hfe, it is probable that they will occur with more frequency and that they will be more severe, while in those in which the attacks begin late in life they will probably not occur so often. Heredity also plays an important part, for in a child in whom there is a neuropathic disposition, and especially one in whom the stigmata of degeneration occur, it is probable that the attacks will become frequent. In those cases in which there are, first of all, minor attacks or attacks of so-called psychic epilepsy, there is also no rule regarding the frequency of the attacks, for most of these cases will finally terminate in typical major epileptic attacks. It is not at all unusual for epilepsy to occur at night, when it is called nocturnal epilepsy, and it may be a number of years before the patient himself becomes aware of his disease, and it may not be until some one sees him in the fit or he has an attack in daytime that the disease is really suspected. Some- times after the attacks have been manifested in daytime they may for a time come on at night. Sometimes one attack follows another without the patient regaining con- sciousness in the interim. Such a condition is known as status epilepticus. The patient may be in this state for hours, sometimes for two or three days, and may have as many as seventy attacks a day. They sometimes terminate in death. Summary of Diagnosis. —History of epilepsy, insanity, or nervous 1048 DISEASES OF THE NERVOUS SYSTEM. disease in parents; convulsions which began in childhood and which have progressively become more frequent, and which maybe ushered in by an aura and maybe followed by an epileptic cry; and then convulsions which are first tonic and then clonic. These are characterized by rigidityof the head, back, and limbs, blueness of the face, frothing at the mouth, biting the tongue, and dribbling of urine, the whole lasting about two or three minutes, and which is followed by a period of exhaustion. Consciousness is recovered in from a few minutes to an hour or a number of hours, with a feeling of weakness. 'Diflferential Diagnosis.— The cardinal point of epilepsy is loss of consciousness and inability to recall anything which has occurred during the attack. The convulsions are characteristic. Sometimes true idiopathic epilepsy may simulate Jacksonian convulsions, but in these cases there is an entire absence of the usual accompanying symptoms, such as headache, nausea, vomiting, vertigo, and choked disc. It is sometimes difficult to differentiate from the convulsions occurring in hysteria, but in the latter the movements do not have the tonic and clonic succession, the tongue is never bitten, and there is never dribbling of urine, and, most important, there is no loss of consciousness. Clinical Course and Complications.— From the very nature of the disease the prognosis is poor, for the convulsions nearly always become more frequent, more severe, and longer in duration. It has been estimated that in about 10 per cent, of the total number of epileptics cure can be expected, but [these cases are nearly all mild and treatment has been early and vigorously instituted. Psychic epilepsy is nearly always followed by petit mal, or later by grand mal, or, what often happens, there may be the three varieties of attacks in one person. The earlier the onset and the fre- quency of the attacks, the worse the prognosis. When the attacks come on after the twentieth year, the convulsions will not be so frequent and the dis- ease will not make such rapid progress. In nearly all cases the mental functions become ultimately impaired, this resulting partially from the lack of development of the other portions of the brain, from the result of attacks and the constant medication which nearly all patients undergo. Besides the usual mental enfeeblement which accompanies the disease, the degree of which depends upon the early onset, severity, and frequency of the attacks, there may be total loss of intelligence, this resulting in what is known as chronic epileptic insanity or dementia. The patient usually dies as the result of some intercurrent disease, and only in rare instances does death occur in a fit. It is probable that epilepsy in itself has some influence in shortening the tenure of life, for most epileptics do not reach an old age. PARTIAL OR TOTAL PARALYSIS. It must be borne in mind that in the motor cortex are represented the centers for movement, and if these are destroyed paralysis of movement will occur, the extent and completeness depending upon the centers destroyed. Paralysis of one limb, the result of a cortical lesion, is very unusual, and if present is always due to a small tumor, or more probably to an injury. If the whole motor cortex is destroyed, hemiplegia will result. Hemiplegia. Definition. — A paralysis of one-half of the body, this including the leg, arm, and lower part of the face, with only a temporary involvement of PARTIAL OR TOTAL PARALYSIS. 1049 such bilaterally acting muscles as are concerned with looking upward, eating, talking, swallowing, and respiration. Most hemiplegias result from the bursting of a cerebral vessel or apoplexy. Unusual paralyses are those in which the regular order of symptoms is not present or some unusual symptom occurs. These will be explained later. It is more often present in the male, probably because of the greater frequency of early arteriosclerosis and syphilis. Predisposing and Bxciting Factors. — Hemiplegia sometimes runs in families, but in most instances heredity plays no important part, with the exception that if a patient inherits a disease such as syphilis, which gives an early arteriosclerosis, hemiplegia is more liable to occur. Any lesion which interrupts the motor fibers between the motor cortex and the decussation in the medulla will give a hemiplegia on the other side, the form of the specific paralysis and the accessory symptoms depending upon the seat and the extent of the lesion. In most instances this is a hemorrhage ; but the other frequent causes are thrombosis, embolism, tumors, injuries of the motor cortex, uremia, and other toxic causes. Varieties. — Hemiplegia may come on as the result of a lesion at birth, at the infantile period, or that period at 'which the child cannot walk, in the time of mature development or between the time when the child is fully able to walk and early adult life, about the twenty-first year, and from this time on. These subdivisions have been made because the clinical type of the paralysis will differ according to the time of life it comes on. Hemiplegia Resulting from Injuries at Birth. — This occurs only when, as a result of difficult or instrumental labor, there is an injury to the motor cortex either of one side or of both sides. Pathologically, meningeal hemor- rhages are most frequently found. If the injury is one-sided, a hemiplegia wiU result, and the child from its earliest life will be unable to use the limbs of one side. The characteristic of this palsy is that the paralyzed limbs will never fuUy develop and will always be smaller than those on the healthy side, and there will be present athetoid movements. If the meningeal hemor- rhage is removed early, it is possible to obtain considerable return of power. Should there be bilateral meningeal hemorrhage, there will be paralysis on both sides of the body, or a so-called infantile diplegia. In such case there wUl be bilateral spasticity, increased reflexes, and the Babinski reflex. Be- sides, the limbs will never become fully developed, and there will be present athetoid movements of the upper and lower limbs and in the muscles of the face, head, and neck. In most instances, also, there will be inability to talk. Paralysis Coming on During the First Two Years of Life or in the Infantile Period. — To understand this it is necessary to have a knowledge of the development of the motor system. The child when it is born cannot walk because of lack of development of the motor fibers. This can be readily seen when a cross-section is made of the spinal cord of a newly born child, for the myelin sheaths of the motor fibers wiU not stain. On the contrary, if the spinal cord of a chicken, which walks immediately after birth, be stained it will be found that the myelin sheaths are fully developed. That is why the chicken can walk and the child cannot. Ordinarily it takes from one to two years for the myelin sheaths to obtain full development, and when this is reached the child will be able to walk. It can be readily seen from this why it is an error to force or urge children to walk before they are able to do so themselves, and also is an evidence of the cause of deformities of such children. Should, therefore, there occur a lesion of the motor centers or fibers in this 1050 DISEASES OF THE NERVOUS SYSTEM. period, there will result a hemiplegia, and, similar to the paralysis which occurs as a result of meningeal lesions, there will be spasticity, increased reflexes, Bal^inski reflex, and lack of development of the limbs, but this will not be as great as in lesions at birth. It can also readily be seen why a lesion occurring near infancy \^'ill cause a greater lack of development. _ Athetoid movements, as a rule, do not occur, and if the lesion should be bilateral, it is probable that there will not be much impairment of speech (Fig. 394). Paralyses Which Occur from the Second Year or the Infantile Period to Full Maturity.— A child grows up and does not reach full tlevelopment until al^out the twenty-first }-ear, sometimes later. The hemiplegia which occurs in this period will differ from the par- alysis occurring later only in the fact that there will be lack of development of the limb, this being greater the earlier the lesion. The causes are generally injury to the head, early syphilis jaar ;-■. w^r^ s . ' >*>N ■.M: f j% \ 'h- Fig. 398. — Facies of a Brain Tumor, showing some Ex- ophthalmos WITH Weakness of Right Internal Rectus. BRAIN TUMORS. 1063 mon. The growths more often are of the sarcomatous variety, and in most instances grow from the frontal bones or from the orbital plate. When the neoplasm is limited to the frontal lobe itself, there are, as a rule, very few locaUzing symptoms. In the frontal lobes have been placed the centers for higher psychic functions, this being especially so in the left; but it cannot be said that any special mental symptoms occur from destruction of these areas. The usual mental symptoms are gradual change in disposition, gradual loss of memory, of intellect, and of the power of reasoning. As can be readily seen, these symptoms may occur from tumors in any portion of the brain. Headache may and may not be present, and is prone to be localized to the orbit and frontal bones. Nausea, vomiting, and dizziness are not very common, and choked disc is a rather rare occurrence except in those instances in which the tumor is mostly localized to the orbital part of the frontal lobes and direct pressure is exerted upon the optic nerve, in which case the choked disc is unilateral. In the latter instance the olfactory nerve is also pressed upon, causing loss of the sense of smell on that side. If the tumor is of large size and involves the precentral convolution, motor symptoms will be present. In the middle portion of the third convolution have been placed the centers for the movement of the head and eyes, and if a lesion irritates these centers conjugate deviation of the head and eyes, or of both, will result to the opposite side. If the lesion, however, destroys these parts, the head and eye will be directed to the side of the lesion. This is because of the unrestrained action of the muscles which are innervated by the op- posite cortical centers. If the lesion involves the inferior posterior portion of the third frontal or Broca's convolution, motor aphasia will be present. The frontal lobes are in direct connection with the opposite cerebellar lobe by the so-called frontocerebellar fibers. In a growth of the frontal lobe in which the tumor is largely subcortical, cerebellar symptoms may re- sult, and it is difficult to differentiate the symptoms from those of a cere- bellar lesion. This, however, is a very rare occurrence. Another symptom which is sometimes supposed to be present is an ab- normal tendency for poor jokes, or the " Witzelsucht" of the Germans. This, however, is of questionable value. The symptoms, then, of a tumor in the frontal lobe are headache, lo- calized mostly to the frontal bones, occasional nausea, vomiting or vertigo, and occasionally optic neuritis, which is mostly unilateral and confined to the side of the lesion. The special symptoms are loss of memory and change in disposition. If the tumor is of large size and presses upon the adjoining motor areas, the above symptoms are accentuated, and there may be, in addition, motor symptoms which may be either of an irritative or a paralytic character, and which are confined to the limbs of the opposite side, conjugate deviation of the head or eyes or of both, and motor aphasia. Tumors of the Motor Area. — Growths in this location are more common than in any other portion of the cerebrum, and are mostly sarcomata or ghomata. The symptoms will depend upon the location and extent of the lesion. If the growth is limited, for instance, to the center for movement of the upper limb, the symptoms will be referred to this part. If the lesion is of large extent, the symptoms, of course, will be referred to the related parts. Jacksonian or focal convulsions nearly always result from a cortical lesion. A tumor, for instance, involving the center for the upper fimb will give Jack- sonian convulsions beginning in this limb. If the growth extends downward, the movement wUl extend from the upper limb to the muscles of the head and 1064 DISEASES OF THE NERVOUS SYSTEM. face. If the growth extends from the middle to the upper portion of the pre- central lobe, the convulsions will extend from the arm to the_ lower limb. It must be remembered that a convulsion which is first Jacksonian may become general in character, and that in an epileptic convulsion there may some- times be Jacksonian manifestations. If the tumor destroys the motor areas, paralysis in the related parts will result. Lesions in the motor area are rarely only confined to the precentral con- volution, and mostly also involve the postcentral convolutions or the sensory centers, in which case sensory symptoms will be present in addition to the motor. If the lesion is irritative, there will be pains of a Jacksonian type in the limbs of the opposite side; or if the lesion is destructive, disturbance of sensation or anesthesia in the related limbs on the opposite side wiU result. If the tumor involves the frontal lobes, and especially the head and eye centers, conjugate deviation will result to the opposite side if the lesion is irritative, and to the same side if the lesion is destructive. If the tumor is on the left side of the brain in a right-handed individual, motor aphasia will also be present. As a rule, tumors in the motor area give symptoms of great pressure, and headache, nausea, vomiting, and choked disc are present in most in- stances. Some of these symptoms may, of course, be absent, but, as a rule, headache and choked disc are present. The symptoms, then, of a tumor confined to the motor area are headache, nausea, vomiting, choked disc, and Jacksonian convulsions on the opposite side, to be followed later by paralysis depending upon the extent of the lesion. If the tumor invades the postcentral convolution, there are, in addition, sensory symptoms, such as pains and disturbances in sensation for touch and pain. If the growth invades the frontal lobes, there may be at first conjugate deviation of the head and eyes to the opposite side, and later to the same side. A lesion in the left side of the brain in a right-handed individual will also always give motor aphasia. The contrary is true in left-handed persons. Tumors of the Sensory Area. — ^This includes the postcentral and supe- rior and inferior parietal convolutions. Growths involving only this part are very rare, for in most instances the adjoining motor centers are also diseased. As has already been stated, most tumors of the motor area involve the post- central convolution. Isolated tumors involving either the superior or inferior parietal convo- lutions may rarely occur. In such case a lesion of the superior parietal convo- lution will give disturbance in the sense of localization, of position, of move- ment, of pressure, and ataxia in the lower limb, with inability to recognize objects placed against the sole of the foot. A lesion involving the inferior parietal convolution wiU give the above symptoms in the upper limb instead of the lower. In addition, in both there may be headache, nausea, vomiting, and choked disc. In most parietal lesions the adjoining postcentral convolution is in- volved, and there are, in addition to the symptoms already enumerated, dis- turbances in touch and pain. Very often in irritative lesions of the sensory areas there may be numbness and spasms of pain in the related limbs similar in character to the Jacksonian spasms, the result of motor irritation. If the growth involves the adjoining occipital convolution, disturbance in vision will result. If the lesion is left-sided in a right-handed person and the angular gyrus is involved, there is, in addition, word and letter blindness, this causing inability to read or write voluntarily, or from dictation. BRAIN TUMORS. 1065 Tumors of the Occipital or Visual Area. — Growths in this area are not very common. They cause early pressure symptoms, as a rule, and distur- bances of vision are among the first manifestations. There may be flashes of light or scintillating scotoma in the related visual fields, to be followed later by disturbance of vision, either for light or for colors, and lastly loss of half vision, or hemianopsia. Visual hallucinations are common, and usually occur on the side opposite the lesion, but may be on the same side. They may occur in the blind fields. Besides there may be a dissociation of the color sense; that is, while the patient may be able to recognize and match all colors, and the form of objects, he is unable to recognize the particular color of an object. If the lesion is right-sided, there will be left lateral homonymous hemianopsia, and vice versa. Occipital headache is always marked, as is also nausea, vomiting, and vertigo, and choked disc will come on early. This is because direct pressure is exerted upon the cerebellum. There may be, in addition, the symptoms of cerebellar incoordination. If the growth involves the adjoining parietal or angular gyres, their re- lated symptoms wiU occur. Tumors of the Temporal Lobes. — Growths in this area are of rare occur- rence, in most instances the adjoining parietal lobes being also involved. If the lesion is on the left side of the brain in right-handed individuals and the growth is confined to the temporal lobes, the symptoms will be those of pure sensory aphasia, i. e., the patient will be able to talk, but he will have loss of memory for words as to their meaning and his speech will be unintelligible. If the lesion is on the right side of the brain in right-handed individuals, no locahzing symptoms will be present. This is the so-called " silent area" of the brain. There may, of course, be headache, nausea, vomiting, and choked disc. If the growth involves the adjoining parietal lobes, their re- lated symptoms wiU occur. Tumors of the Subcortex. — In the process of growth nearly every cor- tical tumor will become subcortical, so that practically every growth of the cerebral hemispheres will have symptoms the result of interruption of cortical fibers. The specific symptoms will depend upon what fibers are interrupted. The differential diagnosis between growths in the cortex and subcortex has already been referred to on page 1062. It is only necessary to add that subcortical growths nearly always are gliomata or sarcomata, that they are slow in growth, and that, as a rule, the first symptoms are those of intracranial pressure, with the symptoms depending upon whether the motor, sensory, or special fibers are involved. Ttunors of the Lateral, Third, and Fourth Ventricles. — Growths in these cavities are rare, and are relatively more frequent in the fourth than in the third or lateral ventricles. They may grow either from the ependymal walls of the ventricles — so-called ependymal glioma — or from the choroid plexus, and may be sarcomatous or glandular in nature. Cysticerci are com- mon abroad, but not in this countiy. Tumors in these cavities may be secondary to growths of surrounding structures, or the growths in the ventricles may involve the surrounding tissue, but, as a rule, a ventricular tumor does not grow into the brain substance. Tumors of the Fourth Ventricle. — The symptoms wiU depend largely upon the size of the growth and upon the pressure symptoms exerted on either the cerebellum, medulla oblongata, or pons. If the tumor is small, it may give no symptoms; but as it grows it may block up the normal flow of fluid, and thereby cause internal hydrocephalus, and give the usual pressure symptoms, as headache, nausea, vomiting, vertigo, and marked choked disc. 1066 DISEASES OF THE NERVOUS SYSTEM. These general symptoms vary because the closure of the fourth ventricle may at times be incomplete. Generally speaking, the specific symptoms of tumors in the fourth ventricle are those of a lesion in the posterior cranial fossa; that is, there will be, besides the general symptoms, cerebellar in- coordination, and if pressure is exerted upon the floor of the fourth ventricle, there may be involvement of the twelfth, and especially of the ninth and tenth nerves; and as a result of this, sudden death, because of respiratory or cardiac failure, is very frequent. Because of pressure upon the pons there may be paralysis of the seventh, and especially of the sixth nerves. Tumors of the Third Ventricle. — It is extremely difficult to diagnose tumors in the third ventricle, and it is doubtful whether a small tumor in this area can ever be diagnosticated in life. If, however, the growth is large, besides the general symptoms of headache, nausea, vomiting, vertigo, and choked disc, which may or may not be excessive, depending upon the closure of the foramen of Monro and the general intracranial pressure, the specific symp- toms will depend -largely upon the direction of the growth. In most in- stances tumors of the third ventricle grow backward and extend into the structures surrounding the aqueduct of Sylvius involving the region of the oculomotor nuclei. If such be the case, besides oculomotor palsy, because of involvement of the posterior longitudinal bundle, there wiU be paresis or paralysis of associated ocular movement upward. For the same reason involvement of the superior cerebellar peduncle or the red nucleus will cause cerebellar incoordination. If the growth is very large, it may press upon the optic chiasm, and, besides causing excessive choked disc, it may produce paralysis of the sixth and third nerves. Lateral pressure upon the internal capsule may cause paretic symptoms either of one or both sides, and pressure upon the thalamus, disturbances in vasomotor and trophic functions on the side opposite the lesion, of mimetic expression, and some- times involuntary howling, circulatory movements, or deviation of the body to the side opposite the lesion, disturbances of sensation, and pains upon the other side of the body. Tumors of the Lateral Ventricles. — Growths in these areas are difficult to diagnosticate, because in most instances the symptoms will be those of fjressure upon the internal capsule, which will cause hemiplegia on the opposite side. It has been thought that lesions of the lateral ventricles produce convulsions, but this is questionable. The general symptoms of brain tumor are here also very marked. Tumors of the Cms or Cerebral Pedtincles. — Growths limited to the cerebral peduncles are very uncommon, and in most cases are either ex- tensions of tumors of the pons or of the third ventricle. The specific symp- toms, if the lesion is unilateral, will consist of oculomotor palsy on the same side, with hemiplegic involvement on the other. Tumors of the Pons. — Growths in this area are usually tubercular or gliomatous in nature, of slow growth, and usually occur in young adults. The symptoms will depend upon what fibers are involved, but as the pons is small, and as in most cases there is involvement of all of the structures, the specific symptoms will be those of involvement of the different cranial nerves in the pons, of the fifth, sixth, and seventh, and, because of disease of the posterior longitudinal bundle, there will result paralysis of associated ocular movement, and as the motor and sensory fibers are involved, their associated symptoms. There will, of course, be the usual general symptoms of headache, nausea, vomiting, vertigo, and choked disc. Cerebellar symptoms will be present if the growth involves either the superior, middle, BRAIN TUMORS. 1067 or inferior cerebellar peduncles. The symptomatology of lesions in the pons has been discussed on page 1031. Tumors of the Medulla Oblongata. — These are uncommon and are usually gliomatous in nature. The specific symptoms will be those of involvement of the ninth, tenth, and eleventh cranial nerves. In such cases, however, there will be interference with cardiac and respiratory functions and death. Tumors of the Cerebellum. — When considering the relative size of the cerebrum and cerebellum, it is probable that tumors are more frequent in the latter. Growths in the posterior cranial fossa may involve either the substance of the cerebellum or the surrounding structures, the latter giving the symptoms of cerebellar disease because of pressure or involvement of this organ. It is also necessary to consider growths which occur in the cerebrum, but which, because of pressure, give symptoms of cerebellar disease. The general symptoms of tumors of the cerebellum are headache, nausea, vomiting, vertigo, choked disc, and incoordination. Headache, as a rule, is present, and is more severe in lesions of the cere- bellum itself than in extracerebellar lesions, and is generally localized to the back part of the head and neck. Sometimes the pain is so severe as to cause retraction of the former. Occasionally no headache is present. Naiisea and vomiting are, as a rule, present early, and are more intense in intracerebellar lesions. Vertigo is present nearly always, and is one of the prominent symptoms. It may consist in a feeling of dizziness in which objects may swim before the eyes and the patient feels as if he were losing consciousness, or in a feeling of rotation of objects before the eyes or of rotation of self. Vertigo, as a rule, is more marked in extracerebellar lesions, and is probably dependent upon involvement of the vestibular branch of the eighth nerve. It is the opinion of -some that when there is a sensation of rotation of objects before the eyes, whether the lesion be intracerebellar or extracerebellar, it is always from the diseased to the healthy side. When there is a sensation of rotation of seK, the direction is the same in intracerebellar lesions, but opposite in extracerebellar lesions. This symptom, however, is by no means certain. Occasionally a sense of dizziness is obtained when the eyes are deviated to one side, generally to the side of the lesion, but there is no dizziness when the head is deviated. In such case the vertigo may be due to a weakness of one of the ocular muscles, and is not a true cerebellar vertigo. Choked disc is one of the early and most constant symptoms of lesions in the posterior cranial fossa. As a rule, it comes on earlier and is more marked than in lesions of the cerebrum. It may be greater on the side of the lesion. Sometimes choked disc comes on after the appearance of other cerebellar symptoms, and when it does so, its development is usually very rapid. Tumors of the substance of the cerebellum itself usually give a greater choked disc because of the direct pressure exerted upon the fourth ventricle. Incoordination results from a lesion in any portion of the cerebellum or its connections. As has already been stated, it is probable that the cere- bellum is concerned with the coordination of every voluntary movement, and therefore whatever symptoms are produced are dependent upon this. A lesion in the middle portion or the vermis will produce the greatest amount of incoordination, this being apparent on either side of the body, whereas lesions involving only a lateral lobe will produce a preponderance 1068 DISEASES OF THE NERVOUS SYSTEM. of symptoms on the side of the lesion. Tumors outside of the cerebellum will produce mostly unilateral symptoms unless the middle lobe or the vermis is involved, in which case bilateral ataxic symptoms will be present. The incoordination of cerebellar disease is manifested only when an effort is made, and is not dependent upon peripheral symptoms, i. e., there is never disturbance of sensation and no involvement of muscular sense. This incoordination becomes apparent in the gait, station, position of the head and limbs, movements of the eyeballs, head and limbs, and in talking, eating, and swallowing. These will be taken up in order. When considering the ataxia present in cerebellar diseases, it is necessary to consider also the possible influence of the weakness and the atonia which sometimes result from lesions of the cerebellum. This question is by no means settled, but there is no doubt that in lesions of the vermis itself there may be paresis or weakness in the muscles of the limbs, and especially those of the trunk, and in lateral lobe lesions weakness has been found in the limbs and trunk muscles of the same side. This can be readily seen after operations upon the cerebellum in which this organ has been injured. The weakness is not prominent and is not always present. It is also character- istic of cerebellar disease that the limbs, especially on the side of the lesion, lose their accustomed tone and are rather flaccid. This symptom is also by no means constant, and is present especially in lesions of the vermis. The gait in cerebellar diseases resembles that observed in a drunken per- son. The patient will make a few steps and then will totter or lurch to one side or the other, or backward or forward, and, recovering, will repeat this. In lesions of the vermis this is most marked, but in lateral lobe, and in extracerebellar lesions in which the former is pressed upon, it wUl not be so prominent. Generally the patient will have a tendency to walk to one side, usually to the side of the tumor, and will occasionally have a tendency to fall to this side. If such a patient's gait were not corrected, he would tend to walk in a circle, the center of the circle being the side of the tumor. The patient is generally aware of this tendencj^ to walk to one side, and in his effort to correct this will sometimes walk to the opposite side. As a rule, the closure of the eyes will not tend to increase the incoordina- tion if the lesion is in the vermis, but sometimes in lateral lobe and extra- cerebellar lesions the gait is distinctly made worse when th^ eyes are closed. If the motor columns are pressed upon, as is not infrequent in extracerebellar lesions, there is added a spastic condition on the side opposite the tumor. A bilateral spastic condition is also often present when there is a compli- cating internal hydrocephalus. This spasticity to a certain extent will modify the incoordinate gait. The station and attitude of a patient with cerebellar disease depend largely upon the position of the growth. In lesions of the vermis itself there may be retraction of the head and extension of the lower limbs with flexion of the upper. There may also be lordosis in the lower portion of the spinal column. It has been supposed that the attitude and position of the trunk and head are considerably modified by the weakness which is supposed to be present in the erector spinse and other trunk muscles. This is questionable, for the alternate contraction of these muscles is probably only an effort to keep the parts above in their proper position and is only a part of the general incoordination. Sometimes in tumors of the cerebellum the head is held in certain positions in such a way so that the growth would avoid pressing directly upon the vermis. In tumors, for instance, of the left lateral lobe, the patient will be inclined to lie on his left side, for when BRAIN TUMORS. 1069 he lies on the right pressure may be exerted upon the vermis. This symptom, however, is not by any means constant. Very often also patients with cerebellar tumors will hold their heads in abnormal positions, not because of the possible influence the change of position would have upon the vertigo and dizziness, but because they see double, and by holding their heads in certain positions they are able to avoid this. If the patient is placed with his feet together, he will have a tendency to fall, generally to the side of the lesion. As a rule, if the eyes are closed the ataxia will be increased, and this is especially so in extracerebellar lesions. The incoordination or ataxia which is present in the limbs is of two types, i. e., it may be made worse with the eyes shut, or this may have no influence upon it. This ataxia is dependent upon the lack of coordination in the muscular contractions, and is not dependent upon any sensory disturbances. As a rule, it is greatest on the side of the lesion, but it may also be observed on the opposite side. If the upper limb on the side of the tumor is moved in any direction, for instance, as in supination and pronation, it will be found that the movement will not be as well or as rapidly performed as upon the other side. The same thing is true if the lower limb is moved. These symptoms are dependent upon the lack of coordinate contraction of the muscles concerned in the movements. Incoordination in the movement of the eyeballs, or nystagmus, is present nearly always in lesions of the cerebellum. This incoordination of the eyeballs is similar to that observed in any other movement, and is present only when the eyeballs are moved, and is greater when they are directed to the side of the lesion. This nystagmus may consist in to and fro jerkings, and is greater in lateral deviation. Incoordination of the muscles which are concerned in talking, eating, and swallowing sometimes occurs in lesions of the cerebellum and its connections. This, however, is not a very common occurrence. Disturbance in these functions dependent upon the incoordination of the muscles concerned must be differentiated from the difficulty observed in these functions when an extracerebellar tumor presses upon the cranial nerves innervating the muscles necessary to perform these acts. Cranial Nerve Symptoms. — The cranial nerves, as a rule, are not involved in lesions of the middle lobe of the cerebellum. In tumors of the lateral lobe it is possible to have involvement of the fifth, sixth, seventh, and eighth cranial nerves on the same side, but, as a rule, such cranial nerve involvement indicates a tumor in the angle between the pons and cerebellum or the cerebello-pontile angle. The first or olfactory nerve is hardly ever diseased. The same is true so far as the third and fourth cranial nerves are concerned. The fifth cranial nerve may sometimes be involved, especially in extra- cerebellar lesions. Very rarely a tumor may grow from this nerve. Unilateral involvement of the sixth nerve is a very common symptom in extracerebellar lesions. Bilateral sixth nerve paralysis may sometimes be present in unilateral lesions, but, as a rule, this indicates a tumor in the middle lobe. The seventh nerve is nearly always involved in tumors of the cerebello- pontile angle, and a fibroma may grow from this nerve. A lateral cerebellar tumor may sometimes cause involvement of this nerve by pressure. Tumors of the cerebello-pontile angle, as a rule, grow from the eighth nerve, and are generally fibromata. At first there may be such subjective symptoms as roaring, hissing, or buzzing noises in the ear, and later com- 1070 DISEASES OF THE NERVOUS SYSTEM. plete nerve deafness. This nerve may also sometimes be involved by pressure from a growth in the lateral lobe of the cerebellum. The ninth, tenth, eleventh, and twelfth nerves may be involved in extra- cerebellar lesions, this resulting from pressure, thus causing difficulty in talking, eating, and swallowing. Bilateral involvement is uncommon, and, as a rule, indicates lesions in the medulla itself. Pupillary Symptoms. — ^Tumors of the cerebellum probably have no direct effect upon the condition of the pupils, alterations in them probably depending upon the presence of optic neuritis or choked disc. Motor Symptoms. — ^The weakness or paresis which is sometimes present in cerebellar lesions has already been discussed, and is not dependent upon pressure on the motor columns. An extracerebellar tumor, as a rule, compresses the motor fibers of the pons, and this causes the spastic condition on the side opposite, with the consequent weakness, increased reflexes, and the presence of the Babinski phenomenon. In complicating internal hydro- cephalus this condition may be bilateral. As a rule, lesions of the cerebellum have no influence upon the state of the reflexes, for they may be increased, diminished, lost, or in normal condi- tion. Convulsions. — Convulsions sometimes occur in the course of cerebellar disease. These may be general or limited to certain parts. If general, as sometimes occurs in lesions limited to the vermis, there is retraction of the head, extension of the lower limbs, and flexion of the upper, and the whole body is held in tonic contracture. Tumors which involve the seventh nerve may cause tremors in its dis- tribution, and sometimes convulsions which are limited to this nerve and are focal or Jacksonian in character. Instead of this there may occur irregular fainting spells, during which time the patient feels giddy and has a tendency to fall. These are not really convulsions, and are dependent upon the vertigo common in this disease. In diagnosing, then, tumors of the posterior cranial fossa it is necessary to consider whether the growth is limited to the cerebellum or whether it is extracerebellar. Not only that, but it is necessary, when hmited to the cerebellum, to recognize, if possible, whether the tumor is localized to the center or to the lateral lobe. Siunmarizing the symptoms of a tumor in the vermis, we have as follows: headache in the back of the neck, excessive nausea and vomiting, intense vertigo, bilateral early and marked choked disc; marked incoordi- nation in every movement of the body, whether in the limbs, trunk, move- ments of the eyeballs, and sometimes in articulation, in eating, and in swallowing; sometimes weakness in the limbs and the muscles of the trunk, with atonia, an ataxic gait, poor station, and rarely so-called cerebellar fits, during which time the head is retracted, the legs extended, and the arms flexed — aU in tonic contracture. Tumors of the lateral lobe of the cerebellum give headache, nausea, vomiting, intense vertigo, bilateral early and marked choked disc, which may be greater on one side, incoordination in all movements of the Hmbs, but which is greater on the side of the lesion, a staggering gait with a tendency to lurch to the side of the lesion, nystagmus, more marked in looking to the side of the lesion, sometimes paresis and atonia in the limbs of the same side, and, if the tumor is large, it may press upon the cranial nerves on the same side. Extracerebellar lesions may be either in the angle between the pons ABSCESS IN THE BRAIN. 1071 and the medulla, i. e., the so-called cerebello-pontile angle, or may grow from the occipital or temporal bone primarily, and secondarily involve the structures in the cerebello-pontile angle and the cerebellum itself. Tumors of the cerebello-pontile angle are usually fibromata, and grow from the eighth, seventh, fifth, and sixth nerves in order of frequency, and the first symptom will depend upon what nerve is involved. If the growth is on the eighth nerve, there is first a roaring, buzzing, or hissing noise on the side of the tumor, to be followed by deafness, and then the symptoms of paralysis of the seventh and sixth nerves as these nerves are pressed upon, and more rarely of the fifth nerve. There are, besides the general symptoms, headache, nausea, vomiting, vertigo, which may be excessive if the eighth nerve is diseased, and choked disc, which, as a rule, is greater on the side of the tumor. When the cerebellum is pressed upon, there are, in addition, incoordinate symptoms in the limbs, greater on the side of the lesion, paresis and atonia, only rarely on the side of the tumor, a staggering and incoordinate gait to the side of the tumor, and less frequently nystagmus, which is greater when the eyes are deviated to the affected side. If the tumor grows from the seventh nerve, spasms in its distribution may be observed. As a rule, the growth will press upon the motor fibers of the pons, giving, in addition, weakness and spasticity, with increase of reflexes in the limbs of the opposite side. // the tumor grows from the dura covering the occipital or temporal bones, the symptoms may be a little more diffuse, and may give not only the symptoms above enumerated in tumors of the cerebello-pontile angle, but, in addition, there may be involvement of some of the cranial nerves on the same and opposite side. Sometimes diffuse syphilitic lesions in various portions of the brain or a pial infiltration at the base of the brain may give the symptoms of a cerebellar tumor to such an extent that it is almost impossible to make a differential diagnosis. There may be present all of the general symptoms of a cerebellar lesion, but there will be, in addition, almost always a greater involvement of the cranial nerves, such as that of the third — a very unusual condition in pure cerebellar or extracerebellar lesions. Multiple sarcomatous tumors may also give the symptoms of a tumor in the cerebellum or of the angle, and in such instances it is almost impossible to differentiate the symp- toms from those resulting from basal syphilis. ABSCESS IN THE BRAIN. Chronic otitis media is the most frequent cause of abscess in the brain. It may be due to such other causes as traumatism, or may be a part of a general process, or it may follow an abscess in the lung. When it is the result of middle-ear disease, the abscess is generally localized to the temporal lobe or to the cerebellum on the same side, but it may cause an abscess in the parietal or other lobes. This," however, is uncommon. Pus may be transmitted along the facial and acoustic nerves from the middle ear and cause an extradural abscess. Occasionally an abscess in the pia will result. In most instances a localized abscess is only a part of a general purulent cerebrospinal meningitis. Sometimes a localized pus cavity may rupture and cause a general purxilent meningitis. The abscess is usually surrounded by a thick wall and considerable inflammation surrounds it. The pus itself is very thick and contains the usual microorganisms. Symptoms.— The localizing symptoms of an abscess in the brain are 1072 DISEASES OF THE NERVOUS SYSTEM. similar to those of any other lesion or growth. Because of the fact that most abscesses occur as a complication of middle-ear disease or extension of such inflammation, most pus cavities or abscesses are to be found either in the temporal area, in the cerebello-pontile angle, or in the cerebellum, or, what often happens, besides a lesion either in the temporal or cerebellar areas there may also be a meningitis, with its accompanying symptoms. Specifically it cannot be said that there are any general symptoms which indicate an abscess in the brain. The inference is that if there is a history of, or if there is an abscess in the middle ear, and if following it there are symptoms which are referred to either the temporal or cerebellar areas or the meninges, the lesion is purulent and secondary to middle-ear disease. There may be, as is usually the case in any growth, headache, nausea, vomiting, vertigo, and sometimes choked disc, these depending upon the extent of the lesion and the pressure exerted in the cranial cavity. There may or may not be changes in the temperature, such as lesult from pus elsewhere. The other symptoms will depend upon the location of the lesion, whether temporal or cerebellar. INJURIES TO THE BRAIN. The general symptoms of injuries to the brain will de- pend largely upon the character and extent of the injury. It is possible to have a fracture of the skull without any injury to the brain tissues, or a severe injury to the brain 'without involvement of the enveloping bones. It is impossible in any given case to foretell what the results of an injury may be, but an effort is made here to classify the symptoms which may occur. It should be understood, however, that this classification cannot be, and is not intended to be, a definite one, for any and all symptoms may occur in any given case. Classification of Injuries. — There may be (1) fracture of the vault of the skull, with or without injury of the brain; (2) fracture of the base of the skull with or without injury of the brain; (3) hemorrhages from the vessels of the meninges, either extradural or intradural, either with or without involvement of the brain itself; (4) injuries to the brain, which may consist, first, of large hemorrhages which are either single or multiple; second, of multiple small hemorrhages which cannot be seen except under the microscope; and, lastly, so-called contusion of the brain; (5) injuries of some of the cranial nerves without any other involvement; and (6) the functional neuroses. General Sjntnptoms. — Inasmuch as certain general symptoms occur no matter what the injury, these wUl be first discussed. As a rule, if the injury is severe enough there will be impairment of consciousness. If this is complete, so that the patient cannot be aroused, it is called a coma. If the patient can be aroused so that questions can be answered, it is called a stupor, whereas an expression of wandering ideas accompanied by stupor is called a delirium. In most instances the period of unconsciousness wiU not last long and the patient mil rally within a few hours, but sometimes the stupor may persist for a number of days and even longer. It is possible for the patient to regain consciousness and then to again lapse into a period of stupor. As a rule, if the patient rallies within a few or less than twenty-four hours, the prognosis is good, whereas stupor lasting for more than a day will make the prognosis very grave. It is necessary in a great many instances to diagnose INJURIES TO THE BRAIN. 1073 such a comatose condition from those arising in alcoholism, uremia, diabetes, and hysteria. There, should, however, not be much difficulty in making a differential diagnosis if the underlying causes are considered. Certain general symptoms may always be present whenever considerable compression of the brain, no matter from what cause, exists. This, of course, can only be apparent after the patient has rallied from whatever mental condition the injury has placed him in. These are headache, which may be localized to the point of injury or may be diffuse, nausea, vomiting, sometimes vertigo, choked disc, stertorous respiration, and slow pulse. These symptoms occur only when there is great compression, such as occurs from hemorrhages or depressed fractures. The physical evidences of injury, such as contusion and laceration of the scalp, swelling of the injured tissues, a subconjunctival and subcutaneous ecchymosis, and the escape of cerebrospinal fluid from the ear or nose, may be present. It is necessary, however, to remember that severe hemorrhages or destruction may occur within the cranial cavity without the slightest external evidence of injury. Fracture of the Vault of the Skull. — Cause and Sjmiptoms. — This, as a rule, results from direct injury, such as are caused by stab, sword, and bullet wounds or blows upon the head. The fracture may be at the point of injury, or the effects of this may be so diffuse that the fracture is on the other side of the skull, or at times at the base. There may be in aU cases a visual point of injury, such as contusion of the scalp, and if there is a fracture, the accompanying depression, which can be felt unless the swelling of the tissues is too great. In most instances the fracture will be depressed and will injure the meninges and the brain tissue underneath. In all instances an incision should be made for the purpose of diagnosis. The general symptoms will be impairment or loss of consciousness, depending upon the force and extent of the injury, and the focal symptoms will de- pend upon what part of the brain is injured. If the frontal lobe is injured, there will be no focalizing symptoms; if the motor part, Jacksonian con- vulsions or paralysis on the other side of the body; if Broca's convolution, motor aphasia if the patient is right-handed and the injury is on the left side of the brain; if the temporal convolutions, sensory aphasia under the same conditions; if the parietal areas, sensory symptoms on the other side of the body; and if the occipital lobes are involved, hemianopsia on the other side. Very often a direct injury to the brain will cause no apparent contusion at the point of insult, and even though a fracture is present it may be of such character as not to cause depression. It is hardly possible, however, for a fracture to be present without some symptoms, for if the injury is severe enough to cause a solution of continuity in the bone, it is severe enough to cause an injury of the meninges, this resulting in a laceration of some of its vessels. It is, then, from the focal symptoms caused by the resulting hemorrhage that we are able to make a diagnosis, the symptoms depending upon the part of the brain which is compressed. Sometimes if the blow is severe enough, or even if the injury is very slight, there may result an accompanying fracture of the base, the symptoms of which will be discussed later. Again, it must be remembered that if an injury is severe enough to cause a fracture, it will also cause a severe contusion of the brain itself, this resulting in multiple areas of small hemor- rhage, which later on may become absorbed and no symptoms remain, or this may be replaced by connective tissue. The occurrence of these multiple 68 1074 DISEASES OF THE NERVOUS SYSTEM. areas of small hemorrhage will be largely influenced by the state of the blood- vessels in the given individual, for if there is present an arteriosclerosis, such weakening of the blood-vessels may result as to cause a secondary hemorrhage into the brain substance. Fracture of the Base of the Skull.— Cause.— It is impossible to tell just when and what kind of injury will produce a fracture of the base of the skull. It may result from a fall on the back or buttock or from a blow upon the head. Whenever there results such a fracture, there will be, as a rule, severe injury to the brain, or there may be an accompanying fracture of the vault. In about two-thirds of the cases there will be loss of consciousness, from which the patient may rally in a few or less than twenty- four hours, although it is possible to have a stupor lasting a week or longer with full recovery of the patient, and in those cases in which no unconscious- ness results there may be a momentary stupor. Sjrmptoms. — Accompanying the stupor there may be the physical evidences of injury, such as bleeding or the escape of cerebrospinal fluid from the nose, throat, or ears, rupture of the membranes of the ear, and subconjunctival or subcutaneous ecchymosis back of the ear. There may also be stertorous respiration, a slow, weak pulse, and either a dilatation or contraction of the pupils. Of these, the most important symptom is the condition of respiration, and especially of the pulse. The pupillary symp- toms may be absolutely disregarded, for while it is held by a great many that a dilatation of the pupils will always result on the side of the injury, this is probably fallacious. It is upon the focal symptoms that the diagnosis of fracture of the base must be made. This will depend upon the line of fracture and upon the possible existence of a hemorrhage. In nearly all cases some of the cranial nerves will be involved, and of these, the optic and the sixth, seventh, and eighth cranial nerves are most commonly the seat of injury. The first or olfactory nerve is frequently involved from a fracture in any portion of the skull, probably because of injury to the ethmoid, unilateral or bilateral loss of smell and impairment of taste resulting. The second or optic nerve is very frequently diseased, either on one or both sides. This may be either because of a hemorrhage in or about the optic chiasm, or, what is more frequently the case, because of fracture through the optic foramen. The impairment of sight will depend upon whether one or both optic nerves are diseased and upon the part of the nerve which is injured. Very frequently there will be neither fracture through the optic foramen nor hemorrhage involving the optic nerve, but a momentary pinch- ing of the nerves. Whether this causes a hemorrhage into the sheath or into the nerve itself, or whether it causes a destruction of fibers with a consequent atrophy, is not known; but' the fact remains that such pinching will in many cases result in a diminution and sometimes total loss of vision. In rare instances it is possible to have such an injury of the optic nerve with consequent optic atrophy, without the accompaniment of any other S3Tnptom, and more rarely still this impairment of vision may be in the form of irregular hemianopsia. The third or oculomotor nerve is rarely involved, and occurs especially when there is a fracture through the orbit and the middle cranial fossa. It may be unilateral or bilateral. In most instances only part of the distri- bution of the oculomotor nerve is paralyzed, this resulting in drooping of the upper lid, or possibly a weakness of some of the ocular muscles. The fourth nerve is only rarely diseased in injuries of the brain. The INJURIES TO THE BRAIN. 1075 fifth nerve is sometimes involved in fracture of the middle cranial fossa, but its occurrence is also rare. The sixth, seventh, and eighth nerves are probably more frequently in- volved in fractures of the base than the other cranial nerves, and in most instances together. This is because the exits of these nerves at the base are so close together. Very rarely the ninth, tenth, eleventh, and twelfth cranial nerves are diseased, this causing difficulty in eating, talking, and swallowing, and irregularity of the pulse and respiration. These are only present in severe cases, which nearly always result fatally. It is characteristic of these cranial nerve palsies that they are not of permanent duration, for in most instances, if the patient lives, a partial and sometimes total recovery may be expected. Sometimes there results in fracture of the base of the skull hemorrhage from one of the basal arteries. The symptoms of this will depend entirely upon the place of hemorrhage and upon the structures compressed. In most instances the hemorrhage is in or about the optic chiasm, this causing paralysis of the ocular muscles and impairment of vision, and if the hemor- rhage is large enough, the general symptoms of compression, such as head- ache, nausea, vomiting, and choked disc. Summarizing, then, the symptoms of fracture of the base of the skull, there may be either coma, stupor, or delirium, which may last from a few to twenty-four hours or a number of days, and from which the patient may or may not rally, stertorous respiration, slow, irregular pulse, bleeding from the nose, throat, or ear, sometimes the escape of cerebrospinal fluid, subcon- junctival or subcutaneous ecchymosis, and paralysis of some of the cranial nerves, with irregular pupils. If there is an accompanying hemorrhage into the substance of the brain, the symptoms will depend upon whether the motor, sensory, or special fibers are involved; if there is a fracture of the vault, the additional symptoms of this. The prognosis will depend upon the extent of the cranial nerve involve- ment, whether or not there are hemorrhages in the brain substance, and upon the stupor and the state of the respiration and pulse. The prognosis is always best where the patient rallies within a few or twenty-four hours, and the state of the pulse is the best indication of the results to be expected. Injuries of the Meninges. — Causes and Symptoms. — Under this head will be considered traumatic diseases of the dura and the pia- arachnoid and rupture of its vessels. In most cases of fracture of the skull there will result some injury of the underlying meninges. This may be a contusion or a laceration of the dura, which may be followed in time by adhesions, the whole giving the picture of an external pachymeningitis. If the internal surface of the dura is involved, there will be adhesions to the pia^arachnoid and the brain itself. The symptoms of external pachymenin- gitis will depend upon the extent and location of the lesion, the focal symp- toms depending upon the part of the brain involved. In all cases there should be some headache localized to the diseased part. More commonly, however, as a result of injuries to the brain there may be an inflammation of the pia-arachnoid which may involve not only the injured parts, but the meninges of the whole brain and cord, giving the symptoms of a cerebrospinal meningitis. One of the most frequent causes of this is infection through the wound. The symptoms will depend upon the severity of the disease. If the meningitis is of septic character, there will be fever, sweats, chills, coma, stupor or delirium, retraction and rigidity of 1076 DISEASES OF THE NERVOUS SYSTEM. the head, stiff neck and back, rigidity of the extremities, va,rious cranial nerve palsies, sometimes choked disc, occasional convulsions, either focal or general in character, and paralysis of the limbs which may be hemiplegic in type. Lumbar puncture will always demonstrate the presence of pus and various pyogenic bacteria. Sometimes an abscess of the brain will follow a septic injury, or it may occur in the course of a purulent meningitis. The symptoms of the former have been sufficiently dealt with under the head of tumors of the brain, while in the latter instance the additional symptoms will depend upon the focal lesions resulting from the location of the abscess. Meningeal Hemorrhages. — Rupture of the blood-vessels of the meninges is one of the commonest results of injuries of the head, and of these the middle meningeal r.rtery is usually involved. It contains three branches, and, as a rule, an injury will produce laceration only of the central or the principal branch, the focalizing symptoms of which will be convulsions, Jacksonian in character, of the other side of the body, accompanied by paralysis of the hemiplegic type, and if the lesion is on the left side in a right-handed person motor aphasia. The anterior portion of the middle meningeal artery supplies the frontal convolutions, and in a rupture of this vessel there will be motor aphasia if the lesion is on the left side of the brain in right-handed persons, with stupor, and no focalizing symptoms unless the motor cortex is also involved. The posterior branch of the middle meningeal artery supplies the occipital and parietal convolutions, and hemorrhage of this part will produce hemianopsia plus sensory symptoms on the opposite side of the body. In all these instances there will be the symptoms of the accompanying shock of the hemorrhage, as stupor or coma, irregular pupils, stertorous respiration, and slow pulse. There may or may not be an accompanying fracture of the skull. Injuries to tlie Brain Substance. — The brain may be severely injured without any external evidence of fracture of the skull. The occurrence of hemorrhage in the brain tissue in conjunction with the latter condition has already been discussed. There may result in any injury to the skull either one hemorrhage or multiple hemorrhages of large size, or, what very frequently occurs, multiple small hemorrhages which can only be detected under the microscope. As a rule, whenever an injury is severe enough to cause a hemorrhage into the brain substance there will be multiple hemorrhages throughout the brain, and the symptoms will depend largely upon the greatest point of hemorrhage, this in most cases involving the motor fibers. There will be either total or partial unconsciousness or stupor, convulsions, and hemiplegia of one side, with conjugate deviation of the head and eyes and sometimes paralysis on both sides of the body. In such cases the prognosis is almost always hopeless. Whenever there results multiple microscopic areas of hemorrhage, the symptoms present will be those of cerebral contusion, the patient being in a mentally irritable condition, complaining of diffuse headache, dizziness, inability to concentrate, lack of energy, and a general nervousness. In such cases the prognosis in the young is excellent, for these multiple small areas of hemorrhage will practically almost always disappear leaving no symptoms; but if they occur in elderly persons, they may be the starting cause of a slow hemorrhage into the brain tissue. By contusion of the brain is meant that condition which results from a shaking up of the cranial contents. There is usually a dazing or a confusion CHRONIC BULBAR PALSY. 1077 of the intellect which may be momentary or last from a few minutes to an hour, and from which the patient recovers, the symptoms being entirely of a mental character. As a matter of fact, it is really the condition described in the previous paragraph as resulting from multiple microscopic areas of hemorrhage or softening. Terminal Effects of Injuries to the Brain. — ^These will depend largely upon the character of the injury and its effects and the benefit of whatever therapeutic measures have been employed. Injuries to the skull such as those which involve the meninges and brain are among the most frequent causes of traumatic epilepsy. If the injury is over the motor area, Jacksonian convulsions may result, but very often injury anywhere in the brain, especially if this occurs in the young, may be followed by general or idiopathic epilepsy. Such other effects as hemiplegia or diplegia and impairment of vision and sensation need no further discussion. The mental symptoms are by far the most important. Very often a trivial injury will cause a change in the disposition of the individual and produce more or less irregular headache, (fizziness, lack of attention to business details, with the addition of many functional symptoms which will be discussed later. It is also a mooted question whether injuries to the brain can produce insanity. It is probable that in very rare instances injury may cause the earlier appearance of insanity where there has been a predisposition for it, but it is hardly possible that direct injury to the brain may cause insanity. There is no denying, however, that mental impairment is not an infrequent occurrence. CHRONIC BULBAR PALSY (Glosso-Labio-Laryngeal Paralysis). Definition. — A disease of the motor cranial nerve nuclei of the me- dulla and pons, usually involving the fifth to the twelfth inclusive, and char- acterized by progressive weakness, atrophy, and fibrillary tremors in their distribution, with progressive difficulty in talking, eating, and swallowing. The pathology is similar to that of chronic poliomyehtis, and consists in a progressive degeneration of the motor cranial nuclei. The disease is slow in its onset, and usually begins in the nuclei of the twelfth nerve, gradually involving the other motor nuclei, and only rarely those concerned with the movements of the eyes. Sometimes this degeneration occurs at the end of an amyotrophic lateral sclerosis, or it may be the starting-point of such disease. Predisposing and Exciting Factors. — ^The disease occurs in the latter end of Hfe, and is probably the result of an early death of the parts concerned. It may be a manifestation of a lack of resistance or of maldevelopment. Usually the disease starts without an exciting cause. Symptoms. — Because of the fact that the nuclei of the twelfth, eleventh, and the motor parts of the tenth and ninth cranial nerves are first diseased, the early manifestations nearly always consist in a slowly increas- ing difficulty in pronunciation of certain words, especially those in which action of the tongue and lips are prominent, as R, L, G, B, P. At the same time or soon after there will be some difficulty in swallowing, and there may be very early regurgitation of food, and eating becomes slow. Speech be- comes more and more difficult, typical bulbar speech being slow, nasal in type, monotonous, indistinct, and hard to understand. Soon after there will be difficulty in chewing, and eating of meat will become almost im- 1U78 DISEASES OF THE NERVOUS SYSTEM. possible, the patient living nearly always on soft or milk tliet. Choking spells are very common, and may come on with the slightest form of irrita- tion of the pharyngeal muscles or independently of the swallowing of food. Coincident with the above symptoms weakness and atrophy will develop first in the tongue, its surface becoming furrowed and irregular, and fibrillary tremors will be prominent. The weakness of the tongue gradually increases until it will be impossible to move it even from side to side. The lips become thin and droop, and with the atrophj^ of the cheeks produce an expression- less countenance, the so-called bulbar face. Dribbling of saliva is a common symptom, and is probablj^ caused by the inaliility of the facial and orbicular muscles to retain the secretion. The palatal, pharyngeal, and laryngeal muscles are next involved, and their reflexes are lost early. If the disease progresses, there may be at the very last involvement of the ocular nuclei, causing inability to move the eyes in any direction ; but, as a rule, the dis- ease terminates before this, the patient usually choking to death. The mentality is hardly ever involved, although the patient becomes somewhat weak-mintled. Sensory symptoms are never present (Fig. 3993- Summary of Diagnosis. — A person past thirty with gradually in- creasing cUfficulty in articulation, this terminating in a slow, thick, monotonous, inchstinct speech; in- creasing difficulty in swallowing and chewing, with choking spells, drib- bhng of saliva, weakness, atrophy, and fibrillary tremors in the facial muscles, lips, and tongue, and ab- sence of the palatal, pharyngeal, and laryngeal reflexes. Differential Diagnosis. — There should be no difficulty in di- agnosing this disease. Occasionally, however, besides the symptoms above enumerated there may be weakness, spasticity, increased re- flexes, with atrophy and fibrillary tremors in the muscles of the upper and lower limbs, such as occur in amyotrophic lateral sclerosis. Again, bulbar palsy may occur at the end of an amyotrophic lateral sclerosis. This subject has been more fully discussed on page 1090. In pseudobullxar palsy besides the difficulty in eating, talking, and swal- lowing, there is always a history of preceding attacks of hemiplegia occurring on one and then the other side, with the accompanying symptoms, and, most important of all, there are no fibrillary tremors or atrophy in the face, tongue, and Ups. Acute Bulbar Palsy. — Sometimes as a result either of a thrombosis of one of the bulbar vessels or a hemorrhage there may be an acute involve- ment of the nuclei of the medulla. Thrombosis of this area nearly always involves the inferior cerebellar artery of one side. The symptoms may coiiie on acutely, with or without unconsciousness, and there will be diflSculty in eating, talking, and swallowing, which subsides somewhat in a few days, and there are usually, in addition, motor and sensory symptoms, gener- FiG. 399. — Chron-i.- Bulbar Palst ix a Chixa- MAN. SHOWIXC TyHIC FaCIKS, LaCK OF E.X- pRESsio.x, .\xD Drooping Lips. CHRONIC BULBAR PALSY. 1079 ally referred to the side opposite the lesion, and unilateral cranial nerve paralysis. Sometimes as the result of or during the course of infectious diseases, alcoholism, or ptomain poisoning, there may occur areas of hemorrhage or inflammation in the medulla or pons. These have already been discussed under the head of superior and inferior polioencephalitis on page 1038. Myasthenia Gravis (Asthenic Bulbar Palsy). — Bj^ this is understood a disease which is characterized by rapid fatigue and exhaustion in certain muscles. It may be limited to movement of the limbs or may be referred to the chstribution of the motor cranial nuclei, especially those concerned with the movement of the eyeballs. It usually occurs in young adults without any apparent cause. When the patient rises in the morning or on fii-st effort there may be no apparent weakness, but gradually, if the symptoms are limited to the cranial nerves, there will be drooping of the upper lids, with 'olumn efli'ssauer jRoss-SECTioN OF Cervic.il Spinal Cord, showing its Anatomic Subdivisions (Schaefer). closure of the eyes, or weakness in the muscles of the face. Sometimes there may be difficulty in talking and in eating and swallowing. If the patient lies quietly, there may be a temporary recovery of function with weakness again as effort is made. When these symptoms are referred to the limbs, the movement may at first be normal, the patient gi-adually tiring. It has also been found that the electric reactions to the faradic current, which are normal at first, soon become diminished — the so-called myasthenic reaction. The prognosis in most cases is not very good. Pathologically a disease of the thymus gland has been found in some cases. The motor cranial nuclei are not chseased. Clinical Course and Complications.— The chsease hardly ever lasts more than two or three years, the symptoms gradually increasing, the patient usually choking to death. 1080 DISEASES OF THE NERVOUS SYSTEM. M ■feFF S(l'i: Diseases of the Spinal Cord. The spinal cord is situated in the spinal canal, and extends from the lower portion of the medulla oblongata to a point opposite the upper border of the second lumbar vertebra. It consists of eight cervical, twelve thoracic, five lumbar, and five sacral segments. The cord is composed of gray and white matter, the former being in the center and surrounded by the white matter. The gray matter is divided equally on both sides of the spinal cord and is con- nected by a commissure and consists of an anterior and a posterior horn. It is composed of nerve-cells and their dendritic processes, axis-cylinders, nerve- fibers, and neurogliar tissue which holds these struc- tures in place. The white matter consists of nerve- fibers and neurogliar and connective tissue, besides arteries, veins, and lymphatic vessels throughout the whole spinal cord. The nerve-fibers which are situ- ated in the white matter are bound together in bun- dles or tracts, each of which has a definite function. Normally these cannot be differentiated, and it is necessary to have pathologic processes, or what is called secondary degeneration, to bring out the dif- ferent tracts (Fig. 460j . From the nerve-cells situated in the gray matter of the anterior horn come the so-called anterior roots, which are motor in function. The posterior roots enter into' the spinal cord in an area called the en- trance root zone, median to the inner surface of the posterior horn of the gray matter. The fillers trans- mitted by the posterior roots come from the periph- ery and ascend into the spinal cord, antl are sensory in function. On each posterior root is situated a collection of nerve-cells called the posterior root gan- gha. The anterior and posterior roots join together to form one nerve which goes through the dura. Each spinal segment has a pair of anterior and poste- rior roots which form two nerves, one coming off from the right and one from the left side of the cord. The spinal cord is surrounded by the pial sheath, and is held in place hy the anterior and posterior roots and connective-tissue septa (ligamenti denticuli) and by the cerebrospinal fluid, these structures l^eing attached to and surrounded by the dura, which in turn is held in place in the spinal canal by the attached peripheral nerves and bands of connective tissue from the anterior surface of the dura to the vertebra. Spinal Roots.— The anterior and posterior roots travel witliin the dura for various lengths iDefore they join to form a peripheral nerve. It is necessary to know the place of exit of each nerve- root, and an easy way to rememlier it is that every nerve-root leaves the spinal canal at the bottom of the corresponding vertebra ; thus, the second lumbar root leaves at the bottom of the second hmiljar vertebra, etc. There is an exception, however, so far as the cervical roots are concerned. There are eight cervical segments and only seven cervical vertebra, so that ^ Fig. 401.— The Figures Indicate the Rela- tions OF THE Verte- bral Bodies and Spines to the Cor- responding Spinal Segments of the Cord (Church and Peterson). DISEASES OP THE SPINAL CORD. 1081 / the eighth cervical root leaves at the bottom of the seventh cervical ver- tebra. As the end of the cord is opposite the upper border of the second lumbar vertebra, the course of the cervical roots in the spinal canal before their exit is very short. It is longer for the thoracic roots and still greater for the roots from the lowest portion of the spinal cord; thus the second lumbar root has a course of three or four inches within the spinal canal. Spinal Segments. — It is also necessary from a diagnostic stand- point to know the relations of the different spinal segments to the vertebra. This, however, is not definite and cannot be irxed by any rule, and reference therefore must always be made to charts. It should be remembered, however, that the spinal cord ends opposite the upper border of the second lumbar vertebra, and that some- times in children it is a little lower. The end of the spinal cord is called the conus medul- laris, and its fibrous prolongation the filum terminale (Fig. 402). Functions. — The spinal cord has two functions: one, to conduct impulses to and from the brain; and, second, to supervise and control the motor and trophic functions of the limbs, chest, and abdomen. A better understanding of the cerebrospinal system will be had if it is remembered that there are two sets of centers in the nervous system, and that in the higher or in the cerebrum is represented the center for every motion, sen- sation, and special act, in this being included also the cerebellum; and that in the lower centers, in which are included the crus, pons, medulla, and spinal cord, are represented the whole surface of the body. For instance, in the crus, pons, and medulla there are collec- tions of nerve-cells or nuclei which are con- cerned with the innervation of the move- ments of the face, eyes, nose, throat, and eating, talking, and swallowing, whereas in the spinal cord the collections of nerve-cells in the anterior horns are concerned with the movements of the limbs, trunk, and ab- domen, and that the peripheral nerves which connect the peripheral musculature wth the spinal cord have exactly the same function which connect their musculature with the medulla. I/OCalization. — There are two enlargements in the spinal cord — the so-called cervical and lumbar. This is necessary because the enormous musculature of the limbs requires a large number of nerve-cells. The cervical enlargement begins in the fourth and includes the fifth, sixth, seventh, and eighth cervical and first thoracic segments, whereas the lumbar enlargement begins in the first lumbar segment and includes the second, third, fourth, and fifth lumbar. From here on, the spinal cord gradually tapers off. That part of the cord which includes the second, third, fourth. Fig. 402. — Showing the Relation OF THE Spinal Cord to the Body Surface (Church and Peterson). that the cranial nerves have nuclei in the crus, pons, and 1082 DISEASES OF THE NERVOUS SYSTEM. and fifth sacral is called the conus medullaris, and just above this, and in- cluding the fifth lumbar and first and second sacral segments, is the so- called epiconus. The nerve-roots coming from the lumbar and sacral cords, when taken together, have been called the cauda equina, from their resem- blance to a horse's tail. MOTOR AND REFLEX FUNCTIONS OF THE SPINAL-CORD SEGMENTS.— (After Starr and Edinger.) Segment. MOSCLEB. Reflexes. Cervical Sternomastoid. Trapezius. 2-3 Scaeni. Small rotators of head. ' I Diaphragm. Lev. ang. scap. Dilatation of pupil by irritating side Rhomboids. of neck, 4-7 cervical. 4 • Spinati. Deltoid. Supinat. long. Scapular reflexes, 5 C.-l D. 5 Biceps. Supinat. long., 5 C. > Supinat. brev. Serrat. mag. PectoraUs (clav.). Biceps, 5-6 C. Teres minor. 6 ■ Pronators. Posterior wrist, 6-8 C. Brachialis ant. Triceps. Long extensors of wrist and Anterior wrist, 7-8 C. 7 fingers. Peotoralis (costal). Latiss. dorsi. Pahnar, 7 C-1 D. Teres maj. • Long flexors, wrist and fingers. Epigastric, 4-7 D. 8 J Dorsal 1 \ Extensors of thumb. Intrinsic hand-muscles. Abdominal, 7-11 D. 2-12 Dorsal and abdominal muscles. Lumbar ( Abdominal muscles. Cremaster, 1-3 L. 1 I Iliacus. Psoas. PateUar, 2-4 L. 2 r Sartorius. Flexors of knee. Quad, femoris. Bladder, 2-A L. 3 ' ■! Int. rotators of thigh. ■ [ Adductors of thigh. Rectal, 4 L.-2 S. 4 Abductors of thigh. Tibialis ant. Gluteal, 4-5 L. r Calf-muscles. ^ Ex. rotators of thigh. 5 Extensors of toes. Peronei. Achilles, 5 L. Sacral 1-2 [ Long flex, of toes. Plantar, 1-2 S. Intrinsic foot-muscles. ^i }3-5S. 3-5 ^ Perineal muscles. Motor functions. — ^The nerve-cells situated in the gray matter of the anterior horns innervate directly the peripheral musculature, and it is probable that a number of nerve-cells are concerned with each nerve-fiber. It is necessary to know what cells are concerned with the innervation of every muscle (see table above) . It will be seen from this that we do not know DISEASES OF THE SPINAL CORD. 1083 exactly this location, and that approximately every muscle has a represen- tation in the nerve-cells of one or two segments. Should there be a lesion destroying the cells supplying any muscle or group of muscles, there will necessarily be loss of power, and as these nerve-cells are also trophic in function, there will be, in addition, atrophy and loss of tone or flaccidity in the related parts. Besides, in the performance of every movement we have a sensory irritation or impulse, a center which is in the nerve-cells and a per- ipheral or motor response; this is the so-called physiologic reflex arc, and an interference with any part of it will cause a loss of any form of reflex. Summarizing, then, the symptoms of a lesion destroying the cells 0/ the anterior horn, there will be loss of power or paralysis in the related muscles, atrophy, loss of tone or flaccidity, loss of reflexes, and electric reactions of degeneration. Such is the case in acute anterior poliomyelitis or acute in- fantile spinal palsy. Should there be a slow or chronic degeneration of the cells in the anterior horn, such as occurs in chronic poliomyelitis, there will result fibrillary tremors in the related muscle-fibers, gradual atrophy and loss of power, loss of reflexes, and gradual reactions of degeneration. The second function of the spinal cord is that of conduction of impulses, either from or to the brain. These are transmitted by means of the different tracts situated in the white matter of the spinal cord. The motor functions are transmitted from the motor cortex by means of the crossed and direct pyramidal tracts. For instance, the right crossed pyramidal tract comes from the left motor cortex, the decussation having taken place in the medulla. From the pyramidal tracts these fibers probably go to the cells of the anterior horn of the spinal cord of the same side, and from these cells come the an- terior roots, and from the anterior roots the motor part of the peripheral nerves. A lesion of the motor columns causes weakness, spasticity, increased reflexes, and the Babinski phenomenon. If the lesion involves the pyra- midal tracts above the cervical cord, these symptoms are present in both the upper and lower limbs, but if the lesion is below the cervical enlargement, it is only possible to have these symptoms in the lower limb on the same side. Reflexes. — ^The reflexes to be considered are the biceps and triceps in the upper, and the patellar or knee jerk and the Achilles jerk in the lower limbs. Whenever there is an exaggerated spasticity, there may be ankle and patellar clonus. In every lesion of the motor columns involving the big fibers there will be obtained the so-called Babinski reflex. Blectric Reactions of Degeneration.— A normal nerve or muscle will respond to any form of electric stimulation. If it is diseased, it will not respond to a faradic current, but will give an increased response to a galvanic current, but the reaction obtained will be slow and sinuous, in opposition to the quick and prompt response obtained when a nerve is normal. The usual method of testing is to first apply a slowly interrupted current to the corresponding normal nerve, and then try the same current on the dis- eased nerve. If the nerve is completely diseased or sclerosed, no reaction will be obtained to either current. The galvanic current is then tried and a minimum current applied to the diseased nerve first, and the response mil be slow and sinuous. The same current applied to the healthy nerve will not cause any reaction, and to obtain a response it will be necessary to increase the current to such an extent that it will be painful. Reactions of degenera- tion are not obtained until about one or two weeks after the severance of the nerve, and should never be sought for as long as a nerve is inflamed or there is pain on pressure. Its presence makes the prognosis doubtful; its absence, good (Figs. 403-407). 1084 DISEASES OF THE NERVOUS SYSTEM. M. zygomnticl M.orblcuI. oris.' MiddU hraitch of M. Dias.'ieter M. IcTator menti M. qiiaiir mcnti M. triang. menti jV. hi/poglosf. Lower branch of /anal M. plalTsma nijoid.;s Muscles of the I root of tODgUB I Siiprnscupular polDt, (Erb'apoiDt. M. (ielloid., bleeps, hrschinl, folern.anil •upicat. lonj;.) EcgioD of the itiinJ frontal M. tmnporallp Upper branch of of ear"' f;.faciatu N. auricuio. pajL Middl' branch of facial Lotrrr br. of facuii M.splenloB M Hlernocleido- N. don. teapvla JV. thoracic. Ifmg. (M. perralufl SQllc. n)l\).) Fig. 403. — Nerver and Motor Points in Face and Neck. M. supinator long. M. radial, eit. long. M. radial, ext. bre». M. exteosor Indicia M. abductor pollic. long. M. extensor pullic. brov. U. Interota. dorsal, I M. triceps (caput Jongnm) M. ulnar, extern. M. aupiuat. brcT. . digits minim. I M, eiteus, poll, long. M. abduct, digit, mio. M, inieru'a. dorsal III Fig. 404. — Nerves and JIotor Points in Upper Extremity. DISEASES OF THE SPINAL CORD. 1085 Sensory Functions. — The sensoiy fibers which enter the spinal cord by means of the posterior roots take various courses after their entrance. This has already been discussed on page 1080. M tensor fustiii; laUe M, adductor magnus M. adduct loni . uastijs Inlernus-i Fig. 4iio. — Xkrves axd Motor Poixt.s in Lowkr Extremity. If a disease iin-olves a posterior root and destro3^s its fillers, there will l>e loss of all forms of sensation in the parts from which these fibers come. The M. biceps fern (cap long.) M. biceps r^m, (cap brev.) M. glalrocoeni. ('ap. < M. Hezor hollucis lori[,'u^ Fig. 40G. — Nerves and Motor Points in Lowi:r Extremity. skin areas of sensati(.)n which are in relation to a posterior root are fairly well known, and run in bands lengthwise in the hmbs and horizontal!}^ in the chest and abdomen. It is necessary to distinguish the area of sensation 1086 DISEASES OF THE NERVOUS SYSTEM. in relation with a certain root from tlaat of the segment which this root sup- phes. In the former the disturbance of sensation will always be umlateral, while in a lesion involving any segment of the spinal cord the disturbance of sensation must be unilateral (Plate XIX). It is probable that sensation iii any part of the limbs or of the chest and abdomen is m relation with more than one root or segment, and in a lesion which destroys one root or segment the disturbance of sensation will be very limited. Bladder, Rectal, and Sexual Centers.— In the second, third, and fourth sacral segments are situated the centers for Isladder, rectal, and sexual functions, and a destruction of this part of the cord will cause a loss of these functions. It seems also that the fibers concerned with the bladder and rectal functions descend in the lateral columns of the spinal cord, and that lesions in these tracts may cause an impairment m these functions. Influence of Secondary Degenerations.— Whenever there is a M. tibial. Bnlle. 1. extuDS digil comm. M. peroncuH brevia yi. gaHlrocDciD extern. M peronoua loQgus M. flexor liallucis loDg. M. abductor digit Fig. 407. — NERVE.S and ]\Iotor Points in Lower Extremity. lesion in any portion of the spinal cord, there will necessarily be secondarj^ degeneration. If the motor columns are involved, the degeneration will be downward; if the sensory, upward. Secondary degenerations do not cause active symptoms, for whatever produced the original lesion has also caused the secondary degeneration, and this is no more than a mechanical death of the part. ACUTE ASCENDING PARALYSIS (Landry's Paralysis). Definition. — An acute disease, characterized by a rapidly ascending flaccid paralysis, with loss of reflexes, beginning in the muscles of the foot and involving successively the muscles of the leg, thigh, buttocks, abdomen, thorax, and upper limbs, with no sensory symptoms, and terminating in most cases in death. In the original description of Landry no alterations in the nervous tissue were discovered. Since then, while we still accept the view that there is a type of acute ascending paralj^sis as originally described, it is a fact that PLATE XIX C.6-7 The Sensory Innervation of the Body by tlie Spinal Segments, according to J\'mptoms increase the rigidity may be- come so extreme that the patient will be unaljle to walk and becomes bed- ridden, and there may develop contractures in which the thighs are drawn up on the abdomen and legs on the thighs. Contractures in the upper limbs are not so common, but may occur. Sometimes there may be a slight dis- turbance of bladder functions, because of the fact that the cortical sphincter fibers are probably transmitted in the motor columns. SYRINGOMYELIA. Definition. — A chronic disease, characterized principally by typical dissociation of sensation, that is, ability to recognize touch, with loss or disturbance of pain and temperature sensations, combined with atrophy, fibrillary tremors, weakness in the upper and sometimes in the lower limbs, with spasticity and exaggerated reflexes, especially in the lower limbs. Pathologically there is usually found a cavity in the central portion of the spinal cord. It is usually largest in the cervical region and diminishes gradually as the thoracic and lumbar segments are approached, and may ex- tend upward into the medulla and pons. The cavity usually involves the gray matter and may extend into the posterior and lateral columns, and may rarely affect only one side of the cord. In life it is filled with fluid. Contributing and ^Exciting Factors. — The syringomyelic cavity in mo.st instances results from lack of normal development of the spinal cord. Sometimes there is first an overgrowth of neurogliar tissue, a central glio- sis, or a tumor which breaks down, forming a cavity. ^lore rarely traumatism may some- times produce hemorrhages into the cord, these breaking down and producing cavities. Some- times the normal central canal is widened, producing what is called a hydromyelia; but un- less it is very large, there may be no symptoms. Symptoms. — The whole symptom-complex of this dis- ease depends upon the interrup- tion of the fibers concerned with pain and temperature sensa- tions, with preservation of touch sensation and the involvement of the anterior cornu and lateral columns. This is because the pain and temperature fillers cross over in the central gray ^ matter, and as the cavity is nearly always in this area, these functions are interrupted. If the cavity is limited only to the central gray matter, there may be present only the dissociation of sensation which is referred to the re- lated peripheral part, usually in the upper limb, but in most cases the cavity Fig. 408.- -Atrophy and Contractures in Syringo, MYELIA. 1094 DISEASES OF THE NERVOUS SYSTEM. also involves the adjacent cells of the anterior horns plus the lateral columns, their related symptoms developing, such as fibrillary tremors, atrophy, weakness with spasticity, and increased reflexes of the lower limbs. It can be readily seen, then, that the symptoms in different cases may vary. The disease usually begins in a young adult, the patient sometimes be- coming aware of it by the fact that he burns himself without pain. If ex- amined, touch sensation will be found to be normal, but heat or cold or both will not be recognized as such. Sometimes one or the other temperature sensations are alone disturbed, or heat may be as cold and cold referred to as hot. The disturbed areas are usually in the upper limbs, chest, and back, depending upon what spinal segments are destroyed. Coincident with this dissociation, or soon after, atrophy, tremors, and weakness in the small muscles of the hand develop, and there may be present a typical claw hand, its progress being very much like that of either progressive muscular atrophy or amyotrophic lateral sclerosis. Soon after there may develop weakness and spasticity of the lower limbs, with exaggeration of the tendon reflexes and the Babinski phenomenon (Fig. 408). The progress of the disease is usuall}^ slow, and may last for twenty or thirty years, with gradual increase of the wasting, tremors, and loss of power, finally involving all of the upper limbs, shoulders, and chest, and sometimes the lower limbs. The areas of sensory dissociation also gradually increase. If the cavity involves the gra)' matter of the lumbar and sacral cords, besides the sensory dissociation in the lower limbs and buttocks there will be impair- ment or loss of bladder, rectal, and sexual functions, and sometimes there may be loss of the knee or Achilles jerks because of interference with the central portions of the reflex arcs. Fig. 409. — Trophic Enlargement of Thumb in Stringomtelia. If the cavity extends into the medulla and pons, the symptoms depend upon the extent of the involvement. Usually in the medulla the cavity is unilateral, and there may be partial difficulty in eating, talking, and swallow- ing; or if bilateral, typical bulbar symptoms develop with tremors, atrophy and weakness in the tongue, facial, masseter, and pterygoid muscles. If the cavity involves the sensory fibers, there may be dissociation of sensation in the face. Rarely primary optic atrophy occurs, and more rarely still pupil- lary symptoms Ijecause of involvement of the cervical sympathetic. Trophic symptoms are very common in syringomyelia. These may con- sist in different forms of skin eruption or a destruction of the joints either of the fingers or of the wrist and elbow or shoulder, resembling very much POSTEROLATERAL SCLEROSIS. 1095 the so-called Charcot joint of tabes dorsalis. Occasionally there may be eharp shooting pains in the hmbs and girdle sense (Fig. 409). Summary of Diagliosis. — ^A young adult suddenly burns himself without being aware of it, or there may develop tremors, wasting, and weakness in the small muscles of the hand, with claw-like contractures. Examination demonstrates preservation of touch, with loss or disturbance of pain or temperature sensations, or of both, in the upper limbs and chest. Atrophy, tremors, and weakness may develop in the lower limbs, and there may be, in addition, spasticity with exaggerated reflexes and the Babinski phenomenon. The dissociation of sensation increases and may involve con- siderable areas of the back, front of the chest, and upper limbs. If the dis- ease progresses into the thoracic and lumbar cords, similar dissociation will be present in the chest, abdomen, and lower limbs. Rarely dissociation of sensation in the face and bulbar symptoms may supervene. Differential Diagnosis.— There should be no difficulty in recogniz- ing this disease because of the typical dissociation of sensation. In its early progress, however, it may be necessary to differentiate it from progres- sive muscular atrophy and amyotrophic lateral sclerosis, but this can be usually done by the sensory symptoms. Clinical Course and Complications.— The disease is of long dura- tion and the patient may live for many years. The pathologic process is progressive, and if the cavity extends into the medulla and pons there may be death from bulbar involvement, but, as a rule, in this disease the patient dies of some intercurrent cause. POSTEROLATERAL SCLEROSIS. Under this heading will be discussed all of the different spinal cord dis- eases in which the posterior and lateral columns are affected. In this are included ataxic paraplegia, subacute combined sclerosis, diffuse sclerosis, and the degenerations which occur in wasting diseases and pernicious anemia. In all the pathology is the same. There is involvement always of the posterior columns, especially of the columns of Goll, of the lateral or motor columns, and to a less extent of the direct cerebellar tracts. The degenera- tion seems to be greater in the thoracic than in the cervical or lumbar seg- ments. The difference in the chnical symptoms depends upon the rapidity of the onset, the preponderant involvement of either the lateral or the pos- terior columns, and the extension of the disease into the direct cerebellar or the anterior tracts. In ataxic paraplegia the degeneration seems to involve principally the columns of Goll and Burdach and the motor columns, with very httle involve- ment of the direct cerebellar tracts. In subacute combined sclerosis and diffuse sclerosis there is, besides the involvement of the posterior and motor columns, a degeneration of the direct cerebellar and the tracts anterior to the pyramidal. Besides there may be isolated areas of degeneration in the gray matter. In the spinal cord changes occurring in pernicious anemia the degenera^ tion may involve the posterior and lateral columns equally or may be greater in either. It may also involve the surrounding white matter. Symptoms. — ^Ataxic Paraplegia. — ^Ths disease nearly always begins in the latter end of life, about the fortieth year, without any apparent cause. The patient experiences a gradual weakness in the lower limbs, with increas- ing spasticity and exaggeration of the patellar and Achilles jerks. The Babinski phenomenon is present. Besides there is ataxia of both lower 1096 DISEASES OF THE NERVOUS SYSTEM. limbs. Only rarely are sensory symptoms present, but when this is the case there is only slight disturbance of touch and pain sensation, especially in the soles of the feet and anterior part of the leg. Girdle sense is uncommon and there is hardly ever any disturbance of bladder and rectal functions, although these may appear late. Because of the ataxic weakness, the gait becomes slow, stiff, and shghtly incoordinate, this increasing when the eyes are closed. The disease is of long duration and of gradual progress, and may after many years involve the upper limbs ana produce increased reflexes and ataxia. The etiology of the disease is not known, but it is probable that it is the result of a lack of vital endurance or early death of the fibers. In some cases there is an antecedent history of syphilis. Subacute Combined Sclerosis and Diffuse Sclerosis. — The symptoms in this disease are similar to those of ataxic paraplegia, with the exception that they are much more rapid and there is greater involvement. The specific symptoms will depend upon the preponderant involvement of the ' posterior or lateral columns. If the posterior columns are preponderantly diseased, there is considerable ataxia, with numbness in the lower limbs, occasionally pains and girdle sense and disturbance of the bladder and rec- tum, loss of reflexes, and the only expression of degeneration of the lateral columns may be the Babinski reflex. If the lateral columns are prepon- derantly involved, there is considerable weakness with spasticity, increased reflexes with the Babinski phenomenon and ataxia of the limbs, rarely some numbness, pain and girdle sense, and occasionally involvement of the bladder and rectum. In the course of a few months there rapidly develops complete paralysis of both lower hmbs, flaccid in type, with loss of reflexes but retained Babinski phenomenon, and considerable disturbance of sensation with in- volvement of the bladder and rectum, giving the appearance of a diffuse myelitis, which the disease really is. The progress of the affection is rapid and rarely lasts more than one year. Sclerosis Occurring in Pernicious Anemia. — ^The symptoms of the spinal degeneration may occur coincident with the anemic changes, but, as a rule, alterations in the blood are demonstrated first. Occasionally it is possible to diagnose anemia from the spinal cord symptoms. These con- sist, besides headache, weakness of the limbs, paleness of the skin and mucous membranes, and changes in the blood, of extreme numbness and a tingling feeling in the lower and upper limbs. Sometimes these are very great and may be the first indication of the disease. There may be also pains of an indefinite character, or there may be sharp shooting pains in the lower or upper limbs and occasionally girdle sense. If the posterior columns are preponderantly diseased, there is considerable ataxia, with loss of the tendon reflexes in the lower and upper limbs, and there may or may not be some dis- turbance of sensation. As a rule, besides the ataxia and pains the tendon reflexes are increased and the Babinski phenomenon may be demonstrated. The weakness may become so marked that the patient is bedridden. The spinal cord degenerations progress according to the rapidity of the blood changes, and it is possible for the symptoms to ameliorate provided the blood condition improves. Sometimes in simple anemia, such as results from acute gastric or other hemorrhages or in wasting diseases, as carcinoma and phthisis, there may develop a diffuse sclerosis of the posterolateral columns. The symptoms will consist in weakness, increased reflexes, the Babinski phenomenon, ataxia, and occasionally numbness with disturbance of sensation. Stunm.ary of Diagnosis. — In aU the different diseases above de- Friedreich's ataxia. 1097 scribed under posterolateral sclerosis the preponderant symptoms are present in the lower limbs, and consist in weakness, increased reflexes, spas- ticity, the Babinski phenomenon, ataxia, occasional numbness and pain in the lower limbs, and more rarely disturliance of sensation and of bladder and rectal functions. Differential Diag'nosis. — With the symptoms above enumerated there should be no difficulty in diagnosing the type of posterolateral scle- rosis. Occasionally, however, there may be such symptoms in myelitis or in multiple sclerosis. In the former there is nearly always a history of an acute onset, with paralysis of the lower limbs, which gradually lessens, leaving the symptoms of a posterolateral sclerosis, while in disseminated sclerosis there is, besides, intention tremor, nystagmus, and scanning speech. FRIEDREICH'S ATAXIA. Definition. — A hereditary or family disease characterized Ijy pro- gressive ataxia of the limits and body, diminution of power, especially of the lower limbs, and loss of reflexes, but no disturbance of sensation or of l^ladder and rectal functions. Pathologically there is degeneration or sclerosis of the posterior columns. Fig. 410. — Frikdrkich's .\taxia — Brothicr and .Sibter. especially of the columns of GoU and of the lateral or motor and direct cerebellar tracts of both .sides. Occasionally there is, in addition, degenera- tion in the cells of the columns of Clarke and some atrophy of the cerebellum. Contributing and Bxciting Factors. — The disease is hereditary, and occurs, as a rule, in several meml^ers of the same famih^ Occasionally sporadic cases are observed. It is probable that the disease is congenital and is due to a maldevelopment of certain tracts of the spinal cord. Symptoms. — As in every hereditary and congenital disease, the symp- toms begin early in life, about the age of puberty. The early development of 1098 DISEASES OF THE NERVOUS SYSTEM. the child is usually slow, and in most cases it has taken more than the usual time for the child to learn to walk. As a rule, it is noticed very early that the lower limbs are not normally developed and that there is present a peculiar deformity of the foot and toes of both sides which is characteristic of Friedreich's ataxia. It consists in a diminution in the length of the foot, the dorsum is prominent, the arch of the sole is deeper than it should be, the large toe is hyperextended at the metatarso-phalangeal and flexed at the phalangeal joint. The position of the foot is that of a talipes equinovarus. There is usually also a deformity of the spine — either a scoliosis or kypho- scoliosis (Fig. 410). The above developmental symptoms may or may not be prominent. It is then noticed that about the age of puberty the child begins to stagger in walking, the incoordination involving especially both lower limbs and the trunk, resembling that seen in cerebellar disease, and soon walking becomes impossible. Ataxia of the upper limbs does not, as a rule, become prominent until late in the disease. Coincident with the ataxia there is an increasing weakness of the lower limbs, and the patellar and Achilles jerks become lost, although the Babinski phenomenon may be present on both sides. The reflexes later on also be- come lost in the upper limbs. There is never any spasticity. Sensation is only rarely disturbed and there is hardly ever numbness or pain. Bladder and rectal disturbances are never present. Fios. 411, 412, AND 413. — Typical Deformity of Foot in Fhiedreich's Ataxia, There is often present a peculiar nodding or to-and-fro movement of the head, and sometimes of the whole body, which resembles to some degree the movements of multiple sclerosis, but these differ in the fact that they do not become very much worse on excitement. There is nearly always also some nystagmus, this consisting in to-and-fro or oscillatory movements of the eyeballs, or there may be only few jerkings on lateral deviation. Speech is nearly always somewhat disturbed and becomes slow, the voice becoming dry, thin, and high-pitched and each word is syllabized. There is never, however, the muffling of the words or difficulty in enuncia- tion that is so common in multiple sclerosis (Figs. 411-413). Summary of Diagnosis. — Several members of the same family may have lateral curvature and a peculiar deformity of the foot and toe, consist- ing in a prominence of the dorsum and in an extension of the large toe on TABES DOKSALIS (LOCOMOTOR ATAXIA). 1099 the metatarso-phalangeal and flexion of the phalangeal joint. The disease begins early in life, about the age of puberty, with ataxia of both lower hmbs and the body, resembling the incoordination of cerebellar disease, weakness of both lower limbs, loss of the tendon reflexes with occasional presence of the Babinski phenomenon, no involvement of the bladder and rectum or of sensation, a peculiar hesitating speech, nystagmus, and tremor of the head. Differential Diagftiosis. — ^The disease may be confounded with juvenile tabes dorsalis, but can be differentiated from it by the absence of numbness, the characteristic lightning pains or girdle sense, and no involve- ment of the bladder and rectum. Besides, pupillary symptoms and the Argyll-Robertson pupil are uncommon. iSereditary Cerebellar Ataxia. — In this disease there is a congenital atrophy of the cerebellum, and the symptoms consist in a gradual ataxia of all the limbs, disturbances of speech, nystagmus, and some tremor of the head, all these resembling the symptoms of Friedreich's ataxia, but the disease differs in the fact that there is hardly ever any deformity of the foot or of the spine, and that there are, in addition, increased reflexes, optic atrophy, and occasionally the Argyll-Robertson pupil. Clinical Course and Complications. — ^The disease is progressive and the ataxia and weakness increase, the patient becoming chair- or bed- ridden, but may live for a long time. There may be in the latter end of the disease bladder, rectal, and sensory disturbances, but this is uncommon. The mind, as a rule, is not affected, but there may be some diminution of intelligence. TABES DORSALIS (Locomotor Ataxia). Definition. — A chronic progressive disease, characterized first by numbness in the lower limbs, then by pains of a sharp, shooting character, girdle sensation, difficulty in walking and in execution of any movement, this being especially made worse with eyes shut, absence of reflexes, distur- bance in the functions of the bladder and rectum, irregular pupils, mth fail- ure of the reaction to light, and later optic atrophy and disturbance of sensa- tion in various portions of the body. Tabes is more frequent in males, and it does not occur in negroes except where there has been an intermingling of white blood. Its distribution is also interesting when one considers that in certain nations, as among Asia- tics, and especially the Chinese, although syphilis is very common, tabes is frequent, while paresis is rare. Contributing- and Bxciting Factors. — It is the belief of many neurologists that every case of tabes dorsalis is due to syphilis. The statis- tics of Erb show that in men in about 97 per cent, of cases there is either a specific history or that there have been present symptoms indicating such disease. In only from 1 to 5 per cent, of the large number of sj^hilitics does tabes dorsalis occur. There must be, therefore, other contributory causes or exciting factors. These may be either a special syphilitic infection or a predisposition to this disease by the infected person, the latter probably being the more potent cause. What this may be has not as yet been determined, but it is probable that exhaustion contributes to it largely. It has been shown in animals that fatigue will produce the characteristic pathologic changes of early tabes dorsalis. While it is probable that the exhaustion itself will not produce this disease in man, occasional cases are seen in which the symptoms follow injuries to the back or are consequent to severe falls. This, however, is of rare occurrence. 1100 DISEASES OF THE NERVOUS SYSTEM. Given a person who has been specifically infected, and even one who has been treated by the proper anti-specific remedies, the symptoms of the dis- ease may appear anywhere from five to twenty years after the infection, as a rule, before the tenth year. It is a curious fact that so far as the patient is concerned no symptoms are apparent for some years. It is probable, however, that were the patient carefully examined, some symptoms would be found, for it is difficult to believe that a toxin will be dormant for a number of years and that its effects will not manifest themselves upon any portion of the economy. However that may be, it has been recently proved that examination of the cerebrospinal fluid will also show an increased number of lymphocytes in all cases in which there has been a syphilitic history. Besides, a positive Wasserman reaction is obtained in nearly all tabetic cases. It can be assumed, therefore, that the toxin of syphilis is present in the blood and cerebrospinal fluid. Pathology. — ^Method of Infection. — It has only recently been shown that in the peripheral nerves, spinal roots, and cranial nerves there is a con- stant stream of lymph ascending toward the central nervous system whose main current lies in the inner meshes or lymph-spaces of the fibrous perineural sheath. Any toxins such as would follow a specific infection would reach the spinal cord and brain by this channel; and although they spread to some extent in the lymph-spaces of the pia-arachnoid, and so affect structures at a distance from their point of entry, for the most part they pass in the main current of the lymph along the nerve-roots into the substance of the central nervous system. Here they apparently follow the nerve-paths of the affected roots, and show little tendency to diffuse among the neighboring fibers. It has been shown that just as long as these nerves are protected from the in- fluence of the toxins by the vital action of their neurilemma sheath, the nerve itself \yill not degenerate, but will on losing this. This is a very important fact. Just before the posterior roots enter the spinal cord they lose their neurilemma sheaths. Should, therefore, there be any toxins circulating in the cerebrospinal fluid or in the nerve, here would be a point of least resistance, provided, of course, there is a contributing cause to weaken these roots which may be fatigue or a lessened amount of resistance of this particular part. Should this be the case, there would begin a degeneration of these posterior roots, and here would start the pathologic process. Just why the posterior roots are taken for this selected action is difficult to explain, but not more so than that other portions of the nervous system are selected by the same poison and that the posterior roots escape. Microscopically in the early stages of tabes there is found a mild menin- gitis, especially in the posterior part of the cord, and a beginning degenera- tion of the posterior roots. As the disease progresses there will be a conse- quent ascending degeneration in the posterior columns or the columns of GoU and Burdach, the cells of the columns of Clark and of the fibers coming from them, or the direct cerebellar tracts. The degeneration finally involves all the posterior roots, although it is probable that those of the lumbar and sacral are first involved. The degeneration of the cells in the posterior ganglia is probably secondary to the posterior root degeneration. Late in the disease it is common to find a slight degeneration of the peripheral nerves. Barly Symptoms.— Numbness and Pain. — As the lumbar roots are the first to be diseased, the primary symptoms of which the patient complains will be referred to their distribution, that is, the lower hmbs. As a rule, the patient will complain of a feeling of numbness in his feet, some- times of a sensation as of walking on leather or of a dead feeling. This at TABES DORSALIS (LOCOMOTOR ATAXIA). 1101 first will only appear for a short time and then will become chronic. Very soon these paresthetic phenomena are succeeded or are accompanied by pains of a sharp, shooting, jagging character. At first they will come on only at intervals, and will appear in various portions of the lower limbs, last- ing from a few minutes to at least a half hour and leaving the muscles very tender. Gradually, however, they will become more frequent, more lasting, and of much sharper intensity, acquiring the lancinating character typical of this disease. The pains are not limited to any one nerve distribution, but appear at irregular places, and as the disease progresses, they are to be found in the upper limbs and other portions of the body. Very rarely the patient will complain of pain in the face, in the distribution of the fifth nerve, resembling very much the pains of tic douloureux, and more rarely still pains will appear in the cervical and occipital distribution. The pains seem to be influenced by the weather, the patient first likening them to rheuma- tism. Girdle Sense. — One of the earliest symptoms the patient complains of is girdle sense, or a feeling of constriction around the waist. The patient very often likens this feeling to that of a band tied around the waist or of a draw- ing sensation. This symptom after it appears is very liable to become per- manent, although its intensity varies. Often these feelings of constriction appear in other places, as around the thighs, knees, ankle, and sometimes around the chest or parts of the upper Umbs. Disturbance of Reflexes. — Necessarily, as the degeneration of the posterior roots progresses there must be some interference with the reflexes, as these roots are integral parts of the reflex arcs. There is, therefore, very early in the disease a diminution of the patellar or knee jerks and the Achilles jerfe. As the degeneration progresses in the posterior roots and in the cor- responding portions of the posterior columns, these reflexes later become totally lost, and cannot be obtained even under reinforcement. The re- flexes in the upper limbs — that is, the biceps and triceps — will in the same waj'- be first diminished and then lost. Bladder, Rectal, and Sexual Sjmiptoms. — As these roots also transmit the fibers which are in relation with bladder, rectal, and sexual functions, these are necessarily first diminished and then lost. Constipation is a very early symptom, while difficulty in the starting of the urine may not make its appearance until later. Sexual functions may be retained until late in the disease, but, as a rule, are lost early. Alterations of Sensation. — It is to be expected that from the very beginning there should be alterations in sensation, and that the very earliest sjonptom of tabes would be a disturbance in touch, pain, temperature, and the sensations in the muscles, ligaments, tendons, joints, and bones. As a matter of fact, this is the case, but these symptoms are not demonstrated, principally because they are not looked for. The patient himself will not call attention to his disease or will not be aware that anything is the matter with him until he finds either that he has pains or that he has some difficulty in coordination. Diminution in the sensation for touch is first to be found in the soles of the feet and over the anterior portion of the legs just in front of the tibia. Another very common location is in the front part of the chest and along its side. Here careful testing will denote a diminution of the sensation for touch and pain sense. Heat and cold, as a rule, are properly interpreted at first, but later in the disease one may be taken for the other, or there may be either diminution or inability to recognize these sensations. As the dis- ease progresses the areas of hypesthesia for touch and pain become a little 1102 DISEASES OF THE NERVOUS SYSTEM. more general and there appears what seems to be a very characteristic symptom of tabes, that is, that sensations are not as quickly appreciated as they should be, and sometimes it will take a number of seconds for a pin- prick to be recognized. Again, sensations are misinterpreted, and a pin- prick will feel as a touch or it will be described as being in the other hmb. In the very last stages of the disease touch, pain, and temperature sensations may be lost over most of the body. Very early in the disease and among the first symptoms it will be found that the sense of pressure is diminished over the calves and feet. This symptom is of value only in the early stages, for it will only then be possible to compare with the pressure sense of the upper limbs. The sense of posi- tion and movement will also be diminished in the early stages. If, for in- stance, with the eyes closed and the patient's body totally relaxed, a toe is moved the patient will be unaware of the position in which it is. As the disease progresses it will be possible to demonstrate these symptoms in the joints and limbs. It is to be remembered that total relaxation must be obtained, or otherwise these tests will be unsatisfactory. We see, then, that because of the pathologic process present in this disease there is a gradual diminution and finally a destruction of all forms of sensation in the muscles, ligaments, tendons, and joints, and apparently less so of the skin. Because of this, the normal relation that these structures bear to each other or their tone is disturbed, and in the performance of any movement the peripheral sensory impressions cannot be normally trans- mitted, interpreted, or performed, and because of this we have the symptoms of ataxia or incoordination of motion. Physiology of Locomotion. — To understand why disturbances of loco- motion appear it is important to understand the normal mechanism con- cerned in walking, standing, and, in fact, in all our movements. The child when it is first born is very ataxic, and has to be taught, for instance, to eat, and then later on to walk. This process of education, while it appears per- fectly simple because it goes on in a rather slow, indifferent manner is really a very complex process, as can be readily understood when one considers the utter helplessness present either in advanced tabes or cerebellar disease. Take, for instance, the process concerned in educating one to play the piano. The movements at first are coarse, irregular, and in a high sense incoordinate. To be able to play this instrument, it will not only be neces- sary to develop the muscles concerned in this act, that is, the motor part of the arc, but it will be necessary to so control them that the proper amount of pressure, accuracy, and coordination can be acquired. Not only that, but these movements will have to be so promptly performed as to enable the player to coordinate with the peripheral ocular impression obtained by reading notes, or a central impression of plajdng from memory. We. see, then, that to perform any movement it is necessary to have a motor and a sensory arc, and a coordinating center which controls and properly maintains the relation between these two, and also with such higher functions as will and inteUigence. In a healthy individual this normal relation between the motor, sensory, and coordinating arcs is constantly maintained, and the individual is always aware of the position of any portion of the body and its relation to other parts. Physically this is manifested by a normal relation or tone between the muscles, ligaments, joints, and bones. Should there be any disturbance of the sensory portion of the arc, this normal relation or tone will be disturbed, and instead of these parts acting in relation to each other, there will be an incoordination. PLATE XXI Moving Picture of (jait ui LoLomotor Ataxia. (Couitebj ut Mr. higmvmd Lubm of Philadelphia, Pa.) TABES DOKSALIS (LOCOMOTOR ATAXIA). 1103 Hypotonia. — ^This disturbance of normal relations between the struc- tures that make up the joint produces the symptom called hypotonia, and is one of the earliest found in the disease. Because of the fact that the muscles do not check one another, and that there is not the normal play between the antagonists, and that normal resistance is not offered in the joints, there is a tendency for any movement to continue beyond the previously fixed maxi- mum. The knee- and ankle-joints are among the first to become involved, and because of this, these joints can be moved in abnormal directions. Clin- ically this is demonstrated by the backward giving of the knees, and in the ankles by the abnormal tendency of this joint to give way. As hypotonia is present in the muscles surrounding the spinal column, and also later on in the other joints of the body, it can be readily understood what an influence this will have upon the attitude and gait of the patient. This symptom in itself will not cause ataxia, but it xmdoubtedly contributes to it. Space does not allow us to take up separately the methods for detect- ing hypotonia of the different joints. It can be easily demonstrated, for it will be found that it is possible to bend more than usual the leg on the thigh and the thigh on the abdomen. In fact, sometimes it is possible with the whole leg extended to flex it and place it in apposition with the trunk. Again, in testing for abduction and adduction of the thighs, it is sometimes possible to completely stretch the limbs in a straight line, while the flabbi- ness of the muscles of the back will enable the patient to bend in any direc- tion. Ataxia. — ^Principally, then, because of the slow alteration of sensation in the peripheral parts, the patient will begin to have difficulty in perform- ing fine movements, and these will become more apparent either when the eyes are closed or when the patient is in the dark. This is because ocular impressions have a great influence upon whatever movement is performed. It may become apparent when the patient attempts to walk in the dark, or when he tries to balance himself with eyes covered, as in washing the face ; or very frequently the patients are not aware that anything ails them until, when attempting to dance, their lower limbs suddenly give way. Un- consciously the patient will begin to walk with his feet a little wider apart, and he will walk more slowly or carefully, and in the performance of any movement it will be found that either the muscles concerned in the move- ment are contracted abnormally, or the contraction is too long or the move- ment too rapid. This difficulty, in walking will gradually become more manifest, and the patient will not only walk with his feet wide apart, so as to give himself more base, but he will bend his knees a little higher than he should, and in replacing them, because of the ataxia and hypotonia, the leg will be thrown in what seems to be an aimless way. With this the patient will gradually acquire a tendency to stoop over, the head bent down and the eyes to the ground, because he is uncertain of the position of his feet, and of his desire to bring to his aid the sense of sight (Plate XXI). Methods of Testing for Ataxia. — While no difficulty will be experienced in demonstrating ataxia in the later stages, considerable skill is required in developing the symptom very early in the disease. Each limb should be tested separately, for it will be found that the degree of ataxia will vary in the different extremities. The patient should be made to stand on one leg with the eyes opened and closed, and then with the knee bent. Romberg's sign, which is obtained by placing the heels and toes in apposition with closed eyes, the patient swaying, can usually be demonstrated. In testing for ataxia of either lower limb, the patient should be placed on his back and asked 1104 DISEASES OF THE NERVOUS SYSTEM. to place his heel on the opposing knee with eyes open or shut, and it will be found that a greater degree of ataxia will be developed as the patient places his heel away from the knee to the distal parts. In testing for ataxia of the knee-joint, the patient should be placed upon his abdomen and the leg bent on the thigh. The usual finger to nose or the finger to finger tests are em- ployed in testing for incoordination of the upper limbs. Ataxia is often present in the muscles concerned in respiration and in the abdominal muscles, but this is not easily demonstrated. The facts to be remembered are that when a movement becomes incoordinate it will be either executed too rapidly, or there will be exaggerated muscular exertion, or an unduly prolonged state of muscular contraction, which continues long after the maximum of excursion has been reached. Pupillary Phenomena. — Pupillary signs are among the earliest and the most constant phenomena of tabes dorsalis. Very early in the dis- ease the pupils will have a tendency to become smaller than normal, the so-called miotic pupils, the margins to be irregular, and at the same time the reaction to light will be unequal and diminished. As the disease progresses the pupils will become still smaller, the margins more irregular, and the light reaction will be lost, although reactions to movement will be retained. This is the Argyll-Robertson pupil, and is one of the most valuable symptoms present in this disease. Paralysis of Cranial Nerves. — One of the commonest and sometimes one of the earliest symptoms of tabes is double vision due to paralysis of one external rectus. This diplopia is not continuous and will last only for a short time, that is, from a few hours to several days, and will reappear at intervals. Just why this involvement of the motor nerve should occur is difRcult to explain. Another occasional early symptom is paralysis of a vocal cord, causing the hoarse, stridulent tones sometimes found in tabetics. The involvement of these two nerves in a sensory disease may be explained by the theory that weakness may occur in those parts which are constantly used, or by the less satisfactory one of locus minoris resistentice. Crises. — So far we have attempted to trace the symptoms and signs step by step as they occur in analogy with the pathologic findings. As this progresses all the symptoms above enumerated will grow in intensity and new ones appear. The numbness and pain will become more persistent and of a sharper intensity, and may appear in almost any portion of the body. Pains may be localized in various viscera of the body, and are then called crises; and of these, the gastric crises are the most common. They may appear at any time, and the pains in the stomach may become very severe, and, as a rule, are associated with nausea and vomiting. They may, how- ever, appear without these symptoms, or with one of them, and may last from a few minutes to several hours or longer. Vomiting, as a rule, does not relieve the pains. Crises next most frequently occur in the larynx, where they are associated with difficulty in breathing and stridulous res- piration. Intestinal crises are next most frequent, and are accompanied by violent pains and evacuations of the bowel. Almost any organ may be the seat of these phenomena, and there may be renal, bladder, rectal, genital, ocular, and oral crises. No satisfactory explanation has ever been given for their occurrence, but it is. presumed that there is a disturbance of function of the organ brought about by derangement of the sympathetic plexus. These crises are not as frequent as is usually inferred. Involvement of the Trigeminus Nerve. — A not unusual symptom is paresthesia of the face, the patient complaining of objects crawling over his TABES DOKSALIS (LOCOMOTOR ATAXIA). 1105 eyebrows, or tnat there is a mask drawn over his face. These phenomena may be succeeded by pain in the same distribution, and are probably the result of degeneration of the sensory or descending root of the fifth nerve, which is found as low down as the third cervical segment, its involvement being an excellent indication of the upward progress of the disease. As- sociated with this, there necessarily will be a diminution of sensation in the distribution of one or both fifth nerves, one of the early manifestations of this being a tendency to looseness of the teeth, it being possible to pull out a tooth without the slightest pain. Later there may be complete loss of sensation in the distribution of the fifth nerves. Optic Nerve Atrophy. — ^Atrophy of the optic nerve is one of the most serious complications to be found in this disease, and is present, according to Gowers, in about one-tenth of the cases. It is usually a late manifes- tation, but if it appears early it seems to have a beneficial tendency upon the other symptoms, for these, as a rule, will diminish. Among the other ocular comphcations is paralysis of part or the whole of the oculomotor nerve and of the sixth nerve. Deafness. — Deafness is a very frequent symptom in late tabes, and some diminution of hearing would be found in every case of early tabes, were it carefully searched for. Very rarely the vestibular branch is involved, causing vertigo, tinnitus, and cerebellar gait. Among the other cranial nerves v/hich may be involved are to be mentioned the facial nerve, and those which supply the organs of the voice. Vasomotor and Trophic Phenomena. — ^Vasomotor and trophic dis- turbances are not unusual, and when it is considered that the sympathetic plexus takes part in the degeneration found in tabes, and that some of these fibers enter the spinal cord by means of the posterior roots, it is not difficult to explain their occurrence. Local sweating in the palms or soles or in the hands, and alterations in the pigment of the skin, are not uncommon. Oc- casionally there may be herpetic eruptions, accompanied by pain, or there may be alteration in growth of hair following pains. Because of the hy-- potonic condition of the joints and of the altered amount of sensibility, there occurs what is called the tabetic joint and the tabetic foot. This is nothing more than a giving way of the parts concerned. As has been previously shown, alteration in the sensation of the structures beneath the skin is one of the earliest symptoms of the disease. Necessarily, then, the bones enter in this, and naicroscopic examination has shown al- teration in their structures. Because of this fractures are very common, and must be guarded against. Should there be any laceration of the tissues, as by stepping on a nail, because of the lessened resistance of the tissues in- fection will be easy and extensive wounds may result, the healing of which is very difficult, an example of this being the perforating ulcer which is found on the soles of the feet of tabetics. Charcot Joints. — Considering, then, the lessened amount of resistance in the tissues and the alterations in the bones, should there be any injury of a joint, there may result what was first described by Charcot and named after him. These Charcot joints are, as a rule, found in the knee, but may be located in the ankle, elbow, shoulder, or, in fact, even in the joints of the vertebra, and are characterized by looseness of the parts and ability to move them in any direction, this not being painful. Pathologically, an erosion of the parts of the joints is found (Fig. 414). XJnusual Varieties. — Juvenile or Hereditary Tabes; Optic or Cervical Tabes; Sacral Tabes. — In the juvenile or hereditary form the 70 1106 DISEASES OF THE NERVOUS SYSTEM. disease begins very early in life, and there are always present other signs of congenital syphilis. This type is very rare. In the usual form of tabes the symptoms," as a rule, come on anywhere from five to ten years after in- fection with syphilis, but may not appear until twenty years after. In the optic form the symptoms come on in the usual chronologic order, but optic atrophy is early manifested and the principal symptoms are confined to the upper limbs, the disease l^eing mostly localized to the cervical cord. _ After the optic atrophy has become complete the ataxia nearly always diminishes, leaving only the general symptoms of the disease with jjains. In the sacral form the pathologic process is first limited to the lowest portion of the spinal cord, giving as early symptoms disturbances of bladder and rectal functions, and also of sensation and locomotion for a long time only in the lower limbs. Summary of Diagnosis. — Early Tabes. — Numbness in the lower limbs, foUowed by sharp, shooting pains; beginning girdle sense; diminution and later loss of patellar and Achilles jerks; beginning hypotonia and loose- ness of the knee-, ankle-, and hip-joints, with some diminution in the sense of movement, position, and pressure in the lower limbs; some difficulty in Fig. 414. ^Charcot Joint in T.\bes, walking, which is increased with the eyes shut; a tendency to constipation and possible loss of sexual functions; irregularity of the pupils with miosis and a slow reaction of the pupil to light, but prompt contraction to move- ment of the eyeballs. Late Tabes. — Constant numbness in the feet; sharp, shooting, lanci- nating pains all over the body; girdle sense, crises; an ataxic gait which is increased with the eyes shut; considerable hypotonia, loss of sense of posi- tion, of pressure, and of movement; diminution or loss of touch or pain sense and bone sensation; absence of all reflexes; failure of the reaction of the pupil to light, with optic atrophy and possibly oculomotor and abducens nerve pais}''; perforating ulcer; Charcot joints. Differential Diagnosis. — The only disease with which tabes is liable to be confounded is the so-called ataxic form of multiple neuritis or pseudo-tabes. The following symptoms are common in both: Numbness in the limbs; sharp, shooting, lancinating pains; absence of reflexes and ataxia. In multiple neuritis, however, we have a history of either alcoholism or arsenical poisoning, plumbism, etc., and their symptoms, the rapid onset MYELITIS. 1107 following the intoxication, wrist drop and toe drop, pain on pressure over the nerve-trunks, reactions of degeneration, and marked disturbances of sensation over the limbs different from the type found in tabes. The follow- ing symptoms of tabes are also never present: irregularity of the pupil or the Argyll-Robertson pupil and disturbances of the bladder and rectum. Again, in multiple neuritis the patient will in most instances fully recover. Occasionally it will be difficult to diagnose this disease from general paresis. In both there is a history of syphilis, and there may be the same pupillary, sensory, and reflex phenomena; but there are, in addition, in general paresis mental symptoms, such as change in disposition and ideas of grandeur, tremor of the facial muscles and sometimes of the limbs, and diffi- culty or tremulousness in speech. As a rule, there is not in paresis the regu- larity of symptoms which is so characteristic of tabes, and not much diffi- culty shoidd be experienced in differential diagnosis. Clinical Course and Complications. — The prognosis in any given case must depend upon the character of the onset, whether the patient has been given anti-specific treatment, and the severity with which the symptoms appear. As a rule, if the patient has been thoroughly treated for syphilis the disease will be longer in its appearance. There are, however, exceptions to this. The earlier the symptoms appear, the more severe is the disease likely to be. While, as a rule, the symptoms of tabes appear in regular order, sometimes there may develop an undue amount or an early hypotonia and ataxia. If this be the case, the probabilities are that the patient will be so incoordinate that it will be difficult to educate him to walk. Again, in the so-called form of optic tabes blindness will appear early, but the ataxic symptoms will almost subside. It must be remembered that the disease is chronic and progressive in most instances, but occasionally cases are met with in which there has been an undoubted arrest of symptoms. It is not unusual for the symptoms to subside in from five to twenty years. The prognosis in large part is influ- enced by the treatment, for should this be carefully instituted, a subsidence of symptoms is more likely to occur. The complications which may arise in the course of this disease are those which are liable to occur as a result of any syphilitic infection. There may be added to the tabetic process, a wide degeneration of the whole cerebro- spinal axis, thus producing the disease, general paresis. Again, there may be a diffuse sj^hilis or a spinal meningitis. In rare instances a hemorrhage may occur, causing hemiplegia, and stiU more rarely there may be a cavity formation in the central portion of the spinal cord, adding the symptoms of syringomyelia. There may also rarely be an inflammation of the peripheral nerves. MYELITIS. Definition. — By this is meant inflammation of the substance of the spinal cord. It may be produced by a great variety of causes, such as direct injury the result of bullet or stab wounds, pressure from a dislocated or diseased vertebra, and tumors of the meninges whether intradv\raj or extra- dural. Inasmuch as in these instances the myelitis\is secondary, its syihp- toms will be discussed under separate headings, and under myelitis wilt be discussed only those forms which are the result of eatises no1^ already men- tioned. Pathologically there are many different forms of myelitis. The inflam- 1108 DISEASES OP THE NERVOUS SYSTEM. mation may involve the whole transverse section of the cord (transverse myeUtis), it may affect only the central gray matter (central myelitis), or irregular areas in the white or gray matter (disseminated myelitis). His- tologically the inflammation may be confined principally to the parenchy- matous structures or blood-vessels, or it may assume the characteristics of both. Myelitis also occurs as the result of a thrombosis or embolism of the vessels, and will produce a necrosis or death of the parts from which the blood- supply has been cut off. Such a condition is known as myelomalacia. If the meninges of the spinal cord are involved, the disease is known as meningomyelitis. As a rule, such a condition is the result of a syphilitic inflammation or an extension of the pathologic process from the vertebra, as in vertebral carcinomatosis. It is possible for the pia alone to be diseased or there may be inflammation also of the dura. Myelitis may also be divided, according to the onset of the symptoms, into acute, subacute, and chronic. Contributing- and Bxciting- Factors. — There are many causes for acute myelitis. It may result from the transmission of the purulent process from small abscesses in the periphery, from gonorrheal inflammations, general septic processes, exposure to cold and wet, or may occur in the course of or follow many infectious diseases, such as typhoid fever, scarlet fever, influenza, grippe, etc. It sometimes occurs without any apparent cause. Symptoms. — Acute Transverse Myelitis; Thoracic Cord. — The onset is usually rapid, and there may be a rise in temperature with headache and a general feeling of malaise. There is usually first a feeling of numbness or a tingling in the lower limbs, which is followed by weakness, which may proceed in a few days to total paralysis. As most cases of acute myelitis occur in the dorsal area and are completely transverse, there will be, besides paralysis of both lower hmbs and of the lower abdominal and gluteal muscles, at first retention, followed by dribbling and later complete loss of urinary fimction, with incontinence of feces and total anesthesia for all forms of sensation in both lower limbs and lower part of the abdomen, the skin area corresponding to the acute transverse lesion. There may also be a band- hke area of hj^eresthesia corresponding to the segment of the spinal cord which is diseased. In most cases the acute loss of motion and sensation is followed by improvement, and very soon there will be return of sensation over the lower limbs and abdomen, and later return of power, and instead of complete flaccidity with loss of reflexes, which first occurs, there develops spasticity with a gradual increase of tendon reflexes, patellar and ankle clonus, and the Babinski phenomenon. The bladder and rectal functions also improve. The further course of the disease is chronic, but the patient may recover sufficient power to be able to walk; as a rule, atrophy and con- tractures develop, and there may sometimes be electric reactions of de- generation. If the patient is bedridden, bedsores may develop and skin eruptions may occur because of the general impairment of nutrition and of trophic functions. If the acute transverse myelitis occurs in the cervical cord, there will be, besides the symptoms above enumerated, paralysis of motion and loss of sensation in, the upper limbs ; and if the lesion is high enough, paralysis of some of the muscles of the neck and diaphragm. If the lesion occurs in the lumbar cord, the symptoms will be similar to those in the dorsal region, with the exception that there will not be any weakness or anesthesia in the abdominal muscles. The subsequent course is the same. MYELITIS. 1109 If the meninges are involved, as in meningomyelitis, there will be, in addition to the symptoms above enumerated, pains of a sharp, shooting character, and especiallj' girdle sense. As a rule, however, a meningo- myelitis is nearlv always of syphilitic origin, and will be cUscussed under that head (Fig. 415)': Disseminated Myelitis. — Because of the fact that in this form the areas of inflammation are diffuse, and may occur in any portion of the spinal cord, there can be no regularity of symptoms, and these necessarily depend upon the parts of the cord diseased. As a rule, disseminated myelitis follows some infectious disease, pyemic process, or abscess of the periphery. The onset is nearly always gradual, and there may or may not be premonitory or feb- rile symptoms. Because of the fact that nearly always there is a pre- dominant involvement of the motor columns, and that motor symptoms are promptly appreciated, the first symptoms may be those of weakness of motion of one or both lower limbs. The weakness increases, and is nearly always accompanied by exaggeration of the tendon reflexes, sometimes with ankle and patellar clonus and the Babinski phenomenon. Rarely the re- FiG. 415. — Contracture with Ixability to Move the Limbb ir^ Myelitis. flexes may Ije absent, provided the areas of inflammation are located so as to interfere with their arcs. As a rule, there will be disturbance of sensation, irregularly distributed over the lower hmbs, abdomen, and chest, and some- times the upper limbs, and there may be numbness and pain, sometimes shooting in character, and girdle sense. Vesical and rectal disturbances are nearly always early in their onset. Gradually the weakness, spasticity, and increased reflexes are followed by atrophy and contractures. The upper limbs may be similarly involved in time. As in disseminated sclerosis, there is nearly always involvement of different portions of the brain, the relative symptoms depending upon the extent and location of the pathologic process. The duration of the disease varies, but, as a rule, it is fairly rapid; that is, it may extend over a number of months, but hardly ever longer than a year. As a rule, disseminated myelitis terminates in death, but sometimes the pathologic process may subside and leave multiple areas of sclerosis. Subacute and Chronic Myelitis. — Under the former is understood a form of myelitis which develops in a number of months, while under chronic 1110 DISEASES OF THE NERVOUS SYSTEM. myelitis is understood inflammation of the spinal cord which comes on over a longer period — a year or more. As a matter of fact, these classifications are arbitrary, and it is better to class myelitis, not according to the length of the onset, but according to the pathology or the extent of the involvement of the spinal cord. There is, however, a form of myehtis in the aged known as senile myelitis which comes on slowly and will be discussed under that head. Senile Myelitis. — Sometimes in the latter end of Ufe, especially in persons who are arteriosclerotic, there occurs a gradual diminution of power in the lower limbs, with numbness, pin or needle-like sensations, or a dead feeling, and some disturbance of bladder function. These may be accompanied by increase of reflexes, and only rarely by the Babinski phenomenon. It is characteristic of this form of myelitis that the symptoms grow better and worse, and extend over a long period of years, terminating in more or less complete weakness of both lower limbs, with increase of reflexes, some dis- turbance of sensation, and pains of varying character. The symptoms here described are similar to those which occur under the symptom-complex known as intermittent claudication, and are dependent upon a gradual lessening of the blood-supply of the spinal cord because of the closing up of the lumen of the vessels due to a gradual developing arterio- sclerosis. The intermittent symptoms depend upon the occasional shutting off of the blood-supply. When the arteries are finally closed up, there de- velops myelomalacia or death or softening of the part, because of abolition of the blood-supply. Caisson Disease or Diver's Palsy. — By this is understood a form of paralysis affecting those persons who work under a heightened atmospheric pressure, as divers, and who suddenly return to the normal pressure. It usually affects those persons who are old or alcoholic or who return too sud- denly to normal conditions. There may be headache, dizziness, flashes of light with pains in the limbs or abdomen, or difficulty in breathing, or there may be complete coma and unconsciousness. In the course of an hour or more there may develop weakness of one or both lower limbs, which may at first be flaccid in character with loss of reflexes, and later become spastic with increase of reflexes. There may also be involvement of the bladder and rectal functions and disturbance of sensation. Sometimes the paralysis only lasts for a short time, and there may only result little disturbance of motion, but rarely the paralysis is permanent. Pathologically are found diffuse areas of inflammation and softening in various parts of the spinal cord and sometimes in the brain and air-bubbles in the myelin. Serous Myelitis. — Sometimes aU of the above symptoms of myelitis may be caused by pressure due to an increase in the cerebrospinal fluid, the result of a serous meningitis. It is, however, impossible to recognize this, for the symptoms are identical. Lumbar puncture, however, will demonstrate a great increase in the quantity of fluid and a heightened tension in the spinal canal. Summary of Diagnosis. — The symptoms will depend upon the form of the myelitis, whether transverse or disseminated, and upon the location of the lesion, whether in the cervical, thoracic, or lumbar cords. If acute, transverse, and in the cervical region, there will be complete par- alysis of movement of all four limbs, of the thoracic and abdominal muscles, and of the diaphragm, and loss of sensation in an area corresponding to the cervical segment involved, with incontinence of urine and feces. If in the thoracic region, the paralysis will involve only the lower limbs, TUMORS OF THE SPINAL CORD. 1111 abdominal and part of the thoracic muscles, and the sensory disturbance will only extend up to the thorax. If the lesion is in the lumbar region, the paralysis of motion and sensation will only involve the lower limbs. If the myelitis is disseminated, the symptoms will be gradual in onset, disturbance of motion and sensation may involve first one limb and then the other, or both at the same time, this gradually increasing and last- ing over a number of months, either terminating in death or persisting with the symptoms of spastic ataxia of the lower limbs and sometimes of the upper. The diagnosis of senile myelitis can be made upon the gradual onset of weakness and disturbance of sensation with numbness in the lower limbs coming on in an old man. Differential Diagnosis. — There should be no difficulty in diag- nosing acute transverse myelitis. It is sometimes necessary, however, to diagnose this from a similar involvement resulting from pressure back- ward of the vertebra, or a myelitis resulting from tumor. In disease of the vertebra, however, there will always be a history of an injury or previous disease, whereas in tumor there will be the gradual onset of the symptoms with pains suddenly terminating in acute myelitis. Disseminated myelitis is sometimes difficult to diagnose from a similar pathologic process occurring in syphilis. In the latter, however, there may be a history of the disease, and there are nearly always irregularities of the pupU with disturbance in their reactions, and sometimes early and transient ocular palsies. Clinical Course and Complications. — These have been indicated in the description of the various diseases, and need no further discussion. ■njMORS OF THE SPINAL CORD. In comparison with tumors of the brain they are rare. They may be extradural, intradural, or involve the spinal cord, but are mostly intradural, tumors of the cord being most rare. Pathologically they may be sarcoma, fibroma, glioma, carcinoma, or cystic. Tubercular and such other tumors as psammoma, myxoma, endothelioma, and lipoma rarely occur. Sarcoma.— -Sarcoma of the cord itself is rare, and is secondary to that of the vertebra when it involves the anterior and especially the posterior roots or may infiltrate in the pia. Generally the lower portion of the spinal cord, and especially the cauda equina, is the seat of multiple sarcomata. Their characteristics have already been discussed, and it must only be re- membered that sarcomata may be soft and infiltrating, and because of this may give only few symptoms. Fibroma. — ^These tumors are mostly intradural and grow in the pia or about the roots. As a rule, they are not multiple, and are favorable for operative removal. Cysts. — ^These may be limited to the meninges and be simple, or may be multiple, as occurs in cysticercus cellulosa and in echinococcus cysts. Circumscribed Serous Meningitis. — ^Recently there has been ob- served a circumscribed serous collection of fluid within the pia-arachnoid which may at times be of large size. The differential diagnosis between such cases and tumor is very difficult, the only difference, perhaps, being in the variability of the symptoms, inasmuch as the pressure of the fluid upon the different roots may alter from day to day, this giving especially a vari- 1112 DISEASES OF THE NERVOUS SYSTEM. ability of sensation and reflexes, whereas in tumor these changes are permanent. Symptoms. — These will depend upon the location of the tumor and ex- tent of the involvement, either of the meninges, root, or cord. As a rule, most tumors are located in the thoracic cord, and are generally situated about the lateral and posterior surfaces. It is impossible to state definitely what symptoms may occur in tumors, but they are due to involvement either of the roots or of the spinal cord itself. Root Sjraiptoms. — Numbness, pain, or girdle sensation, to be followed by pain, are usually among the first manifestations, these being referred to the parts in relation with the posterior root diseased. As a rule, the pains are sharp, shooting, and agonizing in character, and may be of such in- tensity as to prevent the patient from moving. If the growth involves several posterior roots, and is large, there may be tenderness and pain on pressure over the involved part, and jarring may sometimes cause excruciating pains. Later there may be an accompanying disturbance of sensation. Cord Symptoms. — As the spinal cord itself becomes involved, its ac- companying symptoms will develop, such as disturbance of sensation if the posterior part of the cord is affected, and if the lateral columns are com- pressed there will be weakness, spasticity with increased reflexes, and the Babinski phenomenon in the parts below. Of course, if the tumor is around the anterior part of the cord the symptoms will be purely motor. This, however, is uncommon. Tumors of the Cauda Equina. — These are generally sarco- matous and multiple. • The symptoms will depend upon what roots are in- volved. There will usually be pain, referred to the sciatic distribution of one or both sides, or possibly a localized pain in the lower part of the back; but the most distinguishing feature is the segmental disturbance of sensation around the buttock, perineum, and anus, and the anesthesia in the genital organs. There may also be involvement of bladder, rectal, and sexual functions. Paralysis is not very common, but if it occurs will usually be in the distal portions of the limbs. DISEASES OF THE VERTEBRA. These may be divided into diseases of the vertebra itself and those the result of growths. Diseases of the vertebra are generally tubercular, start- ing either in the spongiosa, periosteum, lamina, spinal processes, or ligaments. The process may grow from one or several locations at the same time, and may involve the spinal cord secondarily in three ways: first, by direct ex- tension of the tuberculous process from the vertebra, the tuberculous masses involving the dura and then the spinal cord; second, by direct pressure the result of a backward displacement; and, lastly, by so-called toxic action. It is probable that in the last classification the spinal cord itself becomes diseased through the disturbance of the lymphatic and arterial circulation. The symptoms caused by tubercular disease of the vertebra or Pott's disease are identical with those caused by growths, and will be discussed under that head. Sj^Dhilitic caries rarely occurs. Tumors of the Vertebra. — These are generally sarcoma or carcin- oma, or may be the result of a growth of the bone-marrow, when they are called myeloma. The earlier mentioned tumors are nearly always secondary to growths elsewhere, generally from the lungs, stomach, breast, INJURIES OF THE SPINAL COKD. 1113 or uterus. Such benign growths as osteoma or enchondroma may sometimes occur. Symptoms. — ^These will be divided into, first, those which are the result of diseases of the vertebra itself; second, those resulting from involvement of the spinal roots and cord. Symptoms Due to Affection of the Vertebra. — In nearly all cases, whether the tumor affects the vertebra, lamina, or processes, there should be some displacement and deformity of the vertebra, especially in caries. It must be remembered, however, that both in this condition and in tumors there may not be the slightest evidence of deformity, and the first symptoms will be those the result of pressure on the roots. In most cases besides this evidence of deformity there will be pain over the affected parts, this causing a stiffness and a rigidity of the back and neck with accompanying awkward- ness in movement. Root and Spinal Cord Symptoms. — As the disease progresses, pressure wiU be first exerted on the posterior roots, and the first symptoms wiU be those of numbness, to be followed by sharp, lancinating pains with girdle sense, referred to the distribution of the diseased roots. Any jarring of the back or pressure will bring on a fresh attack or exaggeration of pain. As the disease involves the dura and the cord there will be added disturbance of sensation and of bladder and rectal functions, weakness in the limbs with increased reflexes, spastic condition, and Babinski phenomenon. The extent of the paralysis will, of course, depend upon the amount of involvement, sometimes there resulting complete myelitis and total paralysis. INJURIES OF THE SPINAL CORD. The result of any inj ury, no matter how trivial, cannot be foretold. There may be, first, a sprain or injury to the ligaments of the vertebral column, either with or without injury of the cord; second, fracture or dislocation of the vertebra or both, either with or without involvement of the spinal cord; third, injuries to the cord itself; and, lastly, the so-called traumatic neuroses, which may enter into all the above classifications, and also are independent of these. The symptoms will be discussed in order. Sprain or Injury to the Ligaments of the Vertebral Column with or without Involvement of the Cord. — ^This generally results from over- stretching of the vertebral column or from some severe muscular effort. A direct injury to the back may cause a contusion of the ligaments. As a rule, the cord itself will not be involved, and the symptoms will be those of pain localized to the affected parts with accompanying rigidity of the back and pain on movement. There should be no difficulty in making this diagnosis, were it not for the fact that in medico-legal cases there may be present the symptoms of a traumatic hysteria which may resemble injury of the cord, or there may be, what not infrequently occurs, multiple small hemorrhages or areas of softening in various portions of the cord, and some- times hemorrhages into the substance. Fracture or Dislocation of the Vertebra or Both, Either with or without Involvement of the Spinal Cord. — Fractures of the vertebral column are usually associated with dislocation and are the result of severe injuries. They generally occur either between the atlas and axis, the fifth and seventh cervical, or the first and second lumbar vertebrae. In nearly all cases the spinal cord is involved, the only exception being when the frac- 1114 DISEASES OF THE NERVOUS SYSTEM. ture is of mild nature and causes no deformity, or if there has been a fracture of limited degree involving the lamina or processes. Symptoms. — There are usually present the surgical evidences of in- jury, for here, as elsewhere, the fracture may be simple or compound. Be- sides there will be evidences of deformity of the vertebral column with rigidity and pain in the back. The symptoms will depend largely upon the place of injury. If in the cervical cord, the principal symptoms will be in the upper limbs; if further down, as in the lumbar region, they will be limited only to the lower limbs. Injuries to the Cord. — In nearly all cases where the injury has been severe enough to cause a fracture or dislocation of the vertebra, the cord itself will be severely damaged. This may be either because of a direct pressure exerted upon the cord, the result of backward displacement of the vertebra, or, as sometimes happens, there will be at the time of injury a sudden torsion or twisting of the spine, this causing momentary pressure upon the cord with destruction of its elements. Again, there may be severe injury to the cord, but no evidence of fracture or dislocation, or even sprain or contusion of the ligaments, with either multiple small hemorrhages or softening, or one large hemorrhage. The symptoms of compression of the cord will not differ from those de- scribed under the head of myelitis. As a rule, the destruction will be in- tense, and transverse myelitis and sometimes complete severance of the cord may result, this causing complete loss of power and of sensation in the parts below, with the bladder, rectal, and trophic symptoms. It must also be remembered that, besides the direct destruction of the cord, the result of the injury, there will also be multiple small areas of hemor- rhage above and below the point of injury. If there is only a partial destruction there will be, after the initial complete paralysis of motion and sensation, return of sensation, and then of motion, with increased reflexes, spasticity, Babinski phenomenon, and disturbance of bladder and rectal functions. Hemorrhages into the cord, or hematomyelia, may occur with con- tusion of the substance of the cord, or independently. of this as a result of injuries, without an accompanying fracture or dislocation of the vertebra. As a rule, hemorrhages occur into the substance of the cord, mostly in the central gray matter, and only very rarely in the outer or inner surface of the dura. . The gray matter of the cord seems to be easier to infiltrate than the white matter, and as a consequence any hemorrhage may involve con- siderable length of the cord. The symptoms will, of course, depend largely upon the location of the lesion, whether within the cervical, thoracic, or lumbar parts, and upon its extent. As the hemorrhage involves principally the middle portion of the cord, it will interrupt the fibers concerned with transmission of pain and temperature sensations, and there will result the so-called syringomyelic disturbance of sensation in the lower limbs; i. e., loss of pain and temperature sensations with preservation of touch. Be- sides, there will be weakness with spasticity, increased reflexes, and the Babinski phenomenon, and if the hemorrhage involves the cells of the an- terior horn, loss of power with atrophy and reactions of degeneration in the related parts. If, however, there should be multiple microscopic areas of hemorrhage or softening, no definite symptoms will result, because there has not been sufficient injury to cause disturbance in function unless the injury occurs where marked arteriosclerosis is present, when severe hemorrhages or UNILATERAL SPINAL CORD LESIONS. 1115 softening may be brought on any time through the weakening of the vessel walls. The Prognosis of Injuries of the Spinal Cord.— This will, of course, depend upon the nature and extent of the injury. If the cord has been severely crushed for several segments, there can be no hope for return of function. If the injury has been partial, some return of power will always result. If a hemorrhage has occurred in the central gray matter, there should be some return of power; and if there are multiple microscopic areas of hemor- rhage or softening, complete recovery may en- sue. In all of these instances the prognosis de- pends entirely upon the possible regeneration of fibers in the spinal cord, and this has been the subject of controversy for a long time. It is probable that this cannot occur, and whatever improvement results is because the fibers which have been injured have recovered from what- ever traumatism they have undergone. In every injury there is a certain amount of shock which will temporarily injure the cord, but un- less a complete severance or myelitis ensues there should nearly always be some return of function. UNILATERAL SPINAL CORD LESIONS, OR BROWN-SEQUARD PARALYSIS. Sometimes tumors or injuries resulting from bullet or stab wounds will cause a unilateral le- sion of one or two segments of the spinal cord. The symptoms will depend upon the part of the cord involved and the extent of the lesion. Should, for instance, there be a unilateral le- sion in the eighth cervical and first thoracic segments of the right side of the cord, there wiU be the following symptoms : Because of the destruction of the nerve-cells in the anterior horns, inability to flex or extend the right wrist or move the fingers, besides atrophy and electric reactions of degeneration in these parts. Be- cause of the involvement of the right motor or pyramidal column, weakness, spasticity, in- creased reflexes, and the Babinski phenomenon in the right lower limb. Because of the destruc- tion of the sensory roots, loss of all forms of sen- sation along the under surface of the whole right arm. As the posterior columns transmit the fibers for touch sensation and muscle sense, Fig. 416. — Scheme REPRE8f:NTiNG uord-lesion and effects in Brown-Sequard Paralysis (after Brissaud). CSG, Left sensitive tract; CSD, right sensitive tract; A, B, C, D, lesion involving the left half of the cord; S, S, S, sensory roots from right side of body; Z. Z, Z, sensory roots from left side of body; Z*. Z^, and S^ are irritated only at the points A, B, C, and their peripheral area is hyperes- thetic; Z^ is divided and its skin area is anesthetic on the same side as the lesion. Corresponding to S^ and all the roots below arising from the right side of the body, there is anesthesia. there will be disturbance of touch in the right lower limb and right abdomen and chest with impairment of muscle sense and ataxia in the right leg. In the left lower limb there will be disturb- ance of pain and temperature sensations only, because of the destruction of the right column of Gowers (Fig. 416). 1116 DISEASES OF THE NERVOUS SYSTEM. SPINA BIFIDA. A defect in the closure of the posterior vertel.iral arches, especially in the lumbar and sacral region. It is of embryonal origin, and is usually detected at birth or very soon after, and rarely may interfere with it. The defect may consist only in a lack of union of the posterior vertebral arches, but, as a rule, there is a tumor-like projection in the lower spine, which may consist only in a protrusion of the dura, which may be from the size of a nut to that of an orange or larger and be filled with cerebrospinal fluid, or there may be, in connection with the dural protrusion, an involvement of the spinal cord itself, consisting either in an enlargement of the central canal, a hydro- myelia or attachment of the lumlDOsacral cord or its roots to the walls of the sac. Symptoms. — Most cases of spina bifida die either at birth or soon after. When there is only a dural involvement, there may be no symptoms besides the physical evidences of protrusion. Pressure, however, upon the sac will cause Ijulging of the fontanels with the symptoms of cerebral compression. If, however, the cord itself be involved, there will be paralysis of both lower limbs and disturbance of bladder and rectal functions and of sensation. The disease is of long duration, the symptoms having a tendency to increase, and the prognosis is not very good. There are usually in association embryonal defects elsewhere, such as cleft palate or harelip. DISSEMINATED OR MULTIPLE SCLEROSIS. Definition. — A disease of the l^rain and spinal cord characterized by progressive weakness, spasticity, increased reflexes and ataxia of the limbs and trunk, with tremors which become worse on effort, scanning speech, anfl nystagmus. Pathologically there are multiple areas of sclerosis throughout the whole brain and spinal cord. The sclerotic patches involve equally the gray and white matter and the cranial nerves. The sclerosis in this disease differs from that of any other in the fact that there is no resulting secondary de- generation. The myelin sheaths only are involved and the axis-cylinders escape. It is because of this that there may be little alteration of function although the sclerosis is extensive. Predisposing and Bxciting Factors. — There are many theories as to the origin of the multiple areas of sclerosis, but it is probable that they are due to faidty development of the nervous system. Sometimes the disease appears in several members of a family, and in rare instances in father and son. The exciting causes are not known, but in not a few cases the symptoms seemed to have developed after exposure to cold and wet. Rarely the s^miptoms are due to multiple sj^philitic lesions. The disease is rather rare in this country, but on the Continent it is as common as tabes. Symptoms. — Inasmuch as the multiple areas of sclerosis may occur in any portion of the nervous system, and that in no two cases is the patho- logic process alike, the symptoms must necessarily vary in each case. There are, however, certain general symptoms which are present in nearly all, and these are a tremor which is intention in type, scanning speech, nj'stagmus, spastic ataxia of the lower and upper limbs, and less commonly optic atrophy. The disease nearly always begins in early adult life or around the twen- tieth year, with weakness or spasticity of one or both lower limbs, which gradually increases. Coincident with this or soon after there may develop PLATE XXII II liMlii" iii ^■^Miil ra^^mmm^ .^■^■^'^^-Jl.'-S: ^i. j^« ir.i_ HE iJ 1. m - ■y/wy«-»iaw?* ::^^!?g.. .s>. gaS^^^a«| t i ti_LjL L A '^I'ffiB i':^!^?^ i»?^ Moving Picture Illustrating Treninr nl' Jleail, hnily ami Janilis in Multipk' t^rlerosis. (Courtesy of Mr. Sigmund Luhin of I'luladeljihia, Pa.) DISSEMINATED OB MULTIPLE SCLEROSIS. 1117 ataxia of one or both lower limbs, and the gait, which at first may have been spastic, wiU become somewhat ataxic, the patient staggering from one side to the other much like a drunken man. The tendon reflexes of the lower limbs become progressively exaggerated, and the Babinski reflex is common. Often patellar and ankle clonus is present. It is not at all unusual for the spastic symptoms to be greater in one lower limb, and these symptoms may also be found in the upper limbs. Sometimes numbness and pains are present in one or both lower limbs, and rarely girdle sense and disturbance of sensation. Coincident with the spastic ataxia of the limbs there develops a tremor which is intention in type, that is, it becomes worse on effort. This tremor may, in mild cases or at first, involve only the upper limbs, but later all the limbs may be affected. In fact, in severe cases the tremor involves the head, neck, and the whole body, interfering with locomotion, eating, and talking. When the patient is quiet, there may be no tremor present, but the slightest excitement or movement Ijrings it out (Plate XXII). Disturbance of speech is an early symptom, and is usually described as scanning. The words are uttered slowly, sometimes explosively, the patient having a manifest difficulty in getting a start, although after beginning there is not so much hesitancy. The speech becomes slower and more difficult as the tremor progresses. Often it resembles the speech of a person shivering with cold. Nystagmus is common and may consist of only a few to-and-fro move- ments, and sometimes may not be apparent except on deviation. It is less constant than the scanning speech or the intention tremor. Disturbances of vision are very common. These may consist in a central scotoma for colors or a contraction of the visual fields, and, optic atrophy frequently results. Pallor of the optic discs, especially on the temporal side, is characteristic of this disease, and is found in probably one-half the cases. If the areas of sclerosis are limited to the spinal cord, there may not be present the intention tremor of the head, nystagmus, ocular symptoms, or the scanning speech. If the sclerosis involves the gray matter of the lumbar and sacral cord, there may be loss of the knee and Achilles jerks and inter- ference with bladder and rectal functions, but this is unusual. In not a few instances the first symptoms may be those of hysteria, and it is difficult to establish a diagnosis. Gradually with the hysterical symp- toms there develops spasticity of the lower limbs with increased reflexes and the Babinski phenomenon, and later the intention tremor, scanning speech, and nystagmus. Summary of Diagnosis. — Weakness, spasticity, increased re- flexes, and the Babinski phenomenon in both lower limbs, spastic ataxic gait, intention tremor of one or all the limbs and of the head and neck or of the whole body, scanning speech, nystagmus, optic atrophy, and pallor of the temporal side of the discs. The symptoms differ in each individual case, but the cardinal symptoms are spastic ataxia of the limbs, intention tremor, scanning speech, nystagmus, and optic atrophy. Diflferential Diagnosis. — In the onset of the disease it is diffi- cult to differentiate the spastic symptoms from those occurring in lateral or amyotrophic lateral sclerosis or from myelitis, but as the disease develops the intention tremor and scanning speech establish the differential diag- nosis. The hysterical symptoms may for a long time mask the disease, but later the cardinal symptoms develop. 1118 DISEASES OF THE NERVOUS SYSTEM. Clinical Course and Complications. — ^The course of the dis- ease is usually slow. Usually the spastic symptoms increase slowly, but the intention tremor and the scanning speech grow progressively more and more marked, and the tremor in some cases may become extreme. Re- missions in the disease are very common, and it is because of this that it is sometimes difficult to establish a diagnosis. Later in the disease the patient becomes bedridden, and the paralysis of the limbs will become extreme. Death usually occurs from some intercurrent cause. Syphilis of the Nervous System. It is of the utmost importance to make the diagnosis of syphilitic lesions of the nervous system as early as possible, for it is in the primary stages that therapeutic measures are of most benefit. That the diagnosis of such lesions presents many difficulties is evident, since there is no part of the nervous system that may not be attacked. Certain symptoms are present, however, in nearly all cases, and it is principally by the recognition of these that we are able to make a proper diagnosis. To better understand what symptoms are possible in syphilis, an effort will be made to trace the course and nature of the disease and the method of involvement of the nervous system. Method of Infection of Nervous System. — In only a few of the large number of persons affected does the nervous system become secondarily diseased. The important question, then, is. Why should one person have his nervous system affected and not the other, and what influ- ence, if any, does treatment have upon the prevention of such involvement? Repeated instances have been recorded in which a number of persons, not at all related, have become infected from the same source, and subse- quently developed general syphilis, and, later, specific disease of the nervous system. Here there are two possibilities: one, the most probable, that the specific infection was of such character that it had a special afiinity for these structures; and, second, that there was lessened resistance of the nervous system to the infection. It has always been one of the old theories that only certain forms of specific intoxication will cause disease of the nervous system; the best proofs of this have been such instances as quoted above. That such is the case there can be no doubt, but such a theory will hardly answer for all cases. There is no question that specific manifestations at the present time are not as severe as they have been. This is due partially to the better recog- nition and earlier and better treatment, and also to the fact that all diseases have a tendency to lessen in intensity in the course of time. It is probable that the most important factor which determines whether the infected person will have future involvement of the nervous system is the lessened resistance of these structures, or possibly a special predisposi- tion. Just what determines this is, of course, difficult to tell, but it must be that certain parts of the anatomy are less resistant than others. Hereditary and family influences contribute to this to a large degree. Erb records instances of specific infection in families in which all had tabes dorsalis following infection from the same source. Frequency of Disease. — It is important to know in what per- centage of cases of syphilis the nervous system becomes diseased. This can never be determined with accuracy, and we must rely principally upon the statistics to be obtained from institutions. Erb, for instance, collected some years ago a history of many cases of specific infection, and of these, SYPHILIS OF THE NERVOUS SYSTEM. 1119 in about 1 to 5 per cent, tabes followed. In how many, however, there were other involvements of the nervous system is not recorded, but judging from the fact that tabes is no more frequent than other cerebrospinal diseases, it is probable that a fair percentage would be about from 5 to 10 cases in 100. TMs, of course, is only conjecture. It is also a question whether or not early treatment of the disease will prevent such future involvement. That it does so in the majority of in- stances there is no doubt, but in many it is of no avail. It is, however, in the more chronic cases, or in those in which the symptoms of cerebrospinal involvement appear many years after the infection, that this- question arises. In many, anti-specific treatment had been instituted and carried out vigor- ously, and the patient pronounced well, only to have some part of the ner- vous system become diseased years afterward. The conclusion is forced upon us that in some forms of syphilis the cerebrospinal system will become diseased whether or not treatment is instituted, and no matter how vigor- ously. After an infection, the nervous system may be involved almost immedi- ately, in the midst of treatment, or may not for some years, sometimes as many as twenty. It is generally supposed that the earlier the cerebro- spinal symptoms appear, the more severe the infection. Considering, how- ever, that the s5Tiiptoms produced years after the infection are about of the same severity and character as they are in the early periods, there is probably httle difference. Pathology. — Pathologically, in the early forms, no matter where the nervous system is involved, there is always a round-cell infiltration about the blood-vessels and in the pia, this being especially true of the base of the brain and the posterior part of the spinal cord; and there is also a secondary endarteritis and permanent thickening of the meninges. Rarely, small gummas will be found, but these are not as frequent in the nervous system as is commonly supposed. More rarely, there is also an involvement of the substance of the cord or brain. When such is the case, in the former there is very often an extensive inflammation, this resulting in a myelitis; if in the brain, the cortex and subcortex are diseased, this causing the symptoms of diffuse encephalitis. It is characteristic of these acute in- flammations, such as myelitis and encephalitis, that the s}anptoms appear suddenly. When the disease comes on many years after the infection, the usual pathologic findings consist in a sclerosis of the vessels and thickening of the mieninges, and sometimes in gummas, but it is principally to the results of the endarteritis that the symptoms are due. There are, however, other forms of disease resulting from specific infection which are caused, not by inflammation, but by gradual changes in the nervous structures, thought to be the result of toxins. These changes mostly occur in structures which have more or less functional relation, and are called systemic, the best ex- ample of this being locomotor ataxia or tabes dorsalis. Symptoms. — It can be readily understood, then, that, so far as the symptoms of specific disease of the nervous system are concerned, the major- ity of cases will show an involvement of both the brain and spinal cord, and that the focal symptoms will depend upon what particular portions of these structures are most diseased. No matter what the extent of the affection, there is in every case an infiltration of the meninges, and this in itself will nearly always give certain symptoms. There is a tendency, however, for certain forms of involvement in those cases in which the symptoms manifest 1120 DISEASES OF THE NERVOUS SYSTEM. themselves within a few years after the infection, and these will be discussed first. Early Symptoms. — Myelitis. — Among the earliest is a myeUtis, this usually coming on suddenly, and in most instances affecting the lower thora- cic or thoracic-lumbar region, and often giving the symptoms of a complete transverse myelitis, there being loss of power in both lower limbs, of the bladder and rectal functions, and of sensation. In the majority of cases some return of power can be hoped for, especially if vigorous treatment is promptly instituted. Added to the symptoms of the myelitis there will be those of meningeal involvement, such as girdle sense and pain. Cerebrospinal Involvement. — Other common early manifestations, some- times appearing in the midst of treatment, are those the result of multiple lesions of the brain and spinal cord, giving diffuse symptoms depending upon the location of the lesions. There wiU nearly always be motor and sensory involvement of irregular character, with the addition of meningeal symptoms of the base of the brain and of the cord. Hemiplegia. — Hemiplegia is also common in early syphilis, this resulting from early endarteritis. In fact, hemiplegia occurring in young adults below forty years of age is nearly always syphilitic in origin; but the most common manifestations of syphilis are those the result of meningeal involve- ment of the base of the brain or of the spinal cord. Meningitis. — ^Meningitis of the base of the brain is nearly always greatest around the chiasm, and it is because of this that the optic, oculomotor, and sixth nerves are commonly diseased in sj^philis. Whether it is because of this involvement of the optic nerves, or because the specific toxin has a special predilection for the iridic muscles, disturbances in the reactions of the pupils with irregularities in their margins are the most common and constant symptoms of syphilis. Such general diseases as syphilis nearly always affect those structures which are most commonly used, and it is, perhaps, because of this that the iridic muscles are so early diseased. In most instances there will be found irregularities in the margins, with a loss of the reaction of the pupils both to light and to movement of the eyeballs, and sometimes, in the later stages, a failure of response of the pupils to light, with preserva- tion to movement of the eyeballs, or the Argyll-Robertson pupil. There is no disease which will so constantly give these symptoms, an^ there are no symptoms which are so constant or which can be so much depended upon. Oculomotor palsy, unilateral in tj^pe, occurs most frequently in syphilis. In fact, it has been termed its sign manual. Of the cranial nerves, however, the sixth nerve is probably the most frequently diseased, it causing double vision. This, as a rule, lasts only a very short time, appearing and reappear- ing, until finally it will be permanent. Paralysis of any of the other cranial nerves is a rare manifestation. Meningeal involvement in the spinal cord is nearly always greatest in its posterior portion. Because of this, girdle sense and pains referred to various parts of the limbs are common. Late Symptoms. — Of the diseases which have a tendency to become manifest many years after the infection, that is, after the fifth year, while there is in every case an affection of both the brain and spinal cord, there is nearly always a preponderance of the disease in one of these struc- tures. When the brain is mostly involved, there will be, besides the ir- regularity of the pupils and the slowness of reactions to light and movement, other symptoms depending upon the location of the lesion. These may con- sist in a gummatous deposit in most any portion of the brain, or of a basal infiltration, besides those diseases resulting from the early endarteritis. SYPHILIS OF THE NERVOUS SYSTEM. 1121 It is characteristic of brain symptoms, just as it is of those the result of basal lesions, that they may appear for a time and then disappear, only to reappear again and remain more or less permanently. In those instances in which the spinal cord is mostly involved there may be diffuse symptoms, but in nearly all there is some meningitis, this causing girdle sense and pains. Disturbances in bladder and rectal functions, especially the former, are very common in spinal infections, and sometimes may be the only symptoms indicating such disease. Cases are observed in which there seems to be an equal involvement of the brain and the spinal cord, but even here one of these structures may be more diseased. The symptoms will, as a rule, be multiple, and there will be, besides the specific pupillary phenomena, disturbance of mentality, ir- regular motor and sensory symptoms, and involvement of the bladder and rectum. So far, only those cerebrospinal syphilitic diseases have been discussed which are the result of the direct pathologic processes produced by such in- fection, while other diseases, as general paresis, tabes dorsaUs, and postero- lateral sclerosis, are supposedly produced by its toxins. Their symptoms, as a rule, come on many years after the infection, at least so far as their ap- preciation is concerned. It is curious that a person may be infected with syphilis and have no symptoms for a number of years, and then may develop posterior sclerosis. This does not seem logical, and it is probable that if our methods of observation were better, we should be able to demonstrate some symptoms, for the syphilitic toxin does cause early and constant changes. Serum Tests for Syphilis.— Wassermann Reaction.* — ^Wasser- mann in 1905 described a reaction, known by his name, which is of the great- est help in the establishment of diseases of syphilitic taint. Since the original description many modifications have been made, the most important being by Noguchi. At the present time these tests are cumbersome and can only be made by the experienced laboratory worker and cannot be applied by the general practitioner. In view of this fact, and also because the technic is constantly changing, it has been deemed by the writer inadvisable to give a description of such tests, but only to discuss its significance and applica- bility to therapeutic measures. These tests can be applied both to the blood and to the contents of the cerebrospinal fluid, and while it is possible to give an opinion in reactions applied to either, it is important, if possible, to give consideration to the cellu- lar elements in the cerebrospinal fluid, the globulin content, and the specific reaction of blood and serum found in the spinal fluid. It must be understood that there is not always parallelism between the conditions found in the blood and spinal fluid or between the Wassermann reaction and the lymphocytosis of the cerebrospinal fluid. At times the reactions are alike, but not always. In brief, it is the present opinion that a positive Wassermann reaction means not only tabes, general paresis, or any of the so-called metasyphilitic diseases, but it also indicates active syphilis. This reaction has been ob- tained in a number of instances in leprosy, in sleeping sickness, and in other diseases, but this by no means lessens its value. It must be remembered that the application of mercury negatives the reaction, whereas potassium iodid has no such influence, this being an im- portant indication of the value of mercurial treatment of syphilitic diseases. * Details of the technic of the Wassermann Reaction are given on p. 345. 71 1122 DISEASES OF THE NERVOUS SYSTEM. Diseases of the Heninges. The meninges, which envelope both the brain and spinal cord, are divided into the outer coat, or the dura, and the inner, or the pia and the arachnoid. Inflammation of the dura is called pachymeningitis, and of the inner coats leptomeningitis. With the exception of localized inflammations and those following injury, inflammation of the meninges nearly always involves the coverings of both the brain and spinal cord. CEREBRAL PACHYMENINGITIS. This may affect either the outer or the inner coat, when it is called external or internal pachymeningitis. External pachymeningitis nearly always results'^from injury to the skull, and is not as common as is usually thought. It may be secondary to a growth of the overlying bone, especially in syphilitic, tubercular, and carcinomatous conditions. Internal pachymeningitis is rare. It sometimes is hemorrhagic in nature, there being accumulations of blood between the dura and pia, and usually occurs in old persons, especially in those who are either arteriosclerotic or alcoholic. It is rarely found in some forms of insanity. It may be present in conjunction with external pachymeningitis, especially in purulent, syphil- itic, and tubercular inflammations. Symptoms. — ^The symptoms of pachymeningitis, whether external or internal, are definite, and depend on the pressure exerted on the brain. Generally the patient complains of headache, and rarely of tenderness local- ized to the inflammatory area, the specific symptoms depending upon the part of the brain involved. If in the motor area, there will be irritative symptoms such as Jacksonian convulsions, which may be followed by more or less paralysis; if over Broca's convolution, motor aphasia; if over the parietal areas, where the pachymeningitis is most common, there may be irritative pains or paresthesia on the other side of the body, accompanied sometimes by disturbance of sensation; if over the temporal lobes, aphasia; if over the occipital convolutions, disturbance of vision on the other side. There may sometimes be loss of consciousness, delirium, or stupor, or there may be no symptoms at all. Summary of Diagnosis. — History of a preceding injury to the head or of alcoholism, or syphilis, or the presence of symptoms indicative of tumor of the bones of the skull. The symptoms may come on rapidly or slowly, and consist of diffuse headache, possibly unconsciousness, coma or delirium, with irritative phenomena, such as convulsions on the other side, paralysis of various kinds, either partial or complete motor or sensory aphasia ; or, what is important, there may be no symptoms at all. It is evident that the diagnosis of a pachymeningitis is very difficult and depends upon the location and character of the inflammation. SPINAL PACHYMENINGITIS. Isolated inflammation of the spinal dura without involvement of the membranes underneath is very unusual and its occurrence is doubtful. In some instances, however, the dura is preponderantly involved. As a rule, inflammations of the dura are secondary to disease of the vertebra, as in tubercular, syphilitic, carcinomatous, or sarcomatous inflammations. It is possible to have a sj^hilitic pachymeningitis without involvement of the SPINAL PACHYMENINGITIS. 1123 vertebra, but in most of these cases the pia and spinal cord are also diseased. The symptoms of a spinal pachymeningitis secondary to vertebral inflamma- tions have already been discussed under the latter heading. HYPERTROPHIC CERVICAL PACHYMENINGITIS. Definition. — An inflammation of the dura of the upper portion of the spinal cord, localized principally to the cervical region, and characterized by thickening of the membranes with pressure upon the inclosed roots and spinal cord. Pathologically there is a thickening of the dura, which comes on with- out any apparent cause, and is not secondary to vertebral disease. The dura is thickened thi-oughout its whole circumference and gradually causes a pressure myelitis. An antecedent history of sypliilis is sometimes present. Symptoms. — The disease is progressive, and the symptoms appear gradually. Because of the fact that both the posterior and the anterior roots are involved, and that the spinal cord is ultimately pressed upon, the symptoms will be both sensory and motor. There will be at first pain and paresthetic phenomena referred to the back of the neck, shoulder, and upper limbs, the pains sometimes becoming sharp and shooting. Any sudden jar- ring in the back of the neck or vertebra will increase the pain, and there will also be tenderness on pressure over the cervical area. The pains and pares- thesia increase, and examination may demonstrate segmental disturbance of sensation in the neck, shoulder, and upper limbs. In conjunction with these sensory symptoms, or soon after, there mil be fibrillary tremors in various portions of the upper limbs, to be followed by wasting and loss of power. Because of the fact that the ulnar and median portions are prin- cipally involved, there will develop a contracture of one or both upper limbs, which is characteristic of this disease, consisting of an acute extension of the wrist upon the hand, flexion of the metacarpal, and extension of the terminal phalanges. Gradually as the spinal cord is pressed upon, there will develop weakness, spasticity, increased tendon reflexes in one or both lower limbs, and ultimately the Babinski phenomenon will be demonstrated. Because of pressm-e on the posterior and lateral colunms there may develop sensory sjrmptoms in both lower limbs, trunk, and abdomen, and ultimately distur- bance of bladder and rectal functions. As the pressure upon the spinal cord increases, the tremors, atrophy, and weakness involve all of the upper Umbs and the patient becomes helpless. Summary of Diagnosis. — ^A gradually progressive disease charac- terized by numbness or pain in the neck, shoulder, and upper limbs, with segmental disturbance of sensation, to be followed by fibrillary tremors, atro- phy, and weakness in the upper limbs, \vith typical contracture consisting in an acute extension of the hand upon the wrist and flexion of the fingers. This is followed by spastic pai'esis of the lower hmbs, with increased reflexes and the Babinski phenomenon. Later, disturbance of sensation and of bladder and rectal functions. Differential Diagnosis. — It is somewhat diflRcult to diagnose this disease, because any inflammation of the dura which ultimately involves the spinal cord will cause the same symptoms. Its principal characteristic is the tj^ical contracture in the hands mentioned. In those cases in which the pachymeningitis follows disease of the vertebra, as in tubercular, syphil- itic, and malignant growths, there may be a spinal deformitj^, and in tuber- culous and carcinomatous conditions there may also be a history of similar 1124 DISEASES OF THE NERVOUS SYSTEM. growths elsewhere; and in syphiUs, involvement of the brain and some pupillary and ocular phenomena. INFLAHMATION OF THE PIA-ARACHNOID. Cerebrospinal Meningitis. — In most cases the pia of the brain and spinal cord are involved at the same time, and it is only rarely that either is involved alone. Inflammations may be of various kinds. The epi- demic form has already been discussed on page 836. The other varieties are purulent, tuberculous, and serous. Syphilitic meningitis has been dis- cussed under the head of syphilis, on page 826. PURULENT MENINGITIS. In most instances purulent inflammation of the meninges- is secondary to septic processes elsewhere, such as infected wounds of the scalp or cranium, middle-ear disease, localized abscess of the brain or pia, and gen- eral pyemic processes or abscesses in the various parts of the periphery, or secondary to a septic endocarditis or one of the infectious diseases, as pneumonia or tj^hoid. As a rule, the process involves equally the mem- branes of the convexity, base of the brain, and spinal cord. Symptoms^ — If the meningitis occurs in the course of an infectious disease, as typhoid, pneumonia, septic endocarditis, or is secondary to, pyemic processes, injuries to the head, or middle-ear disease, their accom- panying symptoms will be present, and very often the early symptoms of meningitis are masked. As a rule, they come on rapidly, with headache which at times is excessive, and a rise of temperature, the patient becoming delirious, stuporous, and then unconscious. The pulse generally at first is rapid, and then slow and somewhat irregular, and respiration becomes more or less embarrassed. The head is retracted, the back held rigidly, and often the patient assumes a position of opisthotonos. The arms are retracted, the legs are flexed on the abdomen, and any attempt to extend the limbs is met with resistance (Kernig's sign). About this time the irritative phenomena become prominent, and there may be general convulsions, or the spasms may be limited to one or more limbs, which may be followed by partial paralysis or hemiplegia. The reflexes may be exaggerated, diminished, or lost. Because of basilar involvement the pupils become irregular, their reactions impaired, and there may often be swelling of the optic nerve-heads or choked disc. Cranial nerve palsies are common, especially of the sixth, causing diplopia; the third, resulting in ptosis of the upper lid and inability to move the eyeballs; the seventh, paralysis of the face; and of the vagus, interference with the action of the cardiac and respiratory functions and ultimately death. Vasomotor phenomena may be present, consisting in a flushing up of the skin after stroking, described as tache cerebrale.. Summary of Diagnosis. — Headache with gradually developing stupor and unconsciousness, rise of temperature, retraction and rigidity of the head and back with opisthotonos, rigidity, and retraction of the lower and upper limbs, pains and tenderness in various portions of the body, with con- vulsions which may be general or local, followed by paralysis of various kinds or increased or lost reflexes, pupillary irregularities, choked disc, drooping of one or both upper lids, ocular and facial paralysis, and disturbance of cardiac and respiratory functions. Lumbar puncture will demonstrate pus-cells and increase of lymphocytes and sometimes the specific bacillus. Diflferential Diagnosis. — There should be no difficulty in diag- nosing cerebrospinal meningitis. It is sometimes impossible, however, INFLAMMATION OF THE PIA-ARACHNOID. 1125 to demonstrate the type of inflammation. This, however, can be readily- demonstrated by lumbar puncture. In the tubercular form of meningitis the inflammation is nearly always limited to the base of the brain. In serous meningitis there is not, as a rule, unconsciousness, and the irritative and paralytic phenomena are mild. In the epidemic form the symptoms are like those of the purulent type, but, in addition, there are skin eruptions and the history of an epidemic, although occasionally sporadic cases are found, and the specific bacillus may be isolated by lumbar puncture. TUBERCULOUS MENINGITIS. In this type the inflammation is nearly always confined to the membranes of the base of the brain, although there is some involvement of the convexity and of the spinal cord. In nearly all cases the tubercular meningitis is secondary to similar processes elsewhere, especially of the lung, pleura, intestines, or glands. It may occur in adults, but in most instances it affects children below the fifth year. PathologicaUy there is found tuberculous inflammation with smaU miliary nodules. Besides, there is nearly always some serous effusion. Fig. 417. — Beain of a Patient with Tuberculous Meningitis showing Nodules tvithix the Pia. Sytaptoms. — When occurring in an adult, there are always the ac- companying symptoms of a tubercular inflammation elsewhere, either in the lung, pleura, or glands. There gradually develop headache, irritability, vomiting and nausea, rigidity of the head and neck, some disturbance of consciousness, and then the symptoms of involvement of the cranial nerves at the base of the brain. These are choked disc or optic neuritis, irregular pupils with disturbance of their reactions, ocular palsies, drooping of the upper lid, facial paralysis, disturbance of hearing and of cardiac and respira- tory functions. Sometimes there may be convulsions or paralysis of the limbs of one or both sides. In most instances the disease is fatal. Tuberculous Meningitis in Infants. — When it occurs in infants, there is usually a slow onset with general restlessness, loss of weight, rise of tem- perature, and gastro-intestinal disturbances with delirium, unconsciousness, and retraction and rigidity of the head, neck, and back, retraction of the upper and lower limbs, and the symptoms of basal involvement which have been described above. Usually the disease terminates in death, but if the patient lives there will be closure of some of the ventricular connections with a consequent internal hydrocephalus. Because of this there will be an in- 1126 DISEASES OF THE NERVOUS SYSTEM. crease in the size of the head, bulging of the fontanels, paralysis of one or both sides of the body, diminution of intellect, and a general rachitic con- dition of the body, with its accompanying symptoms of maldevelopment. Summary of Diagnosis.— The symptoms of meningitis occurring in the course of a tuberculous condition in an adult, such as retraction of the FiQ. 418.— Cabe of Tubeectjlous Meningitis, Showing Mabked Emaciation. head with cranial nerye palsies, with increase in temperature, cardiac and respiratory abnormalities. In the infant, generally iDefore the fifth year, with the typical symptoms of meningitis with special involyement of the cranial nerves, and, if the patient lives, the symptoms of internal hydro- cephalus. Lumbar puncture will nearly always demonstrate the tubercle bacillus, although sometimes cultures may be sterile. The fluid will always Fig. 419. — Different View of Case of Tubehcttloub Meningitis in a Child Ten Years of Age. be increased and turbid and the lymphocytes, especially of the mononuclear variety, are increased in number. The atropin test, which is applicable to both meningeal and certain cerebral conditions, may be found of value: Inject subcutaneously 2 mgms. of atropin, noting first the frequency of the radial pulse or of the heart- beats. In event of meningitis being present, the number of heart-beats per minute is appreciably and often decidedly increased. The accelera- tion of the pulse is observed witliin twenty minutes after administration of the atropin, and continues becoming most marked at the expiration of one hour. INFLAMMATION OF THE PIA-ARACHNOID. 1127 SEROUS MENINGITIS-MENINGISM. This is a form of meningitis only recently described in which there is an effusion into the meninges, but in which there is no exudation such as occurs in the purulent variety. Under the term meningism, meningismus, or pseudomeningitis has been described that clinical variety in which the symptoms of meningitis are present, but in which pathologically and by lumbar puncture nothing is found perhaps beyond a congestion and edema of the vessels. It is probable that it is nothing more than the primary stage of a serous meningitis. If the disease goes further, into the second stage or stage of effusion, there will be what is commonly termed serous meningitis. Meningeal processes, whether of an irritative or of an effusive nature, can be likened to similar pathologic conditions occurring in the internal organs, as in the various stages of a pleurisy or pericarditis. Pathologically, in meningism there will be found a congestion of the blood-vessels with either little or no edema, and rarely the bacillus of the disease may be found in the meninges. In serous meningitis a similar con- dition is present, with the addition that there will be a serous effusion with an increase of the lymphocytic elements, and only rarely will a specific organism be found. S37inptotns. — ^Meningism. — ^This may occur in the course of or follow any infectious disease, such as pneumonia, typhoid, rheumatism, scarlet fever, measles, or grippe. It is not difficult to recognize, for there will be present those symptoms which are commonly termed meningeal, such as pain along the back or limbs, which may be of a numb character, or may be described as sharp and shooting, but the principal complaint is headache, especially in the back of the head. Besides there will be rigidity of the head and back, and unwillingness to move the limbs because of fear of increasing the pain. Sometimes there will also be hyperesthetic areas in different parts of the body. There may rarely be muscular twitchings in the limbs and a general increase of the reflexes. Lumbar puncture is negative. The onset is generally acute. The temperature may or may not be increased, and the pulse and respiration are not much altered. The duration of the disease is usually short, and the prognosis always favorable. Sometimes, however, there may be a complicating serous effusion. Serous Meningitis. — ^TMs may involve either the brain or spinal cord alone, or both. There wiU be, in addition to the symptoms enumerated above, which may occur first, pressure symptoms resulting from the presence of fluid, their intensity depending upon the degree of the pressure. When the spinal cord is principally involved, there will be, in addition to the meningeal symptoms, pains in the limbs, girdle sense around the waist, and, because of pressure upon the anterior and posterior roots, and later on the spinal cord, disturbance of sensation, increased reflexes which are later lost, and bladder and rectal phenomena. Lumbar puncture will always demon- strate an increase in the intraspinal pressure and there will be considerable exudation of fluid. In most cases the disease only lasts a few weeks, the patient getting well. In the cerebrospinal forms, besides the symptoms enumerated, there will be, in addition, some disturbance of consciousness and greater rigidity of the head and neck and of the limbs, and sometimes a swelling of the optic nerve- heads. More rarely there may be temporary diplopia and disturbances in the temperature, pulse, and respiration. Lumbar puncture will, of course, demonstrate increased intraspinal pressure with increase of fluid. In most instances the symptoms will subside in a few weeks, the patient getting well. 1128 DISEASES OF THE NERVOUS SYSTEM. If, however, they persist, there will develop a serous effusion in the cerebral ventricles, with its accompanying symptoms of intracranial pressure. Circumscribed serous meningitis may ocdu" in the spinal cord, and gen- erally involves the lower portions, although it may be found in almost any part. It has already been discussed. Cerebral Serous Meningitis. — A serous effusion into the ventricles may be the beginning of a general serous meningitis, or may be confined only to them. The same causes which are active in the production of a serous men- ingitis may produce an internal hydrocephalus. Pathologically there will always be found an internal and sometimes also an external hydrocephalus, or an increase of fluid in the cortical meninges. Histologically there may be cloudy swelling and proliferation of the epen- dyma, accumulation of cells under the ependyma, and cellular infiltration in the brain and spinal cord substance, and in its meninges, especially along the blood-vessels. The choroid plexus is nearly always diseased, as its over-action is supposed to be the cause of increase in fluid. Circumscribed serous meningitis may occur in the pia-arachnoid of the cortex. Its symptoms will in no way differ from those of tumor of that part. Internal hydrocephalus resulting from serous effusion, as a rule, comes on in early childhood, and is not diflB.cult to recognize if the process is active. Very often, however, there may be only mild symptoms such as have been described under meningism, only to have later in life either an acute or a chronic serous meningitis or internal hydrocephalus. In fact, many writers consider that serous meningitis or serous effusion in the ventri- cles in the adult is only an acute exacerbation of an old process which had its origin in childhood. However that may be, there is no question that in the adult a serous effusion may develop either acutely or gradually in the ven- tricles and cause symptoms which are usually recognized as occurring in brain tumor, and from which it is sometimes almost impossible to make a differential diagnosis. If internal hydrocephalus develops acutely, there will be, as a rule, an accompanying high fever, and the course of the disease will be rapid, it resulting either in cure or death. Headache, nausea, vomiting, vertigo, and disturbance in vision and choked disc, sometimes of high caliber, are prominent symptoms. Besides there may be paralysis of some of the cranial nerves, especially of the sixth, either on one or both sides, and there may also develop cerebellar ataxia. Consciousness is nearly always clouded. The disease may last a week or two, terminating in quick recovery, leaving be- hind slight atrophy of the optic nerves, but no other symptoms. Sometimes there may be a recurrence of the disease, this terminating also either in recovery or death. The diagnosis from a brain tumor can usually be made by the rapid onset, the high fever, and the quick recovery or termination in death. If, however, the symptoms of internal hydrocephalus come on gradually, the differential diagnosis from brain tumor will be very difficult. There will be present all the pressure symptoms, such as headache, nausea, vomit- ing, vertigo, and choked disc, and because of the pressure exerted upon the motor fibers in the internal capsule, there will result weakness and spasticity of the Umbs, with increased reflexes and sometimes the Babinski reflex. There may also be paralysis of the external rectus, either on one or both sides. Because of pressure on the cerebellum there will result incoordination in walking and sometimes incoordination of the eyeballs or nystagmus. The differential diagnosis from cerebellar lesions is sometimes very difficult, but can be made principally upon the fact that in cerebellar tumors there is MUSCULAR DYSTROPHY. 1129 hardly ever involvement of the limbs on both sides and the ataxia is more acute and much more marked. It must also be remembered that internal hydrocephalus may also ac- company tumors of either the cerebrum or the cereljellum, and in such case there will be, in addition to the symptoms resulting from the tumor, spastic paresis of the limbs with increased reflexes and the Babinski phenomenon. The prognosis in most cases of uncomplicated internal hydrocephalus is not very good, but sometimes complete recovery ensues, either as a result of operative interference, anti-specific treatment, or sometimes spontaneously, leaving behind nothing but a slight atrophy of the optic nerves. MUSCULAR DYSTROPHY. Definition. — A progressive hereditary and family disease, usually beginning in childhood, characterized by gradual weakness and atrophy of the muscles. Under the general term of muscular dystrophies have been de- scribed many clinical types, but while in the beginning there is a difference in the method and the seat of the involvement, the terminal stages are alike in all. Until very recently it has been thought that in the muscular dystrophies 1 ■ l^^l 1 ~ ^C_4 \~ i 3^ s ^g ^^^s ^^m^ Fig. 420. — Muscular Dystrophy, Last Stage, showing Contractures and Atrophy. the nerv^ous system itself is never diseased, and that the cause is entirely in the muscles. Recently, however, there has been found in a number of cases a chronic degeneration of some of the peripheral nerves and atrophy of some of the motor nerve-cells in the spinal cord. The usual findings in the muscles consist in a gradual atrophy of the fibers with an increase of their nuclei and of interstitial connective tissue. In the pseudo-hypertrophic type there is swelling of the muscle-fibers with a large accumulation of fat-cells. The hj-pertrophy and fatty infiltration is succeeded by gradual atrophy, and there may be found both an increa.se of fatty tissue and atrophy of the muscle- fibers. Symptoms Common to all Dystrophies. — It is probable that the disease is due to a maldevelopment of the muscular structures. Some- times a number of members of the same family may be affected, and it is usually hereditary. In all types the symptoms begin before the twentieth year, and mostly between the ages of five and puberty. There is usually a history of slow muscular development, the child taking a longer period than normal to learn to walk. The weakness and atrophy progress at the same time. There are never fibrillary tremors, the reflexes become gradually 1130 DISEASES OF THE NERVOUS SYSTEM. diminished, and in the last stages are absent, and there are no electric reactions of degeneration. Sensory and bladder and rectal symptoms are never present. In the terminal stages there can be no differentiation made between the various clinical types. Pseudo-hypertrophic Form. — In this type males are more frequently Fig. 421. — Manner of Arising in Psextdo-hypertrophic Muscitlar Dystrophy. diseased and the symptoms usually begin between the fifth and tenth year. It IS first noticed that the muscles, especiaUy of the calves, thighs, buttocks, and shoulders, are disproportionately large, but gradually there develops difficulty in running, the child tiring easily, especially in going up- and down- MUSCULAR DYSTROPHY. 1131 stairs; the gait becomes slow, with a tendency to lift the hips from side to side, and later characteristically waddling. At the same time the shoulders are retracted, the abdomen protruded because of the weakness of the gluteal, lumbar, and abdominal muscles, and there is present a deep spinal frontal curve. Gradually the weakness increases and the gait becomes progressively more difficult, and when the child is placed upon the ground there is usually a characteristic method of rising. The child first turns on his face, extending one and then the other leg, bracing his toe against a stationary object, sup- porting the weight of his body and legs by both hands. When the legs are firmly extended and braced, the hands are brought nearer and nearer to the legs until finally the hands are braced against the ankle, then the leg, knee, thigh, and then with a supreme effort the shoulders and body are finally elevated and held erect. The diagnosis can be usually made upon the char- acteristic waddling gait and climbing-up method of rising. The muscles are soft to the touch, and gradually this pseudo-hypertrophy is succeeded by atrophy, until finally walking is impossible. In the terminal stages the patient becomes chair- or bedridden, the atrophy becomes general and involves all parts of the limbs, trunk, and abdomen, and in the last stages the muscles of the face. The bones also take part in the general atrophy (Fig- 421). Infantile Form. — In this type the disease nearly always begins before the fiifth year. The muscles of the face, scapula, and humerus are prepon- derantly involved, and this form is often known as the f acio-scapulo-humeral. It may sometimes be in association with the pseudo-hypertrophic tjrpe, but, as a rule, the atrophy begins in the muscles of the face and shoulder girdle, and there is no preliminary hypertrophy. The atrophy of the face usually involves the oral and palpebral orbicularis muscles, and it becomes impossible to shut the mouth or close the eyes, and there is a peculiar drawn expression of the face, which is known as the myopathic facies. Articulation, whistling, and laughing are sometimes interfered with. The atrophy gradually ex- tends and involves the muscles of the neck, shoulders, and upper arm, and will finally involve the muscles of the shoulder, chest, abdomen, and then of the limbs. Juvenile Form. — In this type the disease appears nearly always after puberty, and begins with an atrophy and weakness of the muscles of the shoulder and upper arm. In the final stages the muscles of the chest, ab- domen, limbs, and face become similarly involved. Summary of Diagnosis. — A family or hereditary disease, beginning nearly always before the twentieth year, and especially before puberty. In the pseudo-hypertrophic form, a hypertrophy and weakness of the muscles of the thigh, shoulder, and buttock, with gradually increasing difficulty in walking, the gait becoming waddling, with protrusion of the abdomen, retraction of the shoulder, and a peculiar climbing method of rising from the ground. In the infantile form the muscles of the face and shoulder girdle are first involved, with inability to close the eyes and shut the mouth or move the shoulder and upper arm. In the juvenile form the disease begins after puberty, and first involves the muscles of the shoulder and upper arm. In all the types the atrophy gradually involves all the muscles, the patient becoming helpless. There are never fibrillary tremors, the reflexes become gradually diminished, electric reactions of degeneration are not obtained. There are no sensory or bladder and rectal symptoms. DiflEerential Diagnosis.— There should be no difficulty in diagnos- ticating the muscular dystrophies in their terminal stages. It is of no prac- 1132 DISEASES OF THE NERVOUS SYSTEM. tical importance to make a diagnosis of the different types, inasmuch as they all terminate alike. Clinical Course and Complications. — The course of the disease is progressive, and the patient may live for many years. Usually death results from intercurrent disease. Sometimes muscular dystrophy may complicate other spinal cord diseases, such as chronic degeneration of the cells of the anterior horn. PERONEAL OR DISTAL MUSCULAR ATROPHY. (Charcot-Marie-Tooth-Hoffman-Sachs Type.) Definition. — A progressive disease characterized bj^ gradual atrophy and weakness beginning in the distal portions of the lower and upper limbs, with tremors, loss of reflexes, and some sensory disturbances. Pathologically, besides the degeneration of the muscle-fibers, which consists in a gradual atrophy, increase of muscle nuclei and of interstitial tissue, there is some degeneration of the nerve-cells of the anterior horns and of the column of Goll, and more rarely a diffuse degeneration of the lateral columns and peripheral nerves. Contributing and Bxciting Factors. — The disease is heredi- tary, and occasionally occurs in fami- lies. It usually appears in young adults without any exciting cause. It is probalsly a manifestation of mal- development of the parts involved. Symptoms. — The onset is grad- ual, and liegins with atrophy and weakness of the small muscles of the foot and toes, it involving especially the distribution of the peroneal nerves, the tendons of the small toes becoming prominent. As the disease progresses there may develop de- formity of both feet, such as equino- varus, or the patient may become flat-footed. Gradually the muscles of the peroneal and anterior and poste- rior tibial groups atrophy, and then ttie muscles of the thigh, especially the vastus internus. Locomotion becomes difficult, and usually the patient in walking spreads his feet wide apart, and because of the foot-drop the toes are dragged on the ground, and the knees elevated more than they should be. Coincident with the distal atrophy of the lower limbs there may de- velop a similar atrophy in the small muscles of the hand, especially in the thenar and hypothenar eminences and the interossei, this gradually pro- gressing and involving the muscles of the forearm, especially the extensors, and then the muscles of the arm and shoulder. As a rule, the involvement of the upper limb follows the lower, but sometimes the atrophy in the upper limb appears first (Fig. 422). Fibrillary tremors are common in the involved limbs, the reflexes be- FiG. 422. — Primary Nettrotic Atrophy, show- ing Wasting and Contracture of the Lower Limbs. DISEASES OF THE PEKIPHEKAL NERVES. 1133 come gradually diminished and finally lost, and there may rarely be pain on pressure over the nerve-trunks. Disturbances of touch, pain, and tempera- ture are sometimes found in the limbs. The disease is slowly progressive, and may ultimately involve the muscles of the trunk, buttocks, and face, but usually the patient dies before this occurs. Summary of Diagnosis. — A family or hereditary disease occur- ring in young adults, atrophy and weakness beginning in the distal portions of the leg or arm, gradually increasing and extending upward, with fibrillary tremors, gradual loss of reflexes, and some disturbance of sensation. Differential Diagnosis. — It should not be difficult to diagnose this disease if the nature and progress of the atrophy and weakness are clear. Sometimes, however, it is necessary to diagnosticate from multiple neuritis and progressive spinal muscular atrophy. In the former there is always pain on pressure over the nerve-trunks, with considerable disturbance of sensation and a history either of alcoholism, lead, or some similar cause, and the prognosis is good, the patient usually getting well. From progressive spinal muscular atrophy the disease is sometimes difficult to differentiate, especially when the distal form of atrophy begins in the upper limb, for there is present in both tremors, atrophy, weakness, and gradual loss of reflexes, but in the distal type there will be found occasionally pain on pressure over the nerve-trunks with some sensory disturbance, and the progress of the disease is different, inasmuch as the lower limbs become diseased early, this first involving the distal portions. Diseases of the Peripheral Nerves. Every peripheral nerve-fiber consists of an axis-cylinder, of an enveloping substance called the myelin, and of a surrounding membrane — the neuro- lemma sheath. The nerve-fibers in the brain, spinal cord, and sympathetic system do not have this sheath, and some of those of the sympathetic system have no myeUn. The individual fibers are bound together by interstitial tissue called the endoneurium. Every nerve-trunk consists of a number of these bundles held together by interstitial tissue, the perineurium, the whole being surrounded by the epineurium. Pathology. — Inflammation of a peripheral nerve maybe limited to a part or the whole extent of a nerve, when it is called a simple neuritis, or may involve several or most of the peripheral nerve-trunks in the body— a multiple neuritis. Inflammations may be limited to the interstitial tissue — an interstitial neuritis, or to the myefin substance and the axis- cyUnders, when it is called a parenchymatous neuritis. The disease, of course, may affect both the interstitial tissue and the parenchymatous sub- stance. Inflammations are further divided into acute and chronic, depend- ing upon the onset. Most acute inflammations involve both the parenchy- matous and interstitial substance, while chronic inflammations will have a tendency to be interstitial in character, with a secondary degeneration of the parenchymatous tissue, and are commonly called degenerative. MicroscopicaUy, acute interstitial neuritis is characterized by swelling of the connective-tissue fibers and congestion of its vessels, with edema, round- cell infiltration, and swelUng and breaking up of the myelin substance and of the axis-cylinders. Most cases of acute interstitial neuritis subside. If the disease becomes chronic, the acute inflammatory symptoms disappear, the interstitial substance will increase, and the myelin substance and axis- cylinders atrophy slowly. In the parenchymatous form both the myelin 1134 DISEASES OF THE NERVOUS SYSTEM. substance and axis-cylinders swell and break up into nodules, and there is a congestion of the vessels, with some round-cell infiltration, and, unless re- generation occurs, the fibers will be replaced by scar tissue. Degeneration of the peripheral muscles in which the nerves end results. Besides, there is often found, especially in multiple neuritis, a degeneration of the nerve-cells in the anterior horns of the spinal cord, and sometimes even in the cranial nuclei. Functions. — The peripheral nerves have a threefold function: (1) Motor, transmitting impulses from the anterior roots of the spinal cord to certain muscles; so if a nerve is cut, there will be loss of motion in its dis- tribution; (2) they transmit sensation from the periphery as touch, pain, heat and cold, vibratory sensations, and what is known as muscle sense, this including the sense of pressure, localization, position, and movement; and, lastly (3), they conduct vasomotor and trophic fibers which concern nutri- tion of the hair, nails, skin, deeper structures, and joints, and control sweat secretions. A nerve may be either purely motor or sensory, but in most cases com- bines both functions. In a mixed nerve it is impossible to tell what fibers transmit motion, sensation, or vasomotor functions; but the recent work of Head, which has revolutionized our ideas of peripheral sensation, has dem- onstrated the important point that deep sensibility, such as is capable of answering to pressure, and even producing pain when this is excessive, is transmitted mostly in the deep muscular nerves, and is not destroyed by division of the sensory nerves to the skin. This deep sensibility is also con- cerned with movement of the muscles and the extent and direction of pas- sive movements of the joints. It is important to remember this, for these sensations are always preserved when only the peripheral nerves are cut. In Head's second division of sensation, or what he calls protopathic sensibility, there is capability of responding to painful cutaneous stimiili and to extremes of heat. His third classification, or epicritic sensibility, is concerned with the power of cutaneous localization, of the appreciation of light touch, and the discrimination of two points (compass test), and of the finer grades of tem- perature (particularly from 25° to 40° C, that is, those called cold or warm). " The above-mentioned sensibilities are often dissociated in an area affected by the disease or operative procedure. According to the completeness of the lesion, the kind of nerves affected, and the state of repair, all forms of sensibility (superficial and deep) may be absent or more or less partially present. Thus an area may present protopathic sensibiHty and not epicritic sensibility, or even the epicritic and not the protopathic form. Moreover, the nerves subserving these two f orriis of sensibility do not coincide in their areas of distribution. For, provided the peripheral nerves are divided into certain groups, it may be said that, as regards light touch, and other forms of epicritic sensation, very little overlapping occurs, whereas in the case of protopathic sensibility enormous overlapping is found, and it becomes evi- dent that while the unit of supply for epicritic sensibility, looked at broadly, lies in the peripheral nerves, the unit of protopathic supply hes in the poste- rior roots. " Further, the two systems regenerate with unequal facility; for, during the process of regeneration in a divided peripheral nerve in man, protopathic sensibility may begin to return in the subserved area in about seven weeks (average eighty-nine days), and be complete in twenty-nine weeks (average one hundred and seventy-eight days). At this stage of the more primitive DISEASES OR INJURIES OF THE SPINAL NERVES. 1135 form (protopathic sensibility) there is the power to appreciate in the affected parts pin-pricks, extremes of heat and cold (above 45° C. and below 20° C), but no power to appreciate or respond to light touches, small differences of temperature, and no accurate localization is possible; in fact, fine discriminat- ing power is absent. The return of protopathic sensibility brings a cessation of all those destructive nutritive changes that occur in parts where the skin is insensitive, such as ulcers, etc., which form as the consequence of burns or cuts, and do not heal so readily as on normal skin. Such trophic changes are confined to parts deprived of protopathic sensibility. With the return of the latter, ulcers and sores heal as readily as on the normal skin. Moreover, when a peripheral nerve to the hand is divided, it is noticeable that the palm begins to sweat at a time after union which coincides approximately with that of the return of protopathic sensibility. This sweating is innervated and controlled by the motor fibers of the sympathetic (the autonomic fibers of Langley and Anderson) that supply the skin. " As the regeneration proceeds the higher and more discriminating form, viz., epicritic sensibility, begins to return in about three hundred and twenty- one days after the lesion, and, though it varies somewhat, may be complete in about three hundred and sixty-four days. Its return brings a power to respond to light touches, to localize accurately the sites of application of stimuli, and to appreciate correctly small grades and differences of tempera- ture." It is only necessary further to add that after a peripheral nerve is cut or diseased, regeneration is possible provided the conditions are favorable, and there is no continuation of the pathologic process. After a nerve is cut there is degeneration or physiologic death of the parts peripheral to the cut, while only a small portion of the central stump degenerates. This is because the central part still has its trophic supply from the nerve-cell from which it originates, while in the peripheral part this is absent. Diseases or Injuries of the Spinal Nerves. There are thirty-one pairs of spinal nerves, corresponding to their re- spective spinal segments — eight cervical, twelve thoracic, five lumbar, five sacral, and one coccygeal. Because some of these nerves innervate the upper and lower Umbs, two principal plexuses have been formed, the brachial and lumbo-sacral. The individual distribution of the peripheral nerves, in so far as the skin areas are concerned, is shown in Figs. 423 and 424. Only the common inflammations or injuries of the peripheral nerves will be dis- cussed. The general pathology, regeneration of function, and peculiar sensory disturbance resulting from neuritis or injury have already been dis- cussed. Symptoms. — ^These will depend upon the extent and degree of the neuritis, and whether the nerve is motor, sensory, or mixed. Motor Symptoms. — If a nerve is totally diseased or severed, there will be paralysis in its distribution, and within a week or two electric reactions of degeneration, which become complete in three weeks. As regeneration ap- pears the reactions gradually improve, until finally normal responses are obtained. Atrophy appears about the same time as the reactions of degen- eration, and has about the same course. The reflexes are, of course, lost in the distribution of the nerve. Sensory Sjmiptoms. — The disturbances of sensation will, of course, de- pend upon the particular distribution of the nerve. Its extent and character 1136 DISEASES OF THE NERVOUS SYSTEM. have already been discussed on page 1134. It is important to remember that sensation returns before motion. Vasomotor Symptoms. — These inckide disturbances in nutrition of the sldn, hair, nails, and joints, and deeper structures, their degree depending upon the nerve involved and the extent of the paralysis. Duration. — An ordinary neuritis may last from four to six weeks, and then will gradually subside. If it involves a number of nerves, as a plexus. Aariculotcmporal 3 V. Great occipitAt Lacrimal 1 V. Temporomalflr 2 V. Small occipital C. P. Great auricular C. P. SopracIa*lcalar C. P. Acromial braocli Middle branch Circumflex B P. I D te rooa tohu me ra 1 Nerve of Wrliberg h. p. External ci of niusculospiral B. P. Exteraal sapheoous S. P. Anterior tibial S. P, Supra-orbital 1 V. Piiperflcial cerrical C. P. Qches of intercostal Hiobypogaatric L. P. I>oraa]i3 penis of piidic S. P. QioiDguiDdl L. f. toe rural L. P. Middle cntaoeoua L. f. iDternal cutaneous I_ P. Internal sapheoous L. P. Fla. 423. — Cutaneous Distbibutiox of Nerves (after Flower). the duration is longer. In most cases the prognosis is good, this deoendino' largely upon the extent of the paralysis, the removal of the cause and th^ effects of treatment. ' BRACHIAL NEURITIS. The Ijrachial plexus is composed of the fifth, sixth, seventh, and eio-hth cervical and first thoracic roots, and supplies motion and sensation to^the PI ■\ .. 'P"./" Diagram Sliowing Relations and Ijistrib Cervical and Brachial Nerves (Flower). BRACHIAL NEURITIS. 1137 upper limbs. A neuritis may involve all the branches of the plexus, or be limited to its upper part, this including the fifth and sixth cervical, or the lower, involving the seventh and eighth cervical and first thoracic roots, or their continuations. If in association with the brachial neuritis there is disease of the first four cervical nerves, it is called a cervico-brachial neuritis. Most cases of brachial neuritis appear in adults without any apparent cause, although it is probable that such general diseases as gout, rheumatism, Auriculotemporal 3 V, Small occipital C. P. Third cervical Great auricular C P. Poalerlor branches of spina! Lateral braocbes of intercostal lijic biancb of ilio-inguioal L. P. Sccood lumbar Inferior hecuorrholdal of pudic S. P. Superficial perineaJ of pudic iQfcrior piideadal of amall sciatic S. P, Interior gluteal of small sciatic S. P. lateraal cutaaeoaa L. P. Internal aapbenouB L. r. Poeterior tibial a P. External saphenous S. P. Fig, 424. — Cutaneous Distribution of Nerves (after Flower). and anemia are often the causal factors. Direct injuries to the shoulder or plexus, dislocations, caries of the vertebra, birth palsies, cervical rib, and aneurisms are frequent causes. Symptoms. — Whether the neuritis involves all or only part of the brachial plexus, the most important symptom is pain. This may appear gradually or acutely, and is usually sharp and shooting in character, it being aggravated by movement of the arm. If the whole plexus is diseased, the 72 1138 DISEASES OF THE NEEVOUS SYSTEM. pain involves all parts equally; if the upper cords, it will be limited to the neck, shoulder, and arm as far as the elbow; if the lower, to the arm, forearm, and hand. The nerve-trunks and muscles are tender and painful to pressure, and vasomotor and trophic disturbances are common. Associated with the neuritis there will always be some paralysis, with consequent atrophy of the muscles and loss of reflexes. The specific paralytic symptoms depend upon whether all or part of the plexus is diseased. In the upper form the paralysis will be limited to the deltoid, biceps, coracobrachiahs, and supinator muscles; if the lower, to the muscles of the forearm, and especially of the hand. In association with .the lower type of neuritis there may be certain pupillary phenomena, which will be discussed under the lower arm type of paralysis. The duration of the neuritis will depend largely upon its etiology. If due to causes which can be removed, the prognosis is excellent. If idiopathic or due to constitutional diseases, the neuritis is of long duration and difficult of cure. The diagnosis of brachial neuritis should not offer much difficulty. It is important to determine the etiology and remember that in the beginning of a rheumatoid arthritis the pains may be referred to the shoulder and upper arm. BRACHIAL PALSY. Paralysis of the brachial plexus may be total or partial, unilateral or bilateral. If total, the arms hang limply by the side, no movements being possible, the muscles soon atrophy, the reflexes become lost, and electric reactions of degeneration are early olatained. Partial brachial paralysis may be either of the upper plexus type, the so-called Duchenne-Erb form, in which the fifth or sixth cervical roots or their continuations in the plexus are involved; or the lower plexus or Klumpke's type, in which the eighth cer- vical and first thoracic roots or their continuations are diseased. Upper Arm type of Brachial Palsy; Birth or Obstetrical Palsy. — ^This form of paralysis is mostly traumatic in origin, and occurs most frequently at birth when abnormal traction is made upon the head or arm or pressure exerted upon the brachial plexus either by forceps or in breach presentation. Sometimes it may result from abnormal stretching of the arm in the course of etherization. The paralysis may be noticed im- • mediately after birth, and involves the deltoid, triceps, brachialis anticus, supinator longus and brevis, and infraspinatus muscles. It will be impossible to adduct the arm, and the forearm is extended and pronated. The muscles soon become atrophic, the reflexes are lost, and electric reactions of degenera- tion are obtained. Sensation, as a rule, is not destroyed. I/Ower Ann Type of Brachial Palsy.— This is sometimes called Klumpke paralysis, and involves the eighth cervical and first thoracic roots or their continuations. It is a very rare form, and usually results from injury. There will be paralysis of the small muscles of the hand and fore- arm, especially of the flexors, resulting in inability to move the fingers or hand. Atrophy and reactions of degeneration follow, as well as sensory disturbances, especially in the ulnar distribution. Involvement of the Sympathetic System.— Our knowledge of the sympathetic system is by no means exact. We know, however, that in the lower part of the cervical and upper part of the dorsal cord (in the eighth cervical and first thoracic segments) there is a so-called cilio- spinal center, and that the rami communicantes of the anterior roots of the PL/ Diau^raiii ^Sliowinf^ Kelations luid Di^tribi IV .'/:.-„/..,/,.,w ,./7r„.v ,/-7V,.„/- i: I'r^..' ,rn-7..,h >^^*- imhur and 8ucral Xervus (Flower) BKACHIAL PALSY. 1139 first dorsal segment contain tlie so-called oculopupillary or sympathetic fibers. The classic symptoms of irritation of the cervical sympathetic — ^by this being meant either the ciliospinal center in the spinal cord, the anterior root- fibers of the first dorsal segment, or the cervical sympathetic plexus — are en- largement of the pupil, widening of the palpebral fissure, a slight exophthal- mos, dekyed descentof the lid in looking downward, paleness of the face, and increase in the sweat secretion. Paralysis of the cervical sympathetic pro- duces a small pupil, narrowing of the palpebral angle, a slight enophthalmos, warmness or coldness of the face, and disturbance of sweat secretion. It is only rarely, however, that all of these symptoms are present, the most con- sistent being disturbance in the size of the pupil, and either protrusion or re- traction of the eyeball with alteration in the width of the palpebral fissure. It can be readily understood, then, that sympathetic symptoms occur from injuries either of the cervical portion of the spinal cord, the cervical sympathetic plexuses, or in brachial neuritis or palsy in which the rami com- municantes of the first dorsal root are involved. Therefore, in the lower arm tj^e of paralysis, in which the eighth cervical and the first dorsal roots are diseased, there are always oculopupillary symptoms. It is possible, however, to have this type of paralysis without sympathetic involvement, if the fibers coming from these roots in the brachial plexus, and not the roots themselves, are diseased. It is difficult, however, to make such a clinical differential diagnosis, because the symptoms are identical, but it can always be assumed that, if the oculopupillary symptoms are present, the first dorsal root is diseased. In the Duchenne-Erb or upper type of paralysis, due to a birth palsy, or the paralysis occurring in the course of etherization, the traction upon the arms may cause an abnormal stretching and tearing of the rami communi- cantes of the first dorsal root, this causing sympathetic paralysis without the first root itself being diseased. If all the roots of the brachial plexus are diseased, there may be oculo- pupillary symptoms. As a result of gunshot or stab wounds there may be forms of paralysis which do not conform to any of the regular types with sympathetic s3Tnptoms. In these cases either the first dorsal roots are involved, or the oculopupillary fibers in the cervical sympathetic are injured. Paralysis of the Circumflex Nerve; Deltoid Paralysis.— This usually results from dislocation or direct injury to the shoulder, and produces paralysis of the deltoid muscle, there being inability to raise the upper arm from a hanging position. When the anterior part of the muscle only is affected, it will be impossible to adduct the upper arm or place the hand to the opposing shoulder. When the posterior part is involved, the patient will be unable to put his hands in his pockets. Following the weak- ness there will be atrophy, reactions of degeneration, and triangular disturb- ances of sensation. Paralysis of the l,ong or Posterior Thoracic; Serratus Magnus Paralysis. — ^This results sometimes from lifting heavy weights or injuries or dislocation of the shoulder, and causes paralysis of the ser- ratus magnus muscle. The edge of the scapula, to which the serratus is attached, will be winged or prominent, and there will be inability to lift the arm more than to a horizontal position. Disturbances of sensation are sometimes present. Paralysis of the Musculocutaneous Nerves; Biceps and Brachialis Anticus Paralysis. — Isolated paralysis of this nerve is 1140 DISEASES OF THE NERVOUS SYSTEM. rare. The forearm when in supination cannot be flexed, and the supinator action of tlie biceps, whicli is exerted wlien tlie biceps is contracted, is also absent. Musculospiral Palsy. — This nerve is very frequently injured or diseased because of its exposed position around the humerus. Paralysis generally comes on after a debauch, the jjatient while intoxicated lying on his arm, this causing pressure. It is sometimes called Saturday night palsy. The musculospiral ner^-e supplies the triceps, anconeus, supinator longus, the extensor carpi radialis longior, and all of the extensor muscles of the hand. There is wrist-drop with inability to extend the fingers or the hand upon the wrist, and because of the paralysis of the extensor nuiscles flexion of the fingers will be imperfect. There will also lie inaliility to pronate the forearm, and sometimes failure to extend the forearm on the arm. Sensory disturbances are not the rule, but they are sometimes found, especially over the radial side of the forearm and hand. Musculospiral palsy often occurs as a result of lead-poisoning, the supinator longus always escaping. Fig. 425. — Showixg Arcas of Sexsory Loss in' Ixjurics of the JIedian Nerve (Bowlby"). Median Nerve Palsy. — iledian nerve paralysis is generally due to injur}'. It supplies all the flexors of the fingers, the flexor carpi radialis, and the pronator radii teres. The disturbances in motion \\-ill consist in inability to pronate the forearm, to flex the hand to the radial side, the fingers cannot he flexed, and adduction of the thumfi is lost. Sensory disturbances are uncommon, but when present are limited to the radial side, as shown in Fig. 425. Ulnar Palsy. — This is usually produced liy direct injury to the nerve. It supplies the flexor carpi ulnaris, the ulnar half of the flexor profundus digitorum, and the muscles of the hypothenar eminence, the interossei, the inner three lumbricales, the adductor transverse pollicis, and the flexor brevis pollicis. In ulnar paralysis there is disturbance of flexion of the hand and of the last three fingers, and inal)ility to flex the proximal and extend the terminal phalanges of the fingers. This is esiiecially marked in the last two fingers, and there is also some weakness in adduction of the thumb, this dis- DISEASES OF THE LUMBAR AND SACRAL PLEXUSES. 1141 turbance causing the so-called -'claw hand," it being more marked late, when there is atrophy in the involved muscles. Sensory distui'bances are not frequent, and when present are limited to the flexor and extensor sur- faces of the last two or three fingers (Fig. 426). Paralysis of the Diaphragm. — Isolated paralysis is very rare. It is supplied by the phrenic nerve, which is derived from the third, fourth, and fifth cervical segments, and usually results from lesions of the vertebra or direct injury. Unilateral lesions of the phrenic nerve may not cause paralysis, Ijut a total paralysis of the diaphragm can be detected by the in- action of the upper part of the al^domen during respiration. DISEASES OF THE LUMBAR AND SACRAL PLEXUSES. Isolated paralyses of the nerves of the lower limits are rare, and are usually the result of traumatism. In such paralyses it is always necessary to ex- clude muscular dystrophies, anterior poliomyelitis, multiple neuritis, pelvic Fig. 426. — Showing Sen.sory Loss ,\>rD Ordix,\ry Position in Injuries of the Ulnar Nerve iBowlbv). tumors and abscesses, and also lesions of the lowest portion of the spinal cord or of the cauda equina. Paralysis of the anterior crural nerve occurs mostly after injuries. It innervates the iliopsoas and the extensor quadriceps. There will be inaljility to flex the thigh on the trunk, and if the thigh is raised passively, the leg cannot be extended. The patellar jerk will be absent, walking and standing on the leg will become almost impossible, and raising of the trunk on the thigh from a recumbent position will be impaired. Disturbances of sensation are uncommon, but are sometimes found in the inner part of the thigh and leg. Paralysis of the obturator nerve sometimes occurs, and in- terferes with adduction of the thigh, it being impossible to cross one leg over the other. Rotation of the thigh outward is also interfered with. Isolated paraljjses of the gluteal nerves are uncommon, and usually occur in conjunction with muscular dystrophies. The.se nerves .supply the gluteal 1142 DISEASES OF THE NERVOUS SYSTEM. muscles, and paralysis of them causes an inability to extend the thigh on the pelvis, interfering with going up-stairs or with rising from a sitting posture. Sciatic Paralysis. — ^This may come on at the end of a sciatic neu- ritis or sciatica, or may result from tumors of the pelvis, causing pressure on the nerve, or from direct injuries. The sciatic nerve supplies the muscles of the back of the thigh, a lesion of this part causing inability to flex the leg backward on the thigh, due to paralysis of the semimembranosus and semi- tendinosus. Walking, however, will be possible because of the action of the quadriceps. Besides, the sciatic nerve supplies the muscles of the leg below the knee, it dividing into the external and internal popliteal nerves. Paralysis of the external popliteal nerve is common be- cause of its exposed position, it winding around the head of the fibula, where it is liable to direct injury. It divides into the peroneal and anterior tibial branches, which supply the extensors of the toes, paralysis causing foot-drop and inability to abduct the foot. When walking, the patient will lift his knees high from the ground, causing the so-called steppage gait. Disturbance of sensation sometimes occurs in the outer border of the leg and foot. Paralysis of the internal popliteal nerve is uncommon. It supplies the muscles of the back of the leg, and there will be inability to flex or stand on the toes, the plantar reflex will be absent, as will also the Achilles jerk. Meralgia Paresthetica. — By this is understood a paresthesia, which is described as a crawling or tingling feeling, usually in the distribution of the external cutaneous nerve of one thigh or of the anterior crural. As a rule, there is no accompanying tenderness to pressure, but there may be some disturbance of sensation. It is usually the result of pressure upon the involved nerves by either a corset or a truss. TUMORS OF THE NERVES. These are of rare occurrence and are generally fibromata, but they may be sarcoma, angioma, or any of the other usual forms. The tumor may develop within or upon a nerve-sheath. The amputation neuroma is the best example of a true nerve tumor, and it is possible that pure neuromata do not exist. Fibroma may grow upon one nerve, or may rarely involve all the nerves of the body, even the cranial. This is called Recklinghausen's disease. The symptoms will, of course, depend upon the particular nerve involved, and will be those of a neuritis. Besides, there will be present the physical evidences of the growth. MULTIPLE NEURITIS. Definition. — ^An inflammation of many peripheral nerves. The pathology of neuritis has already been discussed. It must be under- stood that there are various grades of the disease, and that in the mild forms the pathologic changes are not marked. If the disease is severe, especially iri the alcoholic form, there are, in addition, alterations in the cells of the anterior horns and medulla and pons. The changes in the nerve-cells consist of a displacement of the nucleus to the periphery and an alteration in the chromatin substance. Diffuse and degenerate inflammations with hemorrhages, especially in the region of the gray matter of the third ventricle MULTIPLE NEURITIS. 1143 and the aqueduct of Sylvius, are sometimes found. Degeneration is often found in the anterior and posterior roots, the cranial nerves, and the an- terior and posterior horns. Predisposing and Bxciting Factors.— Multiple neuritis is pro- duced by a variety of causes, chronic alcoholism being the most common. Toxic disturbances, such as are produced by the various infectious diseases and the different metallic poisons, chronic diseases, as tuberculosis, malaria, beriberi, leprosy, and senility, may produce polyneuritis. It may come on without any apparent cause, or follow a cold, probably being in these in- stances, infectious in origin. Symptoms. — Certain general symptoms are common to all forms of multiple neuritis, and these may be divided into sensory, motor, vasomotor, and trophic, their severity depending upon the extent of the pathologic process. Sensory Symptoms. — ^These nearly always come on first, the patient complaining of a sense of numbness, pin- and needle-like sensation, or a crawling or dead feeling in the lower or the upper limbs. These increase imtil finally the pains become sharp and shooting, accompanied by an in- creasing tenderness of the muscles and nerves, with pain on pressure, some- times becoming so acute that the slightest irritation or jar of the body will cause excruciating pain, and it is necessary to protect the patient from the surrounding bedclothes. Ordinarily these acute hyperesthetic symptoms last for a number of weeks, and then gradually subside, leaving for some time considerable tenderness to pressure over the nerve-trunks and muscles. Disturbances of sensation are common, but can only be demonstrated after the h3fperesthetic stage, when it will be found that the areas of anesthesia involve part or all of a limb, their extent being often stocking- or glove-like. As the disease subsides the sensory symptoms become less and less, and finally disappear, although in the chronic forms of neuritis pain on pres- sure over the nerve-trunks with some sensory disturbances can always be found. Motor Symptoms. — ^The weakness may come on slowly, the patient ex- periencing a gradual diminution of power in the lower or upper limbs, or, what is not at all infrequent, there is sudden inability to walk or to use the upper limbs. The motor symptoms usually come on coincidentally with the sensory or may precede them. The paralysis nearly always affects predominantly certain nerves — in the upper limb the musculospiral, and to a less extent the ulnar and radial ; and in the lower, the peroneal and anterior tibial, this causing wrist- and foot-drop respectively. The muscles are flaccid and both the skin and tendon reflexes are rapidly lost. In the acute stage it is inadvisable to take the electric reactions, but as soon as it subsides reactions of degeneration can easily be demonstrated. Atrophy of the mus- cles comes on rapidly, and contractures may develop. The gait is typically steppage, the patient lifting his knees high from the ground because of the foot-drop, the toes coming down first. Vasomotor and trophic functions are very commonly affected, the skin becoming dry and glossy, the hair may drop out, the nails become shiny and brittle, and in the chronic stages the limbs are cold. Bladder and rectal disturbances hardly ever occur. In the so-called idiopathic or toxic form, which appears without any apparent cause, there may be a rise of temperature with febrile symptoms and a general feeling of malaise. The prognosis and duration in most cases of multiple neuritis depend 1144 DISEASES OF THE NERVOUS SYSTEM. largely upon their etiology. Most idiopathic and infectious forms get well, the duration of the disease being from one to three months. ALCOHOLIC MULTIPLE NEURITIS. The symptoms ma}' come on during an alcoholic debauch, but in most cases they appear after prolonged alcoholism. Women are especially prone. The symptoms are similar to those described above, antl consist in a rapid sensory and motor involvement with acute pains, wrist- and toe-drop. .*L ■ Fig. 427. — Bilateral Wrist-drop in Acute Alcoholic Multiple Neuritis. and loss of reflexes. Disturl^ances in the cranial nerves are not at all un- common, for we have in alcoholic neuritis not only involvement of the peripheral, but a general toxic change in the whole nervous system. Dis- turljances in sight sometimes occur and there may be a central scotoma. Fig. 428. — Bilateral Toe-brop in Acute Alcoholic Multiple Ne especially for colors. Differences in the size of the pupils and slowness in their reactions sometimes occur. Of the cranial nerves, the external rectus ancl the facial are most commonly paralyzed, and there may sometimes also be involvement of the oculomotor and trigeminus. The cranial palsies nearly always occur in the height of the cU.sease, and as a rule only last for a short time, and are always indicative of serious degenerative changes in their respective nuclei. MULTIPLE NEURITIS. 1145 Sometimes mental symptoms occur, these coming on at the height of the disease, and consist of loss or confusion of memory, especially for recent events, and, in addition, peculiar illusions and hallucinations. This is sometimes called Korsakoff's psychosis. The course of the disease is rapid, and within a week or ten days the symptoms are at their height, where they may remain for two or three weeks and then gradually subside, leaving the patient with pain and tenderness over the nerve-trunks and muscles, and wrist- and toe-drop. The sensory symptoms are the first to leave, the palsies remaining. In most uncom- plicated cases, that is, in which there is no involvement of the cranial nerves, the prognosis is good. PSEUDO-TABES OR ATAXIC MULTIPLE NEURITIS. In addition to the symptoms described above, there may develop ataxia of the upper and lower limbs, which may persist even after the acute symp- toms have subsided, and it is somewhat difficult to differentiate the disease from locomotor ataxia. We have, however, in the latter, pupillary ir- regularities, the Argyll-Robertson pupil, girdle sense, bladder and rectal phenomena, and, most important of all, in multiple neuritis atrophy and weakness are prominent and the symptoms have a tendency to become less, the prognosis in most cases being excellent. LEAD MULTIPLE NEURITIS. It is well known that lead acts upon the central nervous system, but accurate knowledge of its pathology is lacking. There is no doubt that in lead intoxications the peripheral nerves may be preponderantly diseased and the symptoms of multiple neuritis demonstrated, but it is probable that a careful microscopic examination will show- alterations throughout the brain and cord. Workers in lead, type-setters, and others who come in contact with this metal may suffer, although it is possible for nervous symp- toms to develop only after mild exposure. Symptoms. — ^These are usually preceded by lead colic. The poison seems to have a peculiar affinity for the posterior interosseus, causing paralysis of the extensors of the hand and fingers, while the supinator longus and triceps muscles are usually spared. The nerves of the lower extremity are not, as a rule, involved, but if they are, the peroneal nerve is usually diseased, the tibialis anticus nearly always escaping. Sensation is not often disturbed. Ataxia hardly ever occurs. The muscles are atrophic and re- actions of degeneration are soon obtained, A blue line on the gums is an aid to the diagnosis. The duration of the disease is long and the symptoms are of slow onset. The prognosis in uncomplicated cases is fairly good, provided the patient does not return to the cause of the intoxication. Lead Encephalopathy. — Sometimes in the course of lead intoxications, accompanying the symptoms of multiple neuritis or without them, there may occur grave cerebral symptoms, such as delirium, coma, convulsions, epi- leptic seizures, hemorrhages, and transient hemiplegia. There may also be paralysis of the cranial nerves, especially of the third, fourth, and sixth, either alone or in combination. Optic neuritis or atrophy may occur as well as involvement of the vocal cords and the laryngeal muscles. Pathologically in these cases there are found diffuse areas of inflammation in different portions of the brain and spinal cord. The prognosis is almost always grave. 1146 DISEASES OP THE NERVOUS SYSTEM. ARSENICAL NEURITIS. Arsenic is a frequent cause of polyneuritis, and this fact should be re- membered when, as is often the case, arsenic is given in increasing drop doses. The symptoms are similar to those described under the general form. They come on, as a rule, very slowly, and are mild, hardly ever pro- ceeding past the inflammatory stage with tenderness, pains, and wrist- and toe-drop. There are, in addition, the gastro-intestinal symptoms of the poison. The prognosis is good, especially if the cause is early recognized. POLYNEURITIS DUE TO OTHER METALLIC POISONS. Mercury, copper, phosphorus, and carbon disulphid and monoxid or illu- minating gas have also been known to produce multiple neuritis, but these instances are rare. The form of polyneuritis due to carbon disulphid is extremely uncommon, and little is known of its pathology, as observations are lacking. Workers in vulcanized rubber are especially prone to this disease. Mental excitation or depression with hysterical manifestations precede the neuritic phenomena, which are, as a rule, of the ataxic form, and resemble greatly the alcoholic form of neuritis. Hysterical symptoms are so common that some authors, as Marie, insist that the hysterical manifestations are among the most prom- inent symptoms. Ocular phenomena are common, and consist, as a rule, of alterations in the visual fields, especially for colors. Amblyopia is fairly constant. Scotoma, either large or small, is found in some cases. Pupil- lary rigidity and even nystagmus have been recorded. It is probable that there is here not a pure multiple neuritis, but a toxic process which so influences the central nervous system as to produce the various mental, ocular, and neuritic symptoms. It must be acknowledged that most of the various manifestations shown in this disease are hysterical in nature; but why should a previously healthy individual who is poisoned by carbon disulphid be hysterical only so long as the influence of the poison lasts? The action of toxins, whether generated within or without the body, upon the brain and spinal cord is becoming better recognized. It is more than probable that their influence is not selective but general, and that we have alterations not only in the peripheral nerves, but also in the central nervous system. Such is the case, for instance, in lead or alcoholic poisons and in uremia. DIPHTHERITIC PARALYSIS. Approximately about one-quarter of the total number of cases of diph- theria are followed by paralysis. It is more liable to follow a severe attack, although paralysis has been known to follow a simple sore throat or diph- theritic inflammation elsewhere in the body. The older the person, the greater the tendency. As a rule, the paralysis does not appear until the diphtheria has entirely disappeared, in the third or fourth week and sometimes later, although in rare cases it may occur in its height. The symptoms of the polyneuritis are generally mild, and consist only in some pain on pressure over the nerve- trunks, rarely sensory disturbances, and the paralytic symptoms, as a rule, are not very marked. Paralysis of the palate is the most frequent and early symptom. It NEURALGIA.. 1147 can be recognized by the nasal voice and difficulty in eating, regurgitation of food through the nose being common. Coincident with this or soon after, paralysis of the cihary muscles appears, with consequent loss of accommo- dation and impairment of vision for near objects. The palatal and ciliary symptoms, as a rule, do not last more than a few weeks, and then gradually disappear. Occasionally there is temporary impairment of some of the ocular nerves, and more rarely there may be interference with the functions of the vagi, hypoglossus, and facial nerves. BERIBERI OR KAKKE NEURITIS, This chsease is rare in this country, although it is prevalent in the sea- coast cities of our southern States. It is quite common in tropical countries. The etiology of beriberi is still in doubt, but it is probably caused by soil infection, and not by a rice diet, although ^ '" \ ■ this may be a contributory cause. There are three princi- pal forms — the trophic, drop- sical, and mixed, these prolD- ably being different stages of the disease. Besides the or- dinary symptoms of multiple neuritis, there is great disa- bility. Ataxia is almost always present. Dropsical ef- fusions in nearly all of the se- rous cavities may be present. MULTIPLE NEURITIS DUE TO OTHER CAUSES. Infectious diseases such as erysipelas, typhoid fever, pneumonia, measles, scarlet fever, gonorrhea, influenza, rheumatism, malaria, and more rarely leprosy, tubercu- losis, syphilis, carcinomatous ^__ and diabetic toxins, may pro- ^^^^ 429.-B™iBEni (Herzog, in -Philippine Journal duce multiple neuritis, but m of Science") most of these instances the neuritic symptoms are very mild and slow in onset. Sometimes in old age there is a form of senile polyneuritis which is characterized by a slow onset, absence of sensory disturbances and of any apparent cause. As a rule, there are severe arterial changes, and the neuritis is probably due to the les- sened blood-supply. NEURALGIA. Definition. — A sensory disturbance characterized by pain of a sharp, shooting character, coming on spasmodically and always in the same dis- tribution. Symptomatically it differs from a neuritis in the fact that there 1148 DISEASES OF THE NEEVOUS SYSTEM. are present only sensory symptoms, the pain is not continuous, and there is no pain on pressure over the nerve-trunks between the attacks. Pathologically, degenerations have been found in the peripheral nerves, sometimes changes in the sensory gangUa of the posterior roots, and, as in trigeminal neuralgia, in the Gasserian gangUa. Again, no changes have been found at all. Neuralgia is really a symptom of sensory irritation, and in some cases, as in sciatica, it is difficult to differentiate between it and a true neuritis, but because of the characteristics of the pain this term is gen- erally applied to the functional condition. ' Predisposing and Bxciting Factors. — Neuralgia may appear without any apparent cause, when it is called idiopathic. It may be due to such general constitutional diseases as malaria, rheumatism, gout, anemia, to local irritations of a nerve resulting from pressure, as from a growth, or it may follow grippe and various metallic intoxications. It occurs mostly in adults and rarely in old age. Symptoms. — Neuralgia, no matter of what part, nearly always comes on slowly, and there may be at first only mild feeUngs of paresthesia, to be soon followed by pains, which become more intense, until finally they are typically sharp and shooting and come on spasmodically. They may last from a moment to a few seconds or longer. Between the attacks there may be a sensation of fullness or a dull ache. It is characteristic of neuralgia that the pains come on intermittently, and that they are nearly always in the same distribution, although in the very beginning they may only involve a part of a nerve, as in tic douloureux. Attacks of pain are brought about without any apparent cause. During the attack the sMn distribution is hypersensitive, and the exit points of the nerve are painful to pressure. Sometimes they are also painful during the intermission. Disturbances of sensation are not common. There are, as a rule, no accompanying motor phenomena except those which are superimposed by the pain and are of reflex character. Disturbances of vasomotor and trophic functions are common, and there may be disturbances of sweat secretion, dropping out of the hair and sometimes even a change of color, the hair becoming grayish after an attack. The skin may also become glossy, and ulcers rarely form, especially in trigeminal neuralgia, in which when the ophthalmic division is diseased, a trophic corneal ulcer sometimes occurs. Herpetic eruptions are common, especially in the intercostal form, and are usually in the distribution of the involved nerve. The course of the disease is frequently chronic, and unless it is promptly treated and the causes eliminated, may last for years. The special forms of neuralgia will now be discussed. Occipital Neuralgia. — In this type the upper or the first four nerves of the cervical plexus are involved, and the pain is distributed to th-e back of the head and neck as far as the occiput, and at times as far as the parietal region. The pains are usually bilateral, and the points of tender- ness are generally in the base of the occipital bones posterior to the mastoid process. Besides the usual causes, caries or tumor of the vertebra should be considered. It sometimes occurs in association with disease of the fifth nerve and torticollis. Brachial Neuralgia. — This usually appears in men without any apparent cause, and the pain may involve the whole brachial plexus, or be limited to any one of its subdivisions, especially the ulnar and radial. NEURALGIA. 1149 Sometimes in association tliere may be pain on the side of tiie neck. Because of tlie pains tlie arm is not used, and there may develop some atrophy. Intercostal Neuralgia.— This usually involves the thoracic nerves between the fifth antl ninth inclusive. Both sides may be attacked, but the disease is usually unilateral. The pains are very severe, antl are so sharp and ag-onizing that the patient fixes his trunk, will not move, and cough- ing, sneezing, and even respiratory movements will be inhibited. HeriK^fic eruptions are especially conunon in this form (herpes zoster), and may come on with the pains or independently of them. Besides the usual causes, disease of the vertebra ]ires.sing upon the posterior ganglia or roots should always be sus- pected. Sciatica. — This form more nearly ap- proaches neuritis than the of lier types of neu- ralgia. The onset is usually slo^'^•, and consists of numliness or pains in the back of the thigh and calf, which gradually increase until finally there are present typical sharp, shooting pains which start in the l.nittock antl gluteal region and extend along the liack of the thigh to the hollow of the knee, and then to the outer part of the leg and foot or to the l.iack part of the calf and leg to the ankle. Besides the exacerba- tions, pain of a constant, dull aching character is nearly always preselit, and is increased by movement of the leg. There is also pain on pressure over the whole nerve-trunk, along the back of the thigh, calf, and especially over the sciatic notch. If the leg is extended on the thigh and the thigh flexed on the abdomen, caus- ing stretching of the sciatic nerve, there will be pain over the sciatic notch. Disturbances of sensation are rarely present, but falling out of the hair and a glossy condition of the skin are common. The knee jerks are not altered, but the .\chilles jerk is nearly always either dim- inished or lost. Sometimes because of the ef- fort of the patient to save his leg there results a characteristic deviation of the trunk to the other side, with a lumbolateral scoliosis. The course of the disease is nearly always pro- longed, and if improvement is not olitained wthin a few weeks, it has a tendency to become chronic. Paralysis of movement does not oc- cur, but there may result, especially late in the di.sease, some atrophy of the muscles of the back of the thigh and leg. Bilateral sciatica is nearly always indicative of a tumor in the pelvis (Fig. -tSO). Unusual Forms of Neuralgia. — Mastodi/nia. neuralgia of the mam- mary gland, nearly alwavs occurs in adult women, and is a form of intercos- tal neuralgia limited to the breasts, which are generallv sensitive to touch. Fia- 430. — .A-reaofTendernkss ANO Pain in Sciatica and Typical Position of Low- er Llmb. 1150 DISEASES OF THE NERVOUS SYSTEM. Neuralgia in the region of the lumbar and sacral plexuses occurs, this causing typical pjains in the buttocks, genital organs, rectal region, and a peculiar form which is called coccygodynia, which occurs in women, and in which the pain is localized to the coccygeal region, it being increased by walking, sitting, or defecation. Sometimes the neuralgia is limited to the insertion of the Achilles tendon, achillodynia, to the heel, tarsalgia, or to the metatarsal hones. Vasomotor and Trophic Diseases. Our knowledge of the vasomotor system is vague. There are supposed to be vasoconstrictor and vasodilator fibers, which no doubt are transmitted by the peripheral and sympathetic nerves to the spinal cord, and then to the brain, this presumption being based upon the fact that lesions in any of these parts cause what are called vasomotor and trophic phenomena. Again, there are diseases which have purely so-called vasomotor or trophic symptoms, or both. These have been described by many authors, and have been given various names, being called after either their leading symptoms or the men who described them, and because of this, confusion exists as to their classi- fication. As a matter of fact, nearly all of these diseases have a common basis, their symptomatology depending upon the method of onset and pre- ponderance of certain symptoms. By vasomotor phenomena are understood an increase, decrease, or loss of the blood-supply, this causing either redness, paleness, or gangrene, and disturbance in glandular secretions, which may be increased, decreased, or perverted. Associated with the above there may be disturbance of sensa- tion, this consisting in either irritative or destructiV^e phenomena, such as paresthesia, described as crawling, pin-and-needle, numb, or a dead feeling, or of severe pain and a loss of sensation which may be partial or total. Under trophic disturbances are understood alterations in the nutrition, structure, or growth of the hair, nails, skin, and the underlying soft and deeper tissues and bones. In this classification of vasomotor and trophic diseases it must, of course, be understood that the phenomena described under these headings may appear alone or in combination, and that the symptoms of one or both may be associated with disease of the brain, spinal cord, and peripheral nerves. Btiology and Pathology. — In a word, the causes which lead to vasomotor and trophic diseases are not known. There is nearly always a neuropathic disposition. Pathologically there may be found, in such dis- eases as erythromelalgia and Raynaud's syndrome, an alteration in the peripheral nerves and vessels and changes in the blood. In the so-called trophic diseases, as acromegaly and progressive facial hemiatrophy, there are, of course, true hypertrophy and atrophy of the tissues. VASOMOTOR DISEASES. Under this heading can be described many diseases, but it is probable that they all have an interrelation, and that their differences consist in the onset, character, and preponderance of certain symptoms. The first classi- fication can be made of those in which the principal symptoms are those of paresthesia, with or without trophic changes. Acroparesthesia. — By this is understood a diffuse sensation of numb- ANGIONEUROTIC DISEASES. 1151 ness or of a dead feeling in any or all of the upper and lower limbs, especi- ally in the hands and feet. At first it is associated with vasomotor changes, and it is probable that, when occurring alone, it is the early mani- festation of a subsequent vasomotor disease, such as chilblain, acrocyanosis, erjrthromelalgia, angioneurotic edema, or Raynaud's disease. Chilblain. — ^This usually comes on after warming of the feet when they have first been either chilled or frozen. There is usually a sensation of pins and needles, associated with a sense of numbness, and the feet feel cold and are so to touch. Often associated with this the skin is pale or red, and there may be ulcerations. It may be the beginning of an acrocyanosis or Ray- naud's disease, but, as a rule, occurs independently. Acrocyanosis. — The leading characteristic of this is a blueness of the extremities, associated with numbness or a pin-and-needle-like sensation. These symptoms may be the only manifestations of the disease, or may be the beginning of Raynaud's syndrome, or, as sometimes happens, after the blueness or numbness disappears the skin becomes profusely red and then white. Rarely there are disturbances of sensation in the cyanotic parts. Erythromelalgia. — By this is meant pain and redness of the terminal parts of the upper or lower limbs, the feet being more frequently affected. The redness, as a rule, comes on gradually or in paroxysms, and is associated with more or less numbness and pain, and when well marked the limb is generally swollen, red, and painful to pressure. The disease is chronic, and may terminate in gangrene of the toes, terminal part of the foot, or fingers. Raynaud's Disease; Symmetrical Gangrene. — ^The disease, as a rule, is slow in onset, and is characterized at first by a sense of crawling or numb- ness in the fingers, toes, or both, with periodic paleness and coldness which may last from a few minutes to an hour or longer. Very soon there will be in association a bluish condition, which may be succeeded by redness, the fingers and toes feeling numb or painful. As this continues there will gradu- ally develop gangrene of the toes or fingers, usually in symmetrical parts. Gangrene may sometimes occur in the ears, nose, and lips, or in different portions of the upper and lower extremities. ANGIONEUROTIC DISEASES. In this group are included those symptom-complexes in which there is a sudden swelling of a part, the result of serous or hemorrhagic effusion from the blood-vessels. Angioneurotic Bdema. — This is characterized by a sudden sweUing, coming on either acutely or in a few hours, in the forehead, face, lips, tongue, larynx, or genital organs — in fact, in any portion of the body. The swelling is round, circumscribed, does not pit on pressure, and is not painful. The superimposed skin is white, pinkish, and irritable, and there may sometimes be in association urticarious eruptions. It usually subsides in the course of a few hours. The attacks, as a rule, are not dangerous, ex- cept when they occur in the pharynx and larynx, when they may cause in- terference with breathing. Sometimes it occurs in the intestines or stomach, when there will be in association colicky pains with either diarrhea or vomit- ing and tenderness to pressure. Urticaria and Purpura. — It is probable that the changes in the skin and other symptoms which occur in these diseases are similar in etiology to angioneurotic edema, the only difference being in their manifestations. Very 1152 DISEASES OF THE NERVOUS SYSTEM. often the three conditions may be present in the same person. Purpura! eruptions may be of various intensity, and sometimes are associated with grave constitutional symptoms. They may consist only in a curious pinkish or purplish mottling of the skin of both lower and upper limbs, this being increased when the limbs are held downward and decreased when held up. , . ■ j. ■ ■ Disturbance of Sweat Secretions.— This may consist in excessive sweating, such as occurs sometimes in the palms of one or both hands or of both feet. In association with this there may be a curious over- growth of the nails with an exfoliation, and sometimes even disturbance m the nutrition of the hands and feet. Disturbances in sweating sometimes occur on one side of the body, or may be referred to one hmb or the face, and are generally associated with hysteria. At times there may be a curious odor of the sweat secretion; it may be bloody or of different colors, ihis, of course, is rare. Sweating may be entirely absent. TROPHIC DISEASES. Under- this heading will be discussed those diseases in which there occurs an alteration in the nutrition, structure, or growth of part or all of the body. Scleroderma, — ^This is a peculiar disease characterized by either a general or local disturbance of the skin and some of the underlying tissues. It may be Umited to the face, neck, upper limbs, genital organs, or to certain other limited portions of the skin, when it is called morphea. It is charac- terized by a peculiar hardening and contraction of the skin, which sometimes becomes discolored, and there may rarely be eruptions over the involved parts. The skin is hard to the touch, cannot be pinched, and does not pit to pressure. It produces deformities, and when over the face it will cause a mask-like condition; when in the fingers, a peculiar deformity and contraction; and if Umited to the chest, may inhibit respiration. Atrophy of the parts may fol- low. Its cause is unknown. It is chronic and recovery very rarely ensues. Myxedema. — ^Pathologic Definition. — A nutritional disorder, associ- ated with atrophy and loss of function of the thyroid gland. There is a myxedematous infiltration of the subcutaneous tissues and a cretinoid cachexia. Clinical Varieties. — (1) True myxedema; (2) cretinism (the absence of thyroid fimction-congenital, or lost during childhood) ; (3) operative myxe- dema, due to total removal of the thyroid glands. Nature of Myxedema of Adults, and Etiology. — ^Atrophy of the thyroid is usually present, and the gland may either be changed into a small fibrous mass or be absent. The therapeutic test of improvement under the admin- istration of thyroid extract sustains this view. The fact that in a good many cases of myxedema a considerable portion of the thyroid gland is unaltered and partly capable of functionating arouses a suspicion that the hypophysis may share in the production of myxedema. Myxedema may be secondary to exophthalmic goiter, but it is then, as ia the case of simple acute goiter, only a transient condition. Women are much more fre- quently affected than men. The disease may attack several members of a family, and hereditary transmission through the mother is probable. Sis- ters may suffer, one from myxedema and the other from exophthalmic goiter. Pregnancy may rarely cause a disappearance of the myxedematous symp- toms, but these symptoms may reappear after delivery. TROPHIC DISEASES. 1153 Sjrmptoms. — There is retardation of psycomotor action. Mental per- ception and thought are slow, and the memory, while retentive, is also slow to respond. Not infrequently there may be irritability, and hebetude al- ternating with sudden periods of excitability. The patient is subject to delusions and hallucinations; or the apathy may pass into a melanchoUa, endmg finally in dementia. Among the minor or accessory features may be abnormal subjective sensations, as taste and smell, and occipital headache. Hemorrhages from the nose, gums, and -bowels sometimes occur. Physical Signs. — The face appears to be swollen, rounded, and the fea- tures somewhat distorted and expressionless. The skin and mucous mem- brane displays a peculiar pallor, or the so-called cretinoid cachexia. The fingers are thick and clubbed, and their cutaneous covering rough and deeply wrinkled at certain portions, while the articular surfaces of the skin may be somewhat elevated. The hair is thin over the scalp and has a rough and lusterless appearance. In extreme cases pubic and axillary hair may be absent. The mucous membranes are also thickened, conse- quently the tongue, lips, and nose are appreciably enlarged, and the teeth may be loosened. The feet and lower extremities present a condition quite similar to that of the hands. The movements are slow and the gait some- what uncertain, and there is often disturbed co-ordination. Palpation. — The hair feels rough and Hfeless. The skin is somewhat roughened, and, while appreciably thickened, does not pit upon pressure. Late during the course of myxedema the signs of peritoneal fluid are occasionally observed. Ordinarily it is impossible to palpate the thyroid gland, and this may be in part due to atrophy of the organ on the one hand, and to thickened mycedematous tissue of the neck on the other. Percussion. — This physical method is of but limited service, except for determining the size of the heart (dilatation) and the presence of ab- dominal fluid, both of which features are seen late during the disease. Auscultation. — The speech is slow, somewhat drawn, and accentuation impaired so that the patient's voice is in monotones, to which are attached a peculiar nasal element. Laboratory Diagnosis. — The quantity of nitrogen excreted through the urine is below that of the normal. In some cases the urine may be found to contain albumin and sugar. Cretinism. — ^This is allied very closely to myxedema, inasmuch as it is due to the same cause — -congenital maldevelopment or atrophy of the thyroid gland. It is endemic in certain localities, as Switzerland, but may sometimes be found sporadically. The symptoms are recognized early in infancy. The growth is stunted, the figure small, walking is delayed, and the bones are usually poorly formed. The facial appearance is typical, con- sisting in a retracted nose, large hps and mouth, and lolling and enlarged tongue with some dribbling of saliva. The face is large, the lower jaw and brow are prominent, and the eyes are small. The intellect is usually im- paired and talking is interfered with. If the disease is marked, there may be an anteroposterior curvature of the spine with protrusion of the abdomen. The skin is usually waxy and pale and the hair brittle (Figs. 431 and 432). Amaurotic Family Idiocy, — A rare disease, first described by Sachs, characterized by mental impairment, observed during the first months of life and leading to absolute idiocy, paralysis or paresis of the greater part of the body, which may be either flaccid or spastic, the reflexes being 73 1154 DISEASES OF THE NERVOUS SYSTEM. either normal, increased, or diminished, with diminution of vision terminat- ing in absolute blindness; the latter is typical of the disease and consists pathologically of a cherry-red spot in the region of the macula lutea, and later in atrophj' of the optic nerve. The disease terminates fatally, as a rule, before the age of two years. The condition is first noticed from about the third to the sixth month, the first symptoms being those of general apathy, followed by disturbance of vision which rapidly leads to blindness. It is a family disease, and nearly all the reported cases have occurred in the Hebrew race. The etiologj' of the disease is still obscure. Fig. i31. Five and one-half 3-ears old RETix BoHN IN Philadelphia of Italian Parents. Height 22-| inches. Fig. -1-32. — Posterior Vif.w of Cas IN Fig. 431. E shown Adiposis Dolorosa. — A disease first descrilDed by Dercum, appear- ing in adult life and characterized by gradual fatty enlargements of various portions of the body, associated v.ith some pain and tenderness. There is usually great muscular weakness and a curious mental disturbance which is generally associated mth a neuropathic disposition. The cause of the disease is unknown. EXOPHTHALMIC GOITER (Graves' Disease , Basedow's Disease). A di.sease characterized by protrusion of one or Ijoth e3-ebans, enlargement of the thyroid gland, palpitation, and a general neurotic condition." It is EXOPHTHALMIC GOITER. 1155 It is the result either of excessive or al)nomi;il secretions of the tliyroid glan more common in women and genei'ally appears in early adult life. Symptoms.— It generally begins with nervousness, the patient becoming easily ex- citable, tirtid, complaining of headache, trenujr of the limbs, and palpitation. These symp- toms are progressive, and are associated with an increase of heart action, the pulse-rate sometimes Ijeing from 1 50 to 200 per minute. There may be a thrill, which can lie detected over the vessels of the neck. As the disease progresses there may be involuntary evacu- ations of the bowel, disturbances of sweat secretion, and insomnia, with a gradual in- crease in the symptoms already mentioned, and anemia. Coincidentally there develops a grarlual enlargement or protrusion of one, genci-;dly of both eyeballs, which is easily detected. When the eyes are made to follow a finger from above downward, there is a lagging of the upper lid (von (jiraefe's sign), and when the patient first attempts to look at tiie fin- ger there is usually a spasmodic conti'action of the upper lid (Kocher-Hcjston sign). Because of the protrusion, the palpebral fissure is widened (Stellwag's sign), and there is often failure of convergence (Mo bius' sign). Vision is usually not interfered with (Figs. 434 and 435). 433. — Exophthalmic Goiter, Photoi;rai'hi';i> \t the Time WHEN Goiter wah not Mark- edly Enear(;i';i). 1 2 Fig. 434. — .Method of Obtainino Hoston-Kocher Sion, wmrH Conribtr in a SpARMonir Oontrac- tion of thk Uppeb Lid whkn Fihst Attempting to Look at a Fingeb. Nos. 1 and 2. Fig. 436. — Method of OnTAtNiNG vox Graefe'r Sign, which Consi.sts in Lagging ok the Upi'er Lid when the Finger is Followed from AnovE Downwaud. Enlargement of the neck gradually develops, and, as a rule, is asymmet- rical, involving one gland more than the other, and is easily detected. 1156 DISEASES OF THE NERVOUS SYSTEM. Summary of Diagnosis. — A young adult with gradually increas- ing protrusion of both eyeballs and lagging of the upper lid on looking downward; widening of the palpeljral fissure; spasmodic contraction of the upper lids on fixing and occasionally failure of convergence; enlargement of the thyroid glands with a general nervousness, consisting in palpitation, rapid- ity of the pulse-rate, a thrill to be detected over the vessels of the neck; occasional diarrhea, tremor of the limbs, and general increase of reflexes. Differential Diagnosis. — There should lie no difficulty in diagnos- ticating this disease when the three principal symptoms of enlargement of the neck, protrusion of the eyeljalls, tremor, and general nervousness are considered. Fig. 436. — ^rcTHOD of Obt.vixing 1I6biu.s' Sign, Coxsistikg ix F.\ilurf, of Convergence. Prognosis and Duration. — The course of the disease is chronic. Sometimes, however, operative interference causes a cure. ACROMEGALY. A rare disease, characterized by enlargement of the soft and bony parts, principally of the hands, feet, and face. In quite a number of cases it has been found in association with disease of the pituitary body, but this is not constant. When such is the case, there will be disturbances of vision, as bitemporal hemianopsia, diminution of sight, with either optic atrophy or choked disc, and rarely the general symptoms of brain tumor, as headache, nausea, and vomiting. The disease u,sually appears in young adults, and is characterized by gradual enlargement of the hands, feet, and face, the hy- pertrophy involving all parts equally. The fingers and toes become Inroad and thick, the hands and feet enormously large, the face becomes hypertro- phied, involving especially the lower jaw, nose, lips, and supraorbital ridges, the eyes may l)e prominent, the teeth are widely separated, the tongue is enlarged, and the skull, especially in the frontal and occipital portions, also ACROMEGALY. 1157 hypertrophies. As the disease progresses the terminal parts of tlie long bones also become hypertrophied, and there tlevelops an anteroposterior curvature of the spine and enlargement of the bones of the chest. The Fio. 437. — Acromegaly in Female Child Five Years oe Age. genital organs may take part in the hj'^Dertrophy. The disease is progres- sive, of long duration, and is usually associated with phj'sical weakness and dullne,ss of intellect (Figs. 437, 438, 439). Fig. 4.3S. — E.vlargement of the Hands in Acromegaly. The enlargement of the bones may be of two kinds. When beginning in early life before the bone has reached its normal development, the hyper- 1158 DISEASES OF THE NEKVOUS SYSTEM. trophy is in the longitudinal direction, causing what is known as gigantism. When occurring later, the tissues enlarge in width and produce acromegaly. There should be no difficulty in diagnosing acromegaly. Sometimes, however, there may be an enlargement of the fingers and toes, and only rarely of the cranial bones in association with chronic pulmonary disease. This is known as hypertrophic osteoarthropathy. Occasionally there may be en- largement only of the bones of the skull, especially of the upper portion. This is known as hyperostosis cranii. PROGRESSIVE FACIAL HEMIATROPHY. This is a rare disease, coming on, as a rule, in early adult life and charac- terized by progressive atrophy of one-half of the face. It involves equally the skin, underlying tissues, and bones, and sometimes one-half of the palate Fig. 439. —Hands in a Case op Acromegaly shown in Fig. 437. and tongue. It is of slow onset, the skin generally puckers, becomes dry, and, as the face becomes smaller, there will develop a groove or ridge in the middle of the brow. Disturbances in the growth of the hair and of sweat secretions are common. It is supposed to be a disease of the fifth nerve, but it probably involves more, inasmuch as its distribution is greater. Rarely there may be an involvement of the muscles of the neck and shoulder. Pro- gressive facial hemihypertrophy is rarely seen. ARTHRITIS DEFORMANS (Rheumatoid Arthritis). Definition. — A disease of the joints characterized by alterations in the structure of the cartilage, synovial membranes, and the articular ends of the bones, with bony deposits causing stiffening and deformity of most of the joints of the body. ARTHRITIS DEFORMANS. 1159' The pathologic processes in this disease have become better recognized since the discovery of the j-ray. There are usually at first changes in the cartilage and synovial meniliranes, with jiroliferation of tissue, the changes in the cartilage being most marked, sometimes disappearing entirely. Grad- ually there appear bony or osteophytic ileposits iu the membranes, articular surfaces of bones, and especially in the ligaments, and the joint becomes en- FiG. 440. — Dorsal View of Hands iv a Case oe Arthritis Deformans. larged and motion limited. Sometimes there is great atrophy and erosion in the ends of the long bones and they become very friable. This occurs es- pecially in old persons. The pathologic process is slow and may invoh^e one joint, a number of joints, or every joint in the body. Predisposingf and Bxcitingf Factors. — Joint diseases in parents predispose toward this affection. At one time it was thought that rheuma- FlG. 441. — Palmar Shrface of Hands in a Case of ,4rthritis Deformans. tism or gout was largely responsible, but such history is only obtained in a few cases, and it is probable that neither is the exciting cause. Auto- intoxication and chronic infections, as gonorrhea, have been thought to be potent factors. Changes in the nervous system have not been definitely demonstrated. The disease is more prevalent in women, and usually ap- pears between the thirtieth and fortieth year. 1160 DISEASES OF THE NERVOUS SYSTEM. Symptoms.— These will necessarily depend upon the number and par- ticular joints diseased and mode of onset. In the usual adult type the in- volvement of the joints, as a rule, is very slow, although occasionally there may be a rapid onset, with some fever and enlargement of the joints, which are often tender and very painful, as in rheumatism. After tire acute symp- toms have subsided, the further progress of the disease is slow. In the usual chronic type the metacarpo-phalangeal joints are nearly always the first to l)e involved, l^ecoming gradually painful and stiff, the pains very often re- semljling those of a neuritis. This is followed by a gradual symmetrical in- volvement of the wrist-, elbow-, and then the shoulder-joints. In the lower limbs the knee- and hip-joints are preponderantly diseased, the ankles and joints of the feet and toes' usually escaping for some time, although occasion- ally everv joint in the body may be affected. It can readily be understood, then, that the symptoms will vary greatly, for it often happens that only one or two joints may be diseased, or the process is so slow that the diagnosis is for a long time made rlifficult unless x-ray ex- amination is made, when the characteristic joint changes are found. This most frequently occurs when the shoulder- or hip-joints are alone diseased, or in those cases in which these joints are first involved, the pains very often being of such intensity that a false diagnosis of neuritis is made (Figs. 440, 441, 442). Soon after the onset of the stiffness and pains the joints become enlarged and tender, and characteristic deformities develop. In the metacarpo- ]jhalangenl articulations these ai'e characteristic, and consist in a nodosity of the joints with a deviation of the fingers toward the ulnar side, the forearms, as a rule, Ijeing pronated and the elbows flexed. When the shoulder and spine be- c(-)me involved, the head is bent forward, no movement being possible, and in the lower limlis the legs are flexed on the thigh and the thigh on the abdomen. Becai.ise of the deformity and contractures there is great mus- cular wasting, the skin may be gloss}' and the hair brittle. Crepitation in the joints is early detected. Tlie reflexes may be increased at first, but soon are lost. Heberden's Nodes. — \erx often the disease limits itself to enlargement of the sides of the terminal phalanges of the fingers, consisting only in round, kno))-like deposits. They are often swollen, tender, and painful, e.specially in the early stages, and more rarely after dietary indiscretion. The disease is chronic, of long duration, and the other joints escape. It is more common in women. Senile Form (Morbus Coxae Senilis). — Very often in old persons, es- peciaU}' in men, there may be an involvement only of one joint, usually Fig. 442. — Distortion of the Toes with Deformity OF THE Foot in Arthritis Deformans. OSTEOMALACIA. 1161 of the hip, and more rarely of the hip and shoulder, the bones becoming atrophic and brittle. There is nearly always considerable deformity, in- ability to walk, and great atrophy. Vertebral Form (Spondylose Rhizomelique). — A disease character- ized by progressive stiffness and ankylosis of the spinal column, shoulders, hips, and more rarely of the spinoclavicular, knee, and other joints of the extremities. The cause is unknown. The pathology consists in a rare- faction of the osseous tissue and an ossification of the ligamentous structures of the joints. It is of slow onset, occurs in adults, and is usually preceded by considerable pain, of a sharp, shooting, or numb character, which is followed by gradual stiffening of the back, shoulder, neck, and upper and lower limbs, and finally no movements are possible in any part of the body, those of the hands and feet being retainecl the longest. Sometimes there may be a preponderance of the stiffness in the upper spine, shoulder, neck, and arms (von Bechterew type), or of the lower spine, hip, and lower limbs (Striimpell-Marie type) (Fig. 443). I/aboratory Diagnosis. — There is an appreciable reduction in the hydrochloric acid of the gastric fluid. OSTEOMALACIA. Definition. — A lione disease characterized by gradual softening or decalcification of its structure, due to disappearance of its earthy salts. It usually comes on in adult life, especially in women, and has a direct re- Frr,. 443. — Spondylose Rhizombliqfe. Complete rigidity of all joints with the exception of the elbow, wrist, and fingers. lation with the child-bearing period, usually coming on during or after preg- nancy. The shafts of the long bones are principally diseased, becoming soft, friable, and decalcified, and because of this the Haversian canals be- come larger than normal. The bones gradually become pliable, and it is possible when the disease is marked to twist and JDend the bones at will. The Ijones of the head nearly always escape, although the teeth may be car- ious. There is usually an excess of excretion of calcium salts in the urine. Pain of a deep-seated character is first complained of, this becoming accentuated by pressure over the bones or by movement. With the gradual softening and pliability of the bones certain deformities occur which are characteristic of the disease. The stature becomes smaller, often the height diminishing a number of inches; the sternum becomes prominent be- cause of the giving way of the bones of the sides of the chest, and there may develop a deformity of the spine, the head l^eing held forward somewhat stiffly; but, most characteristic of all, the pelvis becomes deformed, the symphysis becoming very prominent and the sides of the pelvis approximated. This deformity can be easily detected by pelvic examination, and has an / // 1162 DISEASES OF THE NERVOUS SYSTEM. important bearing upon future maternity. Because of the pelvic deformity there will develop a gradual and characteristic hopping or waddling gait, which is further accentuated by the deformities of the long bones of the limbs. Sensory disturbances are not' the rule, Ijut very often because of spinal de- formity there may be involvement of the posterior roots, and rarely of the spinal cord, with consequent characteristic root pains and disturbance of sensation. More rarely the anterior roots are involved, causing fibrillary tremors and atrophy. The reflexes may at first be increased, but, as a rule, Fig. 444. — Case of Osteitis Deformans (Facet's Disease) seen in 1910 at the Philadelphia General Hospital (Service of Dr. B. Franklin Stahl). (Proc. College of Physicians of Philadelphia, 1911.) become graduallj^ lost. The disease is of long duration, death usually re- sulting from some other cause. OSTEITIS DEFORMANS (PageT'S Disease). A rare disease, usually occurring in males in the latter end of life, and characterized by a gradual irregular thickening of the bones of the head with a softening of the long bones, especially of the lower limbs. Very little is known of its etiology, as few cases have been studied. The changes in the bones are those of a rarefying osteitis with some formation of new tissue. It usually comes on in adults past the fiftieth year, causing enlargement of the bones of the head wdth characteristic triangular deformity, the base being upward. This may be the only manifestation of the disease, when it is called hyperostosis cranii, but, as a rule, there is in association a softening and pli- TETANUS. ] 1(J3 ability of the shafts of the long bones. Associated with this there is great muscular weakness. The disease is of long duration, death generally being caused by some intercurrent disease. TETANUS (Lockjaw, Trismus). Definition. — An infectious disease characterized by stiffness and tonic spasms, usually beginning in the muscles of the jaw, and finally in- volving all parts of the body, generally terminating in death. The specific bacillus has been isolated and is definitely known. The infection is carried Fig. 445. — Case of GsTEiTia Deformans (Paget's Disease) seen in 1910 at the Philadelphia General Hospital (Service of Dr. B. Franklin Stahl). (Proc. College of Physicians of Phila- delphia, 1911.) by the soil, and is usually transmitted by wounds to the hands and feet, and sometimes after injury by rusty nails or firecrackers. The point of entrance may be not at all apparent, or may take some time to heal. Symptoms. — The period of incubation varies. As a rule, the first symptoms appear within a week or ten days, and are usually manifested by a gradual feeling of weakness, malaise, headache, chilliness, and sometimes rise of temperature. Gradually there develops a stiffness of the muscles of the jaw and neck, with an increased difficulty in movement and interference with eating and talking. The muscles of the zygomatic arch usually be- come involved early, their stiffness and retraction producing the charac- teristic "sardonic grin." 1164 DISEASES OP THE NERVOUS SYSTEM. The progress of the disease from the appearance of the stiffness of the jaw is rapid, and there will gradually develop rigidity of the head and limbs. The back will be arched in the position of opisthotonos or rarely laterally. The lower limbs are usually first involved, and are extended, and the upper limbs flexed. The jaw becomes so rigid that it is impossible for the patient to protrude the tongue or to eat. Spasms of a tonic character make their appearance early, and as the disease progresses involve the whole body, and may be brought on by the shghtest cause, as jarring of the bed or noises. They are sometimes so violent that the patient will be shaken froin the bed to the floor. I^ater the spasms may be continuous. The mind is not in- volved, and is clear to the end. In those cases in which the symptoms appear within six or seven days the prognosis is invariably fatal, and it is a rule that the longer the onset, the better the prognosis; and in those cases in which the symptoms do not appear until after the twelfth day the prognosis is fairly favorable. There should be no difficulty in diagnosticating this disease. Cephalic or Head Tetanus. — In this form the infection is usu- ally in the head or face and the onset is rapid. Besides the stiffness and rigidity of the head and neck and retraction of the zygomatic muscles, there is nearly always a paralysis of both facial nerves, and more rarely of some of the ocular muscles. Difficulty in talking and swallowing appears early. Sometimes there is also retraction of the limbs and rigidity of the back. The prognosis is nearly always fatal. TETANY. Definition. — A peculiar form of rigidity and spasm of the terminal portions of the upper and lower limbs, characterized by irritability of the nerve-trunks, resulting from some form of intoxication. The disease is very common abroad, especially in Berlin and Vienna, but in this country it is of rare occurrence, although a number of epidemics have been reported. As a rule, it is ascribed to some form of autointoxi- cation resulting from disturbance of the gastro-intestinal system, but can be produced by removal of the parathyroid glands. It probably is the result of increased elimination of calcium salts, which can be detected by careful metabolic examination. It usually occurs in children, especially in those in whom there is general malnutrition, and is very rare in adults after the twentieth year. Symptoms. — There may be present the general symptoms of gastro- intestinal disturbance, and the first distinctive symptoms are those of numb- ness or pain in the fingers, hands, or feet, gradually followed by an increasing stiffness and a curious and characteristic spasm of these parts, which con- sists in the fingers being extended and approximated in a cone-like manner, sometimes the thumb being in the palms; the wrists are generally flexed, the elbows drawn in toward the side of the chest, and the forearm pronated. In the lower limbs the legs are extended and the feet turned inward, simu- lating the position in equinovarus. This characteristic position is the re- sult of a spasm which may last from a few minutes to an hour or longer, and may involve both the lower and the upper limbs, but generally only the upper. When the disease is very marked, the spasm may involve the muscles of the chest and diaphragm or larynx, causing interference with breathing, but this is rare. The sphincters are rarely affected. It is characteristic of these spasms that they may be brought on by any SPASMS, TICS, AND MOTOB NEUROSES. 1165 form of excitation, such as pressure over the brachial arteries or the nerve- trunks of the arm (Trousseau's symptom) ; by stimulation, especially with the galvanic current, which will produce increased excitability (Erb's sign), and tapping any nerve — as, for instance, the facial on the side of the face — will produce a spasm of the muscles in its distribution (Chvostek's sign). All or these symptoms are only indications of the general irritability of the nerves and muscles, and are given here not as specific symptoms, but be- cause of the fact that they are so frequently described in conjunction with this disease. The prognosis is nearly always good, the disease lasting from a few weeks to a month or longer, the spasms gradually subsiding. Treatment, of course, has an influence upon the length of the disease. Spasms, Tics, and Motor Neuroses. Until recently no differentiation was made between spasm and tic. Chiefly under the influence of the French schools, attempts have been made to distinguish between these, and by tic is meant a movement or movements which are more or less under the control of the will, and result from some emo- tional or functional basis duplicating or resembling voluntary movements. In whatever part the tic takes place the muscular action is complete, as, for instance, in facial tic the contraction is in the whole facial distribution, its occurrence not interfering with the use of the same musculature for other purposes, as eating and talking. On the contrary, by spasm is meant a movement which is not at all under the control of the will and which cannot be voluntarily duplicated. The contraction may involve part or all of a functionally acting group of muscles, and interferes with other functional uses; as, for instance, in a facial spasm the contraction may be limited to a part or involve all of the facial distribution, the movement does not resemble a voluntary action, and its occurrence interferes with eating and talking. As a matter of fact, while such a theoretic and clinical distinction can be made between facial spasm and tic, it cannot be made in so far as most of the other so-called spasms and tics are concerned. Again, it is of no prac- tical importance to differentiate between them, for in neither has there been established a definite etiology, in both the causes are mainly functional, the course of the disease is identical and the prognosis the same. Under the general heading of spasms and tics will be discussed all of the different forms of spasms, contractions, or movements which occur in any portion of the body, although it is customary to treat most of these sepa- rately, as if they were distinct entities. Predisposing and Bxciting Factors. — The causes of most spasms, tics, and motor neuroses are not known, and therefore a func- tional basis is ascribed. As a matter of fact, with the exception of those rare instances due to an organic basis, such as facial spasm resulting from a growth on the seventh nerve, or torticollis from direct irritation of the spinal ac- cessory, there are nearly always two principal causes which enter into the etiology. Given a perfectly normal individual, one whose heredity is good and in whom all bodily functions are normal, there is no reason to expect the development of any form of spasm, tic, or in fact any so-called functional disease, even if he be placed under severe mental strain, shock, or any cause which produces general malnutrition. If, on the other hand, an individual has a neurotic heredity and has inherited a weakened nervous system, or one which has lessened resistance, under the same conditions there would 1166 DISEASES OF THE NERVOUS SYSTEM. probably develop some form of neurosis, the particular type depending upon the previous history of the patient and the lessened resistance or vulner- ability of certain functional activities. In such a person if there should happen to be a diminution of tone in the functional activities of the seventh nerve, there might develop facial tic or spasm; if in the distribution of the spinal accessory, torticollis; if in the functional movements concerning the upper limbs, writer's or any other form of spasm; if in the lower limbs, cramps, etc. It is also probable that in the development of a particular form of neurosis mental impressions play an important part, as, for instance, in a child in whom imitation of certain facial movements will be succeeded by so-called habit spasm, or, because of fright, religious or other emotional causes, there may develop a certain form of jumping or other movements. ' Symptoms. — ^There are certain symptoms which are common to all spasms, tics, and motor neuroses. In aU, excluding the cases in which there is an organic basis, there is a functional or mental element, manifested in many ways. It may be in the impressionability or'so-called neurotic ten- dency, which will be discussed under the general neuroses. So far as the character of the movements is concerned, they resemble each other in the fact that they are influenced by the emotional condition of the patient, or by any form of excitation. Most of the movements are quick, intermittent, have a tendency to become chronic, and cease during sleep. Besides the specific s}Tnptoms of the spasm there may be increase of reflexes and the symptoms of a neurosis, such as pains and tenderness in the back, headache in the back of the head, occasionally dizziness, insomnia, loss of appetite, and sometimes disturbances of sensation, such as hemihypesthesia or mono- hypesthesia. Spasms, Tics, and Motor Neuroses in the Distribution of the Fifth Nerve. — ^These are rare, and, as a rule, are the result of organic involvement of the fifth nerve, or may be a part of tetanus, epilepsy, or tetany. Oc- casionally, however, there may be, in hysteria, unilateral or bilateral spasms of the masseters, causing trismus or lockjaw. When both pterygoids are involved, the jaw is opened in the median line; or if only one, to the op- posite side. In so-called motor neuroses in the distribution of the fifth nerve there may be either spasmodic or continuous movements of the jaw resem- bling chewing. It is generally in association with movement of the tongue and face, interfering with talking and swallowing, and often there is dribbling of saUva. There may be in association a weakness or laxness of the liga- ments of the jaw. Spasms, Tics, and Motor Neuroses in the Face. — These may involve the whole or part of the distribution of the facial nerve, and may be in as- sociation with movements of the eyelids on one or both sides, and often of the eyeballs. Sometimes there are also movements of the tongue and masseter muscles, as already described. In so-called facial spasm the movements may start in part of the facial distribution, as, for instance, in the upper, and in the course of time involve all, or they may start in the whole at once. The movements resemble the contraction obtained by means of faradic electric excitation of the nerve, and cannot be controlled by the will or duplicated. They may be momen- tary, or last several minutes, and during the spasm talking will be im- possible. After it is over there are generally fibrillary tremors in the facial distribution. In so-called facial tic the movements can, in most instances, be partially controlled by the will. They resemble volitional movements and do not SPASMS, TICS, AND MOTOR NEUROSES. 1167 interfere with talking. Very often there may be in old facial paralysis tic of the whole, but especially of the lower part, of the face. Sometimes in association with facial tic, or independently, there are movements of one, but generally of both eyelids and orbicularis muscles. This is called blepharospasm. As a rule, they occur in children, come on gradually, and consist in a tonic or clonic spasm of one or both lids and eye- brows. In exaggerated cases there may be, in association, movement of the eyeballs, elevation of the nasolabial folds, or sniffing or sucking-like movements. This is sometimes called habit spasm, or habit chorea. Spasms in the Muscles of the Tongue, Palate, Pharynx, and Larynx. — All of these conditions are rare, but occasionally there may occur in hysteria isolated spasm of the tongue. Rarely in association with lingual spasm there is involvement of the pharyngeal muscles, producing swallowing movements, and, as a rule, movements of the jaw. Spasm in the laryngeal distribution sometimes occurs, but is generally hysterical or part of chorea or tetany, or it may be in association with spasm of the diaphragm. Spasm in the Respiratory Muscles. — ^This involves the diaphragm, and may be tonic or clonic. When tonic, the lower part of the chest and epi- gastrium become prominent, there is pain over the region of the diaphragm, and breathing is painful, rapid, and performed entirely by the upper respirar tory muscles. If continued, it may cause death. When intermittent or clonic, it causes so-called hiccough or singultus. This is sometimes due to an irritation of the phrenic nerve, or may result from many different causes, such as gastro-intestinal or general constitutional disturbances, but in many cases it is purely hysterical. The course and prognosis depend upon the cause. In most instances it subsides in the course of a few hours, but may last days, especially when functional in character. Spasm in the Distribution of the Muscles of the Neck; Torticollis; Wry-neck. — Inasmuch as the spinal accessory nerve supplies the sterno- mastoid and trapezius muscles, an irritation of it, such as results from pressure, will cause spasm in its distribution, or torticollis. In most in- stances, however, the cause is not known. It may come on suddenly as the result of a fright, but usually the onset is gradual, the spasm growing more and more severe, the particular kind depending upon the muscles affected. If the sternomastoid alone is involved, the head is turned to the opposite side, the chin pointing a little upward; if the trapezius, the head is retracted on the same side to the shoulder, the chin pointing upward; if both the sternomastoid and the trapezius, the head is turned to the opposite side, backward, and the chin higher than when either are alone diseased. Very often in association with the sternomastoid and trapezius muscles the rota- tors of the neck, muscles of the shoulder, the erector capitis and splenius muscles of one or both sides take part in the spasm, and the movements are very complicated. When the rotators alone are involved, the head is turned toward the same side, the chin being on a straight Une; when the splenius, the head is retracted, the chin upward, differing from the action of the trapezius in the fact that in the latter the head is retracted toward the shoulder. When both sternomastoids are affected, the head will be drawn forward, and if the movements are clonic, there will result so-called nodding or salutatory spasms, which are especially common in children. The spasms may be either tonic, when it is difficult to return the head to its original position, or clonic, the movements being intermittent. Ordinary stiff-neck or rheumatic torticolUs hardly enters into the discussion. The course of the disease, as a rule, is long and the prognosis not very good. 1168 DISEASES OF THE NERVOUS SYSTEM. It is best in those cases in which treatment is instituted early, and in which absolute control of the patient can be obtained. Spasm in the Distribution of the Upper Limbs.— These are rare, and may partake of many different forms, and, as a rule, are of functional origin. The spasms may be limited to the fingers, or may involve the whole upper limb, and may sometimes be in association with spasm of the leg and face of the same side. They must be distinguished from hemiathetosis or hemichoreic movements following hemiplegia. The movements of the fingers may be irregular, but, as a rule, are rotatory, and rarely quick and lightning-like. Occupation Neurosis; Writer's Cramp. — ^This generally occurs in those persons who are occupied constantly in the performance of certain rhythmic movements, as writing, typewriting, playing of an instrument, like a piano or violin, or, in fact, in any movement in which there are in association many muscular contractions. It comes on, as a rule, slowly, and is first manifested by a tired or aching feeling, and occasionally tender- ness over the nerve-trunks. This fatigue may last for some time, and then it is noticed that writing is not as free as before, and gradually there de- velops a tremor which interferes ^^ith writing, or a spasm of the muscles, which may be either tonic or intermittent. In writing the pen may sud- denly be dug into the paper or fly forward, or the whole hand may be in a tonic spasm until writing becomes absolutely impossible. Occasionally there is weakness in the muscles, but this is unusual. The spasms come on only when the muscles are used for the particular movements concerned, and can be used for any other purpose. The prognosis, as a rule, is unfavorable. Spasm in the Distribution of the Lower Limbs. — ^These are generally of an organic basis, but occasionally there may develop irregular movements of the lower limbs similar to those described in the upper. Rarely there may be an irregular, symmetrical, spasmodic contraction of the muscles of the thighs and toes, causing sudden jumping or lifting movements. These occur especially under the influence of religious emotions, are common in Oriental countries, and the people presenting this condition are known as "jumpers." Occasionally the spasm may be limited to the muscles of the calves, cramps, and may occur after exertion or independently. Spasm in the Distribution of the Muscles of the Shoulder, Chest, and Abdomen.— These do not occur very often, but occasionally there are present spasms in the muscles of the shoulder in association with contrac- tion of the pectoralis muscles, and rarely there may be unilateral or bilateral spasms of the muscles of the abdomen, causing an approximation of the shoulders and thighs, or bending movements. Tic Convulsif , or Maladie des. Tics. — So far we have discussed those spasms, tics, and motor neuroses which involve a part or all of a limb or body. Under the above headings, however, are understood those spasms which involve most of the movements of the body. It is rather difficult to describe this form, because the movements vary so greatly. As a rule, there are grimacing spasms in the face, associated with sniffing of the nose, sucking or blowing movements of the mouth, with sudden ejaculation, or repetition of certain words, often obscene, known as coprolalia and echolalia respectively. Associated with this there may be movements of the upper and lower limbs, such as sudden lifting up of the shoulder or arm or the taking of a few steps, then a retraction, or there may be, in associa- tion, hysterical contractures in the lower limbs. There are always found many hj'sterical stigmata. CHOREA. 1169 Paramyoclonus Multiplex. — Under the term paramyoclonus multi- plex is understood a form of bilateral, regular, more or less rhythmic clonic contractions of groups of muscles, generally of the trunk and proximal parts of the limbs, and rarely involving most of the body. The cause of the disease is unknown, but it is probably functional in nature. The move- ments resemble to some extent those of generalized spasm or tic, but differ in their regularity, being bilateral and clonic. It generally occurs in adults and the onset is slow. A well-marked case consists in a clonic spasm of symmetrical groups of muscles, for in- stance, of the quadriceps or shoulder and upper arm groups, the muscles standing out prominently as if held, the spasm lasting several minutes or longer. The spasm consists in a series of clonic contractions coming on one after another, sometimes the number of contractions being from fifty to one hundred and fifty to the minute. Besides the spasms there are fasicular contractions. Sometimes they are of such severity and extent that they involve the muscles of the chest, abdomen, and limbs, and cause irregular movements of the body and extremities. This is exceptional. There are, as a rule, no associated symptoms of motor palsy or sensory disturbance, but the reflexes are generally increased. The course of the disease is chronic, of long duration, but occasionally cure is obtained. Sometimes in association with this there may be epileptic convulsions. This has been called the Unverricht's type of myoclonus, or myoclonus epilepsy. If the myoclonus is limited to one-half of the body, the movements resembling those produced by the stimulation of an electric current, they are sometimes called electric chorea, Henoch's chorea, or Dubini's disease. These, however, are bad terms. Myokimia. — By this is understood a well-defined, irregular, fasiCular muscular contraction, involving most of the muscles of the body. The contractions are wave-like and more or less constant. They differ from paramyoclonus multiplex in the fact that they are not symmetrical or clonic, and are constant. Course and Prognosis. — Most spasms, tics, and motor neuroses are difficult to cure, and the prognosis should always be guarded. So much depends upon the kind of spasm, the eUmination of the cause, and the con- trol of the individual. CHOREA (St. Vitus' Dance- Chorea Hinor, Sydenham's Chorea). Definition. — ^A disease occurring principally in childhood, charac- terized by irregular, unpurposeful movements of any portion of the body, and in which the prognosis is almost invariably good. The disease is supposed to be of infectious origin, although the specific bacillus has not been isolated. Pathologically, so-called choreic amyloid corpuscles have been foimd in the nervous system, but are not constant. In about 20 per cent, of the cases it is in association with rheumatism. It generally comes on in children, and especially in the spring of the year, is less frequent in the winter months, and is more common in girls. There is nearly always some malnutrition and a general anemia, manifested by blood-changes, and sometimes a hemic murmur, which is best heard at systole, although there may be an organic murmur, caused by endocarditis. It is probable that the disease is the result of a general lowering of tone, associated with a certain inherited or acquired neurotic disposition, for it generally occurs in school-children, who are more or less overworked 74 1170 DISEASES OF THE NERVOUS SYSTEM. in the spring of the year, and only in those in whom there is a neurotic tendency. Symptoms. — ^These are first manifested by a growing restlessness, and a peevish, irritable condition of the child, associated with more or less gastro-intestinal disturbance, loss of appetite, and insomnia. Gradually there will be noticed irregular, unpurposeful movements, generally of the hands or face. The child begins to make grimaces, pucker the hps, elevate the brow, move the head or arms, extend the legs, twitch the shoulder, and is generally restless. The movements are increased by attention and excitement, cannot be controlled by the will, and generally cease during sleep, although in grave cases they may be present even then. In mild cases the irregular movements may be limited only to the face and arms, but when more severe there may be interference with the respiratory move- ments, and even with talking and sometimes eating because of the involve- ment of the muscular apparatus concerned. The course of an ordinary case is from two to three months, the movements gradually ceasing, but in the more severe cases it may last for a long time. One attack nearly always predisposes toward another, and it is not at all uncommon for a child to have successive attacks for three or four years. As a rule, there is no motor weakness, but sometimes the movements may not only be limited to one-half of the body, but there may be distinct weakness of the arm and leg. This is known as the hemiparalytic form of chorea. Sometimes the limbs may be weak on both sides. The reflexes are not altered, but occasionally on tapping, for instance, the patellar tendon, there may be an irregular jerking propulsion of the leg instead of the usual response. Sensation is hardly ever altered, and there is never involvement of the bladder and rectum, although it is not at all uncommon for children to have an enuresis during the course of the disease. Sometimes chorea occurs in adults, but the form does not differ from that in the child. In rare cases the choreic movements are present from childhood, but in these instances it is probable that there is a cortical condi- tion rather than one of pure chorea. Sometimes choreiform movements may complicate pregnancy, especially in primipara, chorea gravidarum. It comes on in the first half of preg- nancy, as a rule, and in nearly all cases there has been a previous history of such disease. The prognosis in these cases is not so good, and sometimes it is necessary to produce abortion. Summary of Diagnosis. — ^A school-child, especially in spring, becomes peevish, irritable, cannot sleep, is constipated, and begins to have irregular movements of the arms or face, which consist in a purposeless grimacing and twitching of the shoulder or any portion of the limbs, this being increased by excitement and not controlled by the will. It usually stops during sleep. Associated with this there is nearly always malnutrition, with some anemia. There should be no difficulty in diagnosticating chorei- form movements from any other. Clinical Course and Complications.— The course of the dis- ease IS usually regular, ordinary cases not lasting longer than two or three nionths. Treatment, of course, has a direct relation to the length of the disease. In the more complicated cases, and especially in chorea gravidarum or chorea of pregnancy, the prognosis is not so g;ood, and occasionally death results. Occasionally in this type there may arise grave mental symptoms, which occasionally are permanent. PARALYSIS AGITANS. 1171 HUNTINGTON'S CHOREA. A hereditary family disease, characterized by irregular choreic move- ments, generally beginning between the thirty-fourth and fiftieth year, terminating nearly always in mental impairment. The disease was first described by Dr. Huntington, of Long Island. It usually runs in families, and it is characteristic that it seldom skips a generation, and if it does, the disease ends in that particular family. There may be no symptoms in the early life of the individual, but there may be general indications of an inherited neurotic disposition. About the age of thirty-five the choreic movements begin, and resemble very much those of chorea minor, generally involving the face and upper limbs, and interfering considerably with walking. These persist and become worse. Soon after the appearance of the movements there develops a gradual mental deterioration, which in a few years terminates in total mental impairment. The prognosis is invariably bad. PARALYSIS AGITANS (PARKINSON'S Disease). Definition. — A disease of the latter end of life, characterized by rigidity in the muscles of the whole body, with slowness of all voluntary movements and a characteristic rotatory tremor which nearly always improves by effort. It occurs mostly in men, usually about the age of forty, although rarely it may occur in young persons. Its pathology is not definitely known. Microscopic examinations of the brain and cord show the usual changes of senility, the muscles show atrophy, and occasionally disease of the para- thyroids has been found. The disease is sometimes hereditary and may occur in families. Rare instances are reported in which sudden fright has been followed by paralysis agitans. Symptoms. — ^The disease, as a rule, comes on slowly, and is usually first manifested by an increasing rigidity and tremor in one limb, which finally involves the whole body. It usually starts in the right upper limb, to be followed in the course of time by the right lower, and then the left limbs. Occasionally it may be limited to the limbs on one side for a long time. In a well-marked case the attitude is typical, and the diagnosis can be made from it alone. The patient stands with his knees bent, feet close together, the body bent forward, head flexed on the neck, the back is held rigidly, the arms held by the side, the elbows touching the chest, the hands in pronation and the fingers in a typical pill-roUing attitude. The face gradually loses its expression, the wrinkles are smoothed out, and laughing and crying are rarely observed. In fact, all the emotions are sub- dued. Talking is slow and the voice becomes low and monotonous. Occasion- ally there is dribbling of saliva. All movements become slow, as is shown by the slowness in rising or in movement of any of the limbs. It is, of course, to be understood that the rigidity develops gradually, and it may take years before the tj^pical attitude described is obtained. Sometimes the rigidity becomes so extreme that there is great resemblance to rheumatoid arthritis. Coincident with the rigidity and slowness in movement there develops the typical tremor of the disease. In a well-marked case the attitude and movements of the fingers are those of pill-rolling, the tremor involving every portion of the body. It is characteristic of this tremor that it becomes 1172 • DISEASES OF THE NERVOUS SYSTEM. momentarily better on effort, differing from tiie intention type of multiple sclerosis. It also becomes less when the patient is quiet or when his atten- tion is attracted, although occasionally it may be intention. in type. It usually stops during sleep. It is to be remembered that paralysis agitans may occur without any tremor, and that the diagnosis may be made upon the characteristic attitude and rigidity. With the rigidity, attitude, and tremor, there develops late in the disease a certain peculiar form of gait. Because of the attitude the patient's center of gravity is brought forward, and in attempting to walk, to regain his center of gravity, which is always in front, the patient will have a tendency to gradually bend over, causing his steps to become shorter and more rapid, until he either falls on his face or with an effort straightens himself up, the falling gait being again repeated. This is called festination, and when not present can sometimes be brought out by giving the patient a sudden push forward. Very often instead of this festinating gait there may be a tendency to walk backward or to one side (Plates XXV and XXVI). The course of the disease is chronic and the rigidity and tremor increase until finally the patient becomes bedridden. The reflexes are at first in- creased, but later may become lost or diminished on account of the rigidity. There may develop muscular wasting, and the electric excitability of the muscles may become diminished. One of the most distressing features of the disease is the excessive flashes of heat, warmth, or chilliness, these coming on either periodically or con- stantly, the patient sometimes complaining more of this than anything else. The mentality becomes gradually dulled with the progress of the disease. Summary of Diagnosis. — An adult, generally after the fortieth year, develops an increasing muscular rigidity of the whole body, with slowness in movement, lack of expression in the face, tremor of a rotatory type, and festinating gait. This picture is characteristic, and there should be no difficulty in making a diagnosis. Occasionally, however, the disease may be unilateral for a long time, or there may not be present tremors, when the disease should be diagnosticated from the rigidity and attitude. SENILE TREMOR. Occasionally there develops a tremor in the head or limbs, which in nearly all cases is fine and is to-and-fro in character. It generally comes on in old persons, is sometimes hereditary, and is distinguished from paraly- sis agitans by absence of rigidity and characteristic attitude. MYOTONIA CONGENITA (Thomsen'S Disease). A family disease, generally occurring in the male, coming on at infancy and characterized by a tetanic like contraction of the voluntary muscles when they are first put to use. The disease is rare and its cause unknown. Microscopic examinations of the nervous system have been negative, although there have been found changes in the muscles, consisting in an increase in the size of the fibers and nuclei. Symptoms. — ^The symptoms are present from birth, and because of the contraction of the voluntary muscles there will be an overdevelopment, which, at first, especially in young adults, may resemble a muscular hjrper- PLATE XXV Moving Picture uf Attitude and Gait in Paralysis Agitans. (Courtesy of Mr. yigniuud Lubin of Philadelphia, Pa.) PLATE XXVI Moving Picture of Attitude and Gait in Paralysis Agitans. Lubin of Pliiladelpliia, Pa.) (Courtesy of Mr. Sigimuid NEURASTHENIA. 1173 trophy. The tetanic like spasms or contractions are apparent when the patient arises or attempts to walk after resting, the movements being stiff, slow, and only made with difficulty. Gradually, however, the spasm diminishes, until finally the patient walks with comparative ease, only to have the spasm reappear on the next effort, after another rest. There are no other motor and no sensory symptoms, the reflexes may be exaggerated, but there is nearly always an increased and heightened contraction to a constant galvanic or a rapidlj' interrupted faradic current — the so-called myotonic reaction. The lower limbs are preponderantly involved, but in a well-marked case the upper also take part in the spasm. The disease is of long duration, the symptoms continuing until the death of the patient. AMYOTONIA CONGENITA (Oppenheim'S Disease). ''A condition of extreme flaccidity of the muscles, associated with an entire loss of deep reflexes, most marked at the time of birth, and always showing a tendency to slow and progressing amelioration. There is great weakness, but no absolute paralysis of any muscle. The limbs are most affected, the face is almost always exempt. The muscles are small and soft, but there is no local muscular wasting. Contractures are prone to occur in the course of time. The faradic excitability in the muscles is lowered, and strong faradic stimuli are borne without complaint. No other symptoms indicative of lesions of the nervous system occur." (Op- penheim.) There have been so few autopsies that the etiology has not been made very clear. It is probably the result of congenital changes in the muscular system, the condition being prenatal. The symptoms are noticed either directly or soon after birth. The affection is strictly symmetrical, and may- involve all the muscles, but, as a rule, the muscles of mastication and degluti- tion escape. The lower extremities are most often involved, next the upper, and then the trunk and face. The muscles are completely toneless, small and soft to touch, and a striking pecuharity is the impossibility of distinguishing by touch between the skin and underlying structures. There is no wasting. The lack of tone is freely demonstrated by the fact that it is possible to place the limbs in any position. The loss of power is hardly ever complete, although this varies in different cases. Contractures some- times develop in the latter end of the disease. It is necessary to have an increased faradic current to obtain a reaction, and while this condition is present in most of the muscles, it is best demonstrated in those which are most affected. The deep reflexes are lost, but the superficial are normal. The sphincters are never involved. The course of the disease is slow and there is a tendency to spontaneous improvement. This is shown by the increasing tonicity of the muscles and the fact that the reflexes return. Neurasthenia. Definition. — A term given to a combination of nervous and physical symptoms in which the general characteristics are irritability, abnormal sensitiveness, mental depression, and physical weakness. Predisposing- and l^xciting- Factors. — A neuropathic hered- ity, whether it be some form of nervous or mental disease in the parents, or any disease of the individual which would have a tendency to cause a 1174 DISEASES OF THE NERVOUS SYSTEM. diminished resistance in the nervous system, are important factors in the production of neurasthenia; for it is well known that in a number of per- sons under the same mental and physical strain, only a certain few will develop so-called neurasthenia. While it is probable that a congenital weakness or lessened resistance are the prime causal factors, it is possible for the disease to develop in one in whom these conditions are not present. It is probable that the various symptoms which are described under the term neurasthenia result primarily from a lack of proper mental appreciation and ideation, for in the development of a neurasthenic, while it is probable that there may have to be a fertile soil, the mental symptoms always pre- dominate and the physical are the result of these. It is a well-known fact that neurasthenia is much more common in well educated persons, especially among professional men and society woman, and although this symptom- complex is present in persons not well educated, the symptoms are neces- sarily few and not so well defined. It has been estimated that neurasthenia is much more common in men than in women, although this is doubtful. It may develop at any age, but is a disease essentially of adults. The exciting causes are many, but worry, especially financial, is the predominating cause. Prolonged mental work with lessened bodily activities; injuries, especially those produced in rail- road accidents; and then the countless causes which may be referred to almost any part of the body, such as eye-strain, disturbance of the nose, throat, ear, the various internal organs, and sexual functions are frequent factors. In fact, neurasthenia has been described as resulting from any and every cause. Even in perfectly normal individuals who develop, for instance, such a disease as pneumonia and typhoid, or possibly a slight surgical contusion, there may develop for the time being so-called neuras- thenia. Symptoms. — These are rather difficult to describe, because they vary so greatly in different persons, for while there may be a general resemblance, no one case has the exact symptoms of another, and the preponderance of certain symptoms will depend upon the education, station in life, occupation, previous health, resistance, and the immediate exciting cause. It is possi- ble for a neurasthenic to have very few symptoms which he himself recog- nizes. Then, again, there may be many. Perhaps the most important are the mental, for the other symptoms are dependent upon them. Mental Sjmiptoms. — ^Their development will depend largely upon the immediate cause of the disease. If resulting from injury, they will be manifested promptly. If resulting from the usual cause of worry and overwork, they will be gradual in their development, and will be generally first manifested by an increased worry over whatever is occupying the patient's mind at the time, and inability to clearly comprehend and appre- ciate external conditions. Such a person will become depressed, will be unable to see any method of getting out of the trouble he is in, will assume a pessimistic attitude, everything will go wrong, and nothing of a cheerful nature will appear in his horizon. He will become easily annoyed, ordinary things which would not have bothered him before will irritate him, the shghtest noise or whatever may occur will distract his attention, he will be unable to concentrate, and because of this will usually complain of loss of memory. Generally such a person, if he is addicted to smoking or drink- ing, will increase his habits in this direction, and if in women they will drink more tea and coffee to brace themselves up. Very soon they will be unable to sleep, and the harder they try, the less they succeed, and will NEURASTHENIA. 1175 rise in the morning more tired, irritable, fretful, and discontented with themselves. If this continues such a patient will constantly think of his own troubles, until finally these will be the only source of his thoughts, to the exclusion of everything else. If he should happen to have some malady, this will be exaggerated. If a physician, he will probably develop what occupies him most, and will have a special dread for locomotor ataxia and general paresis; if a medical student, generally heart disease; if a nurse, tuberculosis; if in a layman, they are not so marked and are generally of a diffuse character; but the specific mental symptoms are nearly always dependent upon some form of mental suggestion, based upon a preconceived knowledge or the suggestion of others. If, for instance, a patient should have a history of carcinoma in the family, he wiU have a dread of that; or if insanity, may fear that he will become insane. Again, patients may develop a curious form of predominating ideas or obsessions; for instance, some will not walk under a ladder, or when going to a theater or church will have a dread of fainting or having a spasm; others will have a fear that the chandelier will fall down or the house wiU catch afire. Again, other persons may have a dread of walking on certain sides of the street or riding backward, or per- chance when going to sleep, if they do not think they say their prayers with the proper amount of devotion, may repeat a number of times until satisfied. If the condition continues, there will develop in the patient the so- called neurasthenic habit, which, after it becomes well established, is diffi- cult to lose. In a well-marked case the patient may cease the occupation previously engaged in and do nothing besides sit all day, and if given an opportunity will constantly talk of herself; and very often when consulting a physician, for fear that she will not remember all of her symptoms, will have long written descriptions of them. Under proper treatment the neu- rasthenic mental condition may become largely alleviated, but nearly always there will remain a neurasthenic tendency. Of course, it is to be understood that the above symptoms are those of the gravest sort of case, and that in the mild form there may only be few manifestations. Physical Symptoms. — ^These will develop in conjunction with the mental, and are manifested in many forms. They may be divided into general, motor, sensory, and special. General. — ^There is nearly always a diminution of the different bodily functions. The patient will nearly always become constipated. The urine may become scanty and concentrated, principally because the neuras- thenic very rarely drinks water. Indigestion is commonly complained of and there is a well-known nervous type. Appetite is generally poor, al- though sometimes the patient may eat voraciously and unusual things, this being especially so in women. There is usually a bad taste in the mouth and there may be flatulence. Often there may be serous and copious evacuations immediately after eating or before the performance of certain mental work, like giving a lecture. Coughing sometimes develops without a respiratory cause and may become distressing. Pulsation of the vessels, especially palpitation, is very common, and often patients will be prevented from sleeping on the left side because of the beating of the heart or of the pulsation of the vessels of the head or Umbs. Insomnia develops in most cases very early, and the patient usually complains of not being able to sleep at all and of feeling much more tired in the morning than on retiring. Often such patients may drop asleep after meals or without any appa- rent cause. Urine examination may sometimes demonstrate an increased 1176 DISEASES OP THE NERVOUS SYSTEM. amount of urates and indican; and blood examination a diminished amount of hemoglobin and of red and white ceUs. Motor. — These develop gradually, and in a well-marked case any mus- cular effort will be followed by great exhaustion, so that some patients are confined to bed. The predominating motor symptom is fatigue. The grip of the hands, as a rule, will be poor, as well as the resistance against movement. Fasicular and sometimes fibrillary tremors in the limbs and muscles of the body, but especially the face, are very common, and when shutting the eyes there is nearly always fluttering of the lids. The reflexes, as a rule, are increased, and rarely, when ankle clonus is attempted, there may be one or two abortive movements. Sensory Sjmiptoms. — These are very common, and, as a rule, are manifested early. The patient usually complains of headache, this being nearly always "at the base of the brain," the occipital region, top or front of the head, and is nearly always described as a pressure sensation or as if a weight were pressing down. Sometimes it is described as a tight band or a "rush of blood to the head." Dizziness is often complained of, and is usually described as a swimming sensation, and is especially present when suddenly rising from a sitting posture. Pain along the spine is very common, and it is only rarely that it is not possible to demonstrate a point of tenderness somewhere along the back, generally in the mid or lower spine, this being described nearly always as a pressing or drawing sensation. Sometimes a drawing or pressure sensation is described in the front of the neck or in the throat. Pain on pressure can also sometimes be demonstrated over the ovarian and inframammary regions in women and inguinal areas in men. Instead of pains it is very common for the patient to complain of burning, itching, numb, or pin-and-needle-like sensations, in various portions of the body, as, for instance, in the limbs, face, and most commonly in the genital region. Special Symptoms. — These depend entirely upon the particular organ involved. Ocular disturbances are perhaps present more frequently than any other, and may be diversely manifested. A patient when reading may have the letters swim together, or have the lines blur, and because of this may be forced to limit his reading. Often dark spots or curious linear and various shaped specks or lines may appear in the visual fields, but it is a fact that they appear only when the patient thinks of them or when some- thing worries him. There may also be a contraction of the visual fields, but this, as a rule, is for white and not for colors; and often there may be a curious rapid alteration in the size of the pupils — so-called hippus. Some- times there may be photophobia or dread of light. In association with the ocular phenomena, or independently of them, there may be disturbance of taste, smell, or hearing. The patients may complain of peculiar taste or odors or of a hissing, buzzing noise in one or both ears. This, however, is not very common. Sexual Neurasthenia. — This generally occurs in young boys or adults, but is sometimes present in girls. It generally occurs in those who are or have been addicted to self-abuse, but may come on independently. As a rule, the symptoms develop in early adult life. If, for instance, a neuras- thenic condition should develop through extraneous causes, such as mental or other worry, and if there should have been in the previous history of such an individual any sexual factor, this will usually be ascribed as the cause. This is unfortunately furthered by the many advertisements of the so- called specialists who gain a livelihood by the furtherance of such doctrines. HYSTEEIA. 1177 The symptoms are various. They may be manifested by impotence, lessened desire, premature ejaculation, frequent nocturnal emissions, or constant seminal discharge. Very often in conjunction with these symp- toms or without thern there may be itching sensations in the genital organs. Summary of Diag:uosis. — A gradually developing functional ner- vous exhaustion whose chief characteristic is an abnormal tendency to mental and physical fatigue, to worry, an exaggeration of symptoms to the detriment of the person concerned, with headache, numbness, pain, insomnia, loss of appetite, indigestion, intestinal difficulty, circulatory disturbance, ocular weakness as shown by the early fatigue in reading, occasionally specks before the eyes, and sexual symptoms. Diflferential Diagnosis.— There should be no difficulty in diagnos- ing this disease by the many symptoms given. It must be remembered, however, that in general paresis the early manifestations may be those of neurasthenia, but in the former there are always pupillary irregularities with diminution in their reactions, disturbance of reflexes, and a general happy, expansive, optimistic mental attitude, which is so different from the selfish depressed mentality of the neurasthenic. Clinical Course and Complications.— The course of a neuras- thenic condition varies according to the severity of the attack, the predis- position of the individual, and the promptness with which treatment is instituted. Mild cases nearly always get well, provided conditions are favorable, but after a neurasthenic habit is once established for a number of years, it is probable that it will become chronic, and although the patient may get well, the slightest untoward influence may bring on a renewal of some of the symptoms. Sometimes there may develop a hypochondriacal condition, but this is not the rule. Hysteria. Definition. — It is almost impossible to give a brief and accurate definition of hysteria because so many symptoms are included under it. It is, however, an altered mental condition resulting from inhibition of mental processes in which the normal relation and appreciation of thoughts, ideas, ordinary occurrences of daily life and of the bodily functions are distorted and falsely appreciated. It is a distinct disease and a grave one, and should not be spoken of and considered lightly — a habit which is only too prevalent, not only among the laity, but among medical men. The reason for this is because its principal symptom is suggestibility, and that many of the symptoms can be alleviated by persuasion. Predisposing and Bxciting Factors. — As in all neuroses, especially is it true in hysteria, that a neuropathic tendency dependent upon such heredity is an important predisposing factor. In the majority of cases there is a history of " nervousness" in early life, and of such diseases as chorea, tic, or of a more or less unstable physical and mental childhood. Again, in others there is no appreciable cause. Sudden fright is perhaps the most frequent exciting cause, and this is especially true of railroad and other accidents, in which it is not so much the physical injury as the mental impression that is the important exciting factor. • It is also noticeable that the character of the symptoms is largely dependent \ipon the exciting cause; for in a person, for instance, who has been injured in the back, the sjrmptoms will be preponderantly present in that area; while in a fright. 1178 DISEASES OF THE NERVOUS SYSTEM. in which one sees another hurt in the knee, there may develop hysterical contracture in that part. Emotional disturbances of any form, sexual errors, and religious excitement are frequent causes. Imitation plays an important role, for often whole communities may become hysterical. It must also be remembered that functional symptoms often accompany or comphcate organic diseases, as in early multiple sclerosis, and as comphca- tions of various infectious diseases they are not infrequent. Not every patient, however, will develop hysteria due to fright or other causes, and it may be necessary to have a tendency to the disease which may consist in an altered physical and mental condition or an unstable nervous system. It is much more common in women than in men, although serious cases are seen in the male. It usually occurs in young adults, generally about the twentieth year, but is not at all infrequent in children. It is peculiarly prevalent among the Slavs and the Jewish race, who have a tendency to so-called functional disorders. Sytnptoins. — It is difficult to describe the symptoms of hysteria, because they vary greatly, for one case hardly ever has the identical symptoms of another. Again, we hardly ever see in this country the grave forms which are so common in Europe, and especially in France. All hysterical symp- toms, however, have a certain general resemblance : first, they are dependent upon a "functional" basis, because they appear and disappear and leave no trace; second, their suggestibility, in the sense that most of the symptoms can be suggested; third, they may be made to disappear by persuasion; fourth, there are certain symptoms known as " stigmata" which are present in nearly all cases, these being principally of a sensory nature; and, lastly, in all cases, whether the symptoms are mild or severe, there may occur convulsions or spasms, which, while they differ greatly in their form, have a certain general resemblance to each other. For the purpose of facility in description, and not because the symptoms appear in this manner, divi- sion will be made into mental, physical, sensory, motor, and special. Mental. — Hysterical patients generally describe themselves as "ner- vous," and are highly impressionable, emotional, irritable, sometimes irra- tional, and are given to extremes of passion. In a well-marked case the patient's own condition is the principal burden of thought, and all occur- rences will be made to apply to themselves. They generally complain of loss of memory and inability to concentrate, although it is possible some- times for them to do highly creditable mental work. The more severe mental symptoms, such as those which occur in hysterical spasms, wiU be described under that head. Physical and Visceral S3miptoms. — There is, as a rule, lessening of the bodily activities, but sometimes the patient may apparently be in per- fect physical health and still have the gravest form of hysteria. There may be diminution in the amount of hemoglobin, and the quantity of urine may be increased or diminished and there may be frequent urination. Loss of appetite and indigestion are very common, and constipation is a constant fault. Not infrequently there may be involuntary evacuations from the bowel, and sometimes there may be excreted casts of the intestinal wall. Borborygmi, or rumbling of the bowels, and sometimes so-called phantom tumors of the abdomen, resulting from localized gaseous swelling of the intestines, may be present. Flatulence and gaseous eructations are com- plained of, and there may sometimes be excessive vomiting, with or without nausea. The heart action, as a rule, is not disturbed, but palpitation is not uncommon, and is usually associated with pain over the precordial HYSTERIA. 1179 area, and often there may he pHeudo-angina pectoris. The pulse-rate may be altered and rapid, but, as a rule, its rate is not disturbed. Hysterical cough is quite c(jmmon, and hiccough is frequent and may last for days. The respiratory rate is, as a rule, not disturbed, but there may be all sorts of alterations, consisting in repeated sighing, sobbing, sneezing, laughing, or crying. Aphonia or loss of voice is frequent, and may come on suddenly, the patient not toeing able to talk at all or only in a whisper. The tempera- ture, as a rule, is not altered, but elevation, even as far as 10.5° F., has been reported, but its occurrence is doubtful. Vasomotor and trophic dis- turbances may occur, and consist in flushing of the skin, excessive or per- verted sweating, and, rarely, skin erup- tions of various sorts. Sensory Symptoms. — Headache is common, especially in the back or top of the head, and is usually described as a boring, aching pain, and sometimes as if a nail were driven into the skull, or as a tight l)anfl or a drawing sensation. There is nearly always pain and some point of tendei'ness in the spine, espe- cially in the middle and lower portions (Fig. 446). Pain on pressure is almost constant over both ovarian and infra- mammary regions in women and the inguinal areas in men. Because of the frequency of these hypersensitive areas over the back, ovarian, inguinal, and inframammary areas, they are com- monly known as the sensory atiginata of hysteria (Fig. 447). Often pressui'e over one of these so-called hysterogenic areas will produce or stop a hysterical spasm. Pains of a diffuse character may be present anywhere, — in the eye, ear, nose, etc., — and are especially com- mon in the throat, where they are de- scribed as drawing or band-like, anrl sometimes as a ball — so-called " globus hystericus." In fact, there is hardly a place in the body where pains may not be present. Numbness, tingling, pin-and-needle, or dead-like sensations are often complained of in the limbs, body, and frequently in tire rectal and genital organs. Diminution or loss of sensation is present in nearly all cases of hysteria. It is characteristic of these and all other sensory symptoms that they may vary from day to day or in successive examinations, either Ijecause of sugges- tion or other cause, and that the patient may be not at all aware of their presence until an examination is made. Because of this it is thought by some neurologists that sensory symptoms are nearly always the result of suggestion by the examiner. Hemianesthesia is quite common and its Fifi. 44G Areas of Pain, Tenderness, AND Anesthesia in Hysteria. 1180 DISEASES OF THE NERVOUS SYSTEM. form is characteristic. It is limited entirely to one-half the body, and the moment parts past the median line are approached recognition is prompt. It nearly always involves all forms of sensation, that is, touch, pain, temper- ature, and often vibratory and electric stimulation, and is sometimes asso- ciated with loss of half-vision on the same side. It can be differentiated from organic hemianesthesia by the fact that the latter is never limited by the median hne, Ijut nearly always projects over; that it is rarely complete for touch, pain, and temperature, and the loss of sensation is always more marked in the peripheral than in the central parts of the hmb (Fig. 449). Again, it is nearly always in association with some motor symptom, and, most important of all, it is permanent and cannot be modified liy suggestion. Hys- terical anesthesia nearly always involves all forms, sometimes only pain and temperature sensations, and hardly ever touch alone. Over the anesthetic areas there may be vasomotor disturbance, demonstrated by the fact that pricking by a pin will not cause immediate flow of blood. In conjunction with loss of Hystero- genic zfine Fig. 447. — Hysterogenic Zone in Hysteria. Fig. 448. — Loc.\tion of Pain and Tendehness IN Hysteria. sensation there may be loss or disturbance of muscle sense or of some of the special senses, as sight, hearing, taste, and smell. Motor Symptoms. — These vary greatly, and may be of either an irri- tative or a paralj'tic nature. Tremors are common, and may consist only of a fluttering of the eyelids, of twitching or fasicular movements of the muscles of the face, or of violent movements of a limb. They may be present for j^ears, and usually cease during sleep. It is characteristic that their rate and character may alter as the result of suggestion, and when the patient's attention is attracted elsewhere, may cease for a time. HYSTERIA. 1181 The tendon and superficial reflexes, as a rule, are exaggerated. It has been a mooted question as to whether ankle clonus can occur in hysteria, but its presence in rare cases is undoubted. It has a distinct character which renders its recognition easy. As a rule, when obtaining ankle clonus in an organic disease it is best to bend the leg on the thigh, and sometimes a true ankle clonus can be obtained only when this is done. On the other hand, hysterical ankle clonus can be obtained •\\'hen the leg is fully extended on the thigh and the foot is suddenly bent forward. In organic cases the movements are rhythmic, the rate never varying; its intensity gradually becomes exhausted, while in hys- teria the movements may he irreg- ularly rapid or slow, and can be kept up sometimes indefinitely, and de- FlG. 449. — Hysterical Hemianesthesia, show- Fig, 4.50. — Hysterical Anesthesia of Lower ING THE Absolute Limitation to the Me- Limbs. DiAN Line. pend entirely upon the mental condition of the individual. (Personally I have observed this in a number of cases, and have at one time obtained ankle clonus in a hysterical patient for over ten minutes. I have also obtained patellar clonus in hysteria, its character being similar to the hysterical ankle clonus.) There are certain reflexes which are very often absent in hysteria, which are of diagnostic value. Among these is the pharyngeal reflex, in which it is possible to irritate the pharynx without producing gagging. Again, 1182 DISEASES OF THE NERVOUS SYSTEM. when irritating the nasal mucous membrane there is, as a rule, a flow of tears, while in hj'steria this may be absent. Sometimes, also, irritation of the cornea does not produce winking. This is nearly always associated with anesthesia of the cornea. It is also sometimes possible to pass a stomach- FiG. 451. — Tonic Phase, the Tongue Roi.ung from One Angle of the Mouth to the Other (Richer). tube in hysterical patients without the slightest resistance, due to the anesthesia of the parts concerned. Hysterical paralysis is quite common, and, like anesthesia, varies greatly. It usually comes on suddenly, and may involve one-half of the body, so- FiG. 4.52. — Schem.^tic Representation of the Wide Tonic Movements (Richer). called hysterical hemiplegia. It can be distinguished from an organic lesion by the fact that the lower part of the face is hardl}' ever involved, and that there is either complete flaccidity or exaggerated tonicity in the Fig. 453. — Tonic Phase, Circumduction Movements of Upper Members (Richer). paralyzed limbs, and, most important of all, the Babinski reflex can never be demonstrated. Again, in walking there is not the typical hemiplegic gait, the leg being dragged instead of swung around, as in organic hemiplegia. HYSTERIA. 1183 Hysterical hemiplegia is hardly as common, however, as paraplegia, which occurs especially after railroad injuries. There may be paralysis of both upper and lower limbs or of one limb. Weakness of the lower limbs, with giving way of the limbs when walking, is sometimes called astasia abasia. Hysterical paralysis may be recognized by the suddenness of the onset, the extreme exaggeration or fiaccidity of tone, the absence of the Babinski Fig. 4o4. — Clonic Phase, Schematic Representation of Clonic Movements (Richer). refie.x, and in association there are nearly alwaj's hysterical sensory stigmata, and, most important of all, the paralyses may be altered or relieved Ijy suggestion. Paralysis of an eyelid, so-called spastic lid paralysis, is rarely seen, and ocular paralyses are very uncommon. Involvement of the vocal cords has already been mentioned. Fig. 455. — Phase of Resolution (Richer), Hysterical contractures are common and may develop with or without paralysis. The form of the contracture differs from the organic variety and may assume any shape. For instance, in organic hemiplegia the con- tracture in the upper limbs is greater in the flexor, and in the lower in the extensor, distribution. In hysteria this may be reversed. Again, in the Fig. 456. — Phase of Resolution, Retaining Partial Contractures (Richer). functional condition the contracture may come on without paralysis, and the distortion may be extreme. It may cease during sleep and is usually absent during ether narcosis. Convulsions may appear in any hysterical patient, but they are not as common in this country as in continental Europe. The attacks usually 1184 DISEASES OF THE NERVOUS SYSTEM. have certain recognized stages. They may come on at any time, either suddenly or there ma}' 1)6 a so-called prodromal period, which may last for a day or longer, in which the patient becomes irritable, depressed, emotional, Fig. 4.57. — Posterior Arc de Cercle (Richer). or somnolent, and sometimes maniacal. There is usually a so-called hysteri- cal aura, which consists of a .sensation of a l^all rising from the stomach to the throat, and is known as globus hystericus. This is succeeded by the epileptoid stage, which hardly ever lasts more than a few minutes. The Fig. 458. — .Interior Arc de Cercle (Knobloch). movements are characteristic, the patient usually throwing the limbs in a wild, irregular manner, the back is usually rigid and arched, and while there may iDe at first a tonic movement, which is succeeded by a clonic, this is not constant. It is then succeeded by the third or so-called emotional Fig. 459. — L.\tera.l .Arc de Cercle (Richer). or passionate stage, in which the patient assumes different attitudes, de- pencling upon whatever hallucinations may happen to pos.sess him, and may consist either in expression of wild exhilaration, joy, anger, or passion. HYSTERIA. 1185 This may last for several hours or longer, and then is succeeded by the last stage, during which the patient generally quiets down and passes into a deep sleep or may have various hallucinations or deliriums. These attacks can be differentiated from epilepsy by the fact that there is no epileptic cry, there is hardly ever frothing at the mouth or passing of urine, and while Fig. 460. — P.issional Attitude of Struggling WITH AN Ass.AiLANT (Richer). Fig. 461. — P-issional Attitude OF Solicitation (Richer). there may be clouding of consciousness, there never is absolute loss of memory and there is not the typical tonic and clonic succession of move- ments which is so characteristic of the organic disease. This is hysteria major. Instead of the typical succession described above there may be only a Fig. 462.— Zoopsia (Richer). Fig. 463. — Delirium of the Fourth Period (Richer). so-called mild attack, or hysteria minor, in which the patient is suddenly launched into any of the stages described or may become cataleptic, in which there is both physical and mental inertia, and in which it is possible to bend the limbs in any direction, they remaining in the position in which they are placed; or he may pass into a deeper mental stupor, lethargy, or 75 1186 DISEASES OF THE NERVOUS SYSTEM. Right Left Flu 464— HtSTEHICAL CO^CENTBlC Co%TRlCTION OF ViBUAL FlELD OF RiGHT Ete; AMAUROSIS OF Left Eye (Tourette). Fig. 465 — Hysterical Bilateral Concentric Contraction of Visual Fields (Tourette). Fig. 466. — Concentric Retraction of Visual Fields for Colors Usually Found in Hysteria (Souques). Red field inclosed thus: + + +; -nhite field, ; blue field, ; green field, H i 1- . HYSTERIA. 1137 trance. Rarely there may be so-called automatic ambulatory automatism, in which the patient wanders for days at a time, performs apparently normal acts, and has only a faint recollection of what has happened in the interim, or there may be disturbance of sleep or somnambulism. The usual hysterical spasm, however, seen in this country is different from that described. It usually comes on quite suddenly, with an emotional outburst, or may be brought about by pressure on any of the hysterogenic areas and may be stopped in a similar manner, the patient falling to the ground but never hurting herself, and nearly always in the presence of others whose sympathy she desires to arouse. Usually the patient assumes a rigid attitude, the back is arched and rigid, and the limbs are thrown about in a wild, irregular manner, the whole lasting from a few minutes to an hour or longer. There is hardly ever loss of consciousness, the patient being nearly always able to describe what has happened during the spasm. Special Symptoms. — ^Under this head will be discussed those phenomena which are concerned principally with the special senses, for many of the so-called special symptoms have been described under the physical. Ocular Symptoms. — ^These are quite common and vary greatly. They may consist only in a photophobia or pain in the eye, flashes of light in the visual fields, and total loss of vision in one or both eyes. Amblyopia, however, is not very common, and its occurrence is somewhat doubtful. Hemianopsia has also been reported in hysteria, but it is probable that its occurrence is also somewhat doubtful. The most common ocular manifes- tation of hysteria, however, is the concentric, regular, or irregular contrac- tion of the visual fields. This is usually for form and color, but either may be present alone. Quite commonly there is reversion of the color fields, or there may be a loss of vision for certain colors or a distortion to one color only. There may be loss of the central field of vision, the per- ipheral being intact, or a so-called tubular field in which the patient is able to see only in a certain limited area for both near and far points. Still more rarely there may be enlargement of the visual fields (Figs. 464- 466). Loss of smell or taste or perversion of these functions is quite common. It may be present only on one side, but it is generally bilateral. There may also be buzzing, hissing noises in the ear or loss of hearing, but nerve tests will always demonstrate an intact auditory nerve. Summary of Diagnosis. — A peculiar mental and physical condition, characterized by suggestibility of symptoms which may be of any character. The patient is usually a young adult who is emotional, irritable, and one who constantly complains and thinks of herself, and perverts everjrthing which may occur as having something to do with her own condition. There may be headache, backache, pains in various portions of the limbs, numbness or pin-and-needle-like sensations, hemianesthesia or anesthesia anywhere, points of tenderness in the back, ovarian, and mammary region, increase of reflexes, paralyses of various sorts, contractures, tremors, disturbance of vision, smell, and taste, and convulsive attacks which may assume almost any character. The most important point of all is the suggestibility of all the symptoms, their variance from day to day, and the fact that any or all may be removed by persuasion. Clinical Course and Complications. — The course of the dis- ease varies greatly, and depends upon its intensity. In most cases the symptoms can be alleviated to a large degree, but in a well-marked case, after the symptoms have been well established, it is rather difficult to effect llgg DISEASES OF THE NERVOUS SYSTEM. a permanent cure. Sometimes the symptoms progress to such an extent that the patient becomes bedridden. Trauhatic Neuroses. Under this head will be discussed those functional nervous disorders which result from injury. Most patients present the symptoms of both neurasthenia and hysteria, and therefore it is inadvisable to discuss them under a separate classification. The degree of the injury in many cases is no criterion of the symptoms that may develop, for very often the slightest trauma may produce the severest neurosis. In some cases it is not so much the injury as the accompanjdng mental fright which produces the symptoms, and often fright alone is the sole causal factor. It is a matter of common knowledge that not every person who is hurt develops a neurosis, and its occurrence is somewhat dependent upon the health of the individual at the time of the injury and the presence of a neuropathic tendency. Another factor which enters into the promulgation of the symptoms is the fact that most of these cases become sources of litigation. Corpora- tions or those who are responsible for the injury nearly always assume the attitude that there is not much the matter with the patient, and create in the mind of the litigant a resentful attitude — a factor which does not tend to alleviate the symptoms. On the other hand, very often, for the sake of money, the patient will consciously or unconsciously exaggerate the symptoms, seeing in each a possible source of income. This is furthered by the constant examination of different physicians and lawyers. It is therefore best for the patient, from the medical standpoint, to settle the case promptly. It must be remembered, however, that while it is the rule that most neurotic symptoms are increased during the course of liti- gation and tend to diminish after its disposition, there are exceptions, and there may be present the severest form of neuroses when there is no question whatever of litigation. Symptoms. — ^These vary largely, and depend upon the previous history of the patient and the nature and severity of the accident. As has already been mentioned, the severest form of neuroses may develop from the mildest form of injury. Again, it must be remembered that so-called neuroses are associated nearly always with actual injuries to the brain, the spinal cord, or the muscular structures, and that it is necessary in forming an opinion to carefully exclude an organic basis. In most instances the symp- toms are those of both hysteria and neurasthenia, and do not differ from those which have been described under the separate headings. It is only necessary to add that the symptoms come on promptly, and that their specific nature will depend somewhat upon the form of the injury. For instance, a patient who is hurt in the back may develop so-called traumatic lumbago, in which the pain may become so excessive that movement of the trunk and limbs will be almost impossible. This may last for years, and is sometimes dependent upon an actual change in some of the ligamentous and muscular structures about the vertebra. Tremor is common and may be violent. Often in association with tremor of the lower limbs there is produced a pseudo-patellar and ankle clonus, especially when there is an accompanying hysterical paralysis. Paralysis of both lower limbs is prob- ably more common than any other form, especially when there has been an injury to the lower part of the back, and there should be no difficulty in recognizing its hysterical character. GENERAL PARESIS. 1189 In the ordinary cases of injury, however, in which the patient is only jarred up slightly, there will usually be excessive nervousness, irritability, emotionalism, loss of sleep, anorexia, loss of memory, inability to concen- trate or do work, and muscular fatigue. Examination will nearly always demonstrate a hemihypesthesia or anesthesia with increase of reflexes, and the usual hysterogenic zones of hysteria with tremor; and if there happens to be contusion or injury of a certain part, great tenderness of this area. Clinical Course and Complications.— This, of course, depends upon the nature and severity of the injury and the influence of litigation. While, as has already been emphasized, most patients improve after their case is settled, there are very frequent exceptions to this rule. General Paresis. Definition. — This disease is known under various terms, such as general paralysis of the insane, paresis, paralytic dementia, and "soften- ing of the brain." It is a disease of the brain characterized by progressive diminution of the mental faculties, terminating in total dementia and accompanied by progressive paralysis of different portions of the body. Pathologically there is found a diminution in the size of the brain, with lessening of its weight, and atrophy or shrinking of the convolutions, especially in the frontal and to a less extent in the motor and sensory por- tions, with a widening of the intermediate fissures and thickening of the pia-arachnoid, often with adhesions to the underl}dng cortex. Microscopi- cally there is a marked degeneration of the cortical cells, with infiltration of round cells, destruction of the nerve tissue, and thickening of the vessels, which is present in nearly all parts of the brain. Similar changes are often found in the spinal cord. Sometimes in the so-called tabetic form of paresis the disease involves equally the brain and cord, and for a long time the spinal cord symptoms predominate, but pathologically the process attacks equally both structures. Predisposing and Bxciting Factors. — A previous history of insanity or paresis in the parents or some neuropathic disease is found in about one-third of the cases. No better evidence of the importance of heredity in the production of this disease can be had than the fact that there is a tj^e of paresis appearing in infants, known as the juvenile form. There is obtained in about 60 per cent, of the cases a previous history of syphihs, and it is the opinion of many that almost every case is due to that disease. However that may be, it is a fact that in certain countries in which syphilis is common, as in China, paresis is rare; so, besides the occurrence of syphilis, which is all-important, there must be some predisposition for the disease. Overwork, mental worry, alcoholic and other excesses are often given as causes. Symptoms. — The disease occurs more often in men, and usually mani- fests itself about the thirty-fifth year. The symptoms are generally slow in onset, although rarely they may be ushered in with an epileptoid or hemi- plegic attack. In the ordinary case there are present for many years such symptoms, which are usually recognized as neurasthenic, and it is im- portant, therefore, to examine every neurasthenic for the physical symptoms of paresis. There is in most cases a slow change in disposition, and a per- son who had previously been living a moral hfe may now begin to live loosely and indulge in sexual, alcohohc, and other excesses. His habits 1190 DISEASES OF THE NERVOUS SYSTEM. gradually change, and he becomes more or less irritable, forgetful, and somewhat emotional. He may complain of headache, dizziness, and may have an indefinite sensation that there is something the matter with him, and may often have fits of depression; but, as a rule, most paretics, in contra- distinction to neurasthenics, do not dwell very much upon their own symp- toms. This preliminary stage may last for a year or longer, constantly increases, and the patient becomes more or less irresponsible, does not attend to his business, and begins now to have certain physical symptoms. These generally consist in a tremor in the hands, producing tremulous writing. Tremor is especially manifest in the muscles of the face, and can be demonstrated when closing the eyes or showing the teeth, being at first fine and becoming more marked as the muscular action is continued. The tremor not only involves the facial muscles, but also those which are con- cerned with speech, and gradually it is noticed that the patient has diffi- culty in pronunciation, and such test words as "truly rural," "fibrillary," "February," and "perspicacity" are slurred over and pronounced with difficulty. The pupils become irregular and their reactions to light and movement become gradually diminished and finally are lost, and there may be the so-called Argyll-Robertson pupil. Temporary ocular palsies are not at all uncommon, the patient complaining of seeing double for two or three days or longer at a time, this disappearing and reappearing and sometimes becoming permanent. The reflexes generally become increased and irregular, and it is not at all infrequent to find one knee jerk more prompt than the other or lost. Ataxia sometimes is present in both the upper and lower limbs, and hearing is often interfered with, and there may occasionally be dizziness. Coincident with these physical stigmata, the mental symptoms develop. These generally consist in a growing irresponsibility of the patient, who now has well-marked loss of memory for current and past events, may have no idea of time or space, and the whole mental attitude is one of general good nature, cheerfulness, and irresponsibility, the patient on questioning always saying that he is well, is not sick, and there is not much the matter with him. Delusions may develop very early, and are expansive in type, the patient in a well-marked case claiming that he or she may be the richest person in the world, may possess untold strength, may be a deity, or may have any other idea of grandeur. These patients become very extravagant, buy things without any need for them, and will give away anjrthing they possess and many things they do not. As the disease progresses dementia gradually supervenes, until finally the patient is a hopeless dement. Coin- cidently the physical sj'^mptoms increase, the tremor becomes very marked, and the patient will become bedridden. They usually die from an apoplectic attack or uremia. Differential Diagnosis. — This disease is considered here principally because in its early forms it may resemble neurasthenia. There is this difference, however, that while in paresis the patient will complain of indefinite headache, pains, insomnia, and all sorts of trouble, he will not, as a rule, disoiss these as does the neurasthenic, and generally assumes an optimistic attitude. There may be in both a tremor of the facial muscles. In fact, in neurasthenia this is quite common, but in paresis the tremor may interfere with speech, which is not the rule in neurasthenia. In paresis there gradually develops such physical symptoms as irregularity of the pupil with diminution of the light reflexes, and either increased or diminished tendon reflexes. In neurasthenia these are not present. Lastly, in paresis there wUl gradually develop extensive delusions, which are never present MIGRAINE. 1191 in neurasthenia, and lumbar puncture will demonstrate the usual changes found in syphilitic disease, and the Wassermann reaction. Migraine (sick headche , hemicrania). Definition. — A disease characterized by paroxysmal attacks of headache, usually preceded by sensory irritation, especially ocular, and followed by nausea and vomiting. Pathologically no cause has been found. There are two theories: one, that it is the result of autointoxication, especially gastro-intestinal; the other, and the more probable, that it is a cortical disease similar in type to epilepsy. Heredity plays an important r61e in the development of the disease, and most persons who suffer from it have a history of some organic or func- tional nervous disease in the parents. The symptoms nearly always develop either before the tenth year or at the time of puberty, and very rarely after the twenty-fifth year, and are such as would be obtained from cortical irritation. Taking these facts into consideration, it is probable that the disease is not an autointoxication in the sense that it is not an acquired disease, but that those who are migrainous have a congenital tendency for it, and that extraneous causes, such as gastro-intestinal or other forms of intoxication or irritation, bring on the attacks. Sjrmptoms. — ^The disease is slightly more common in the female sex. The development of the attacks is, as a rule, gradual. In the history of most patients they come on either before or at the time of puberty, and are characterized as sick headaches, and, as a rule, are not at first of great intensity. Gradually the attacks attain the typical characteristics of the disease. They may come on periodically, especially in women at the time of the monthly period, or may be brought about by different forms of irritation, such as mental worry, eye-strain, gastro-intestinal disturbances, or, in fact, any cause may bring on an attack. The character and frequency of the attacks of course' varies. As a rule, patients are aware of the onset, and there may be either a sense of exhilaration and well-being from a few hours to a day, or the patient may feel depressed, irritable, and sleepy. Occasionally there are no prodromal symptoms, the patient waking up in the morning with headache. In about one-third of the attacks there is a preliminary sense of irritation, which is nearly always ocular. This may vary from a sense of pain in the eye, photophobia, occasional flashes of light in the whole or part of the field to the zig-zag, round, or various shaped bright colored lights which are so characteristic of the attacks. These ocular irritative symptoms may be manifested in the whole or part of the visual fields, corresponding to a hemianopic distribution, and are sometimes followed by a typical homony- mous hemianopsia which may last for several hours. Shutting the eyes does not stop them. They may last from a few to ten or fifteen minutes, and are succeeded by the headache. Pain in the head may be first localized to one spot, generally the temple, and then rapidly spreads over one side of the head, and rarely to both. The headache is nearly always localized to the temporal area, but may be in the frontal or occipital regions. The scalp is generally tender to pressure, although there is no pain over the exit points of the fifth nerve. The headache may last from one to twenty-four or more hours, but the ordinary pain lasts only for two or three hours. During its height the patient feels weak, exhausted, and prefers to be in a darkened room, because irritation or movement of 1192 DISEASES OF THE NERVOUS SYSTEM. any sort will increase the pain, although sometimes pressure over the head will cause a sense of relief. Generally at the height of the headache nausea develops, the patient feeUng sick in the stomach, with a tendency to vomit at first the contents of the stomach and then bile, the retching sometimes being distressing. Generally after the nausea and vomiting the headache is relieved, and the patient, after sleeping for some time, generally wakes up in a fairly good condition. Sometimes instead of the usual ocular irritative phenomena there may be a tingling or numbness on one side of the face, neck, or upper or lower limb; in fact, it may resemble closely the so-called sensory central pains occurring as a result of parietal or other sensory lesions. More rarely there may be motor symptoms, such as drooping of one upper lid with diplopia and diminution of vision, sometimes called ophthalmic migraine, or temporary weakness of an upper or lower limb, and, more rarely still, a temporary sensory or motor aphasia, all these symptoms indicating a possible cortical origin. Rarely mental symptoms complicate the attacks. Because of the chron- icity of the disease these patients acquire a so-called migrainous habit in which they learn to do or not to do certain things which have an influence upon the frequency of their attacks. Again, there may sometimes be, preceding or during an attack or following it, confusion, loss of memory, and a mental irritability, this varying greatly in different cases. In a fair percentage of patients vasomotor symptoms may precede the headache or may accompany the sensory irritative phenomena. This may consist in either a unilateral or bilateral pallor of the skin, especially of the face and rarely of the extremities, followed by profuse sweating, or there is a flushing of the skin with marked throbbing of the vessels and rarely dilatation of the pupil. These vasomotor symptoms may last from a few minutes to an hour or longer. Summary of Diagnosis. — Paroxysmal headache, usually preceded by sensory irritative phenomena, such as flashes of light, tingling of one side of the face or limbs, lasting from ten to twenty minutes, succeeded by headache generally starting in the temporal area and involving one or both sides of the head, which may last from one to twenty-four hours. At the height of the headache nausea, and vomiting, this usually relieving the head- ache. This is followed by sleep, the patient generally waking up in fairly good condition. Clinical Course and Complications. — Most patients with an established migrainous habit have a tendency to recurring attacks, al- though in women after the menopause and in men after the fiftieth year there is a tendency .to cessation. The occurrence of the disease has no influence upon the length of life. Treatment, of course, has a direct bearing upon the length and course of the disease. Pellagra. _ Diefinition. — A disease characterized by gastro-intestinal and cerebro- spinal irritation, with skin eruptions on the exposed parts of the body, especially over the extensor surfaces of the hands, accompanied by prostra- tion. Contributing and i^xciting Factors.— Up to 1901 it was thought to be endemic to Italy and the countries surrounding the Mediterranean Sea and confined to people who subsisted on com. Since 1901 many cases have PELLAGRA. 1193 been described in the United States, and especially in the south, particularly in the asylums for the insane, but cases have been found in the north, and I have seen one in Philadelphia (March, 1910), this probably being the first to be observed in Pennsylvania. Sporadic cases were described in the United States previous to 1901. It has been thought that the disease was of a toxic nature, due to the eating of maize, whether or not decomposed. It is probable, however, that the com theory will have to be discarded, because authentic cases have been described, as in my case, in which there has been no suggestion of the eating of com. At the present time no explanation for the disease can be offered, other than that it is of a toxic nature, the cause not being definitely known. Symptoms. — ^The onset varies considerably, but inasmuch as in a well- established case there are present gastro-intestinal, skin, and cerebrospinal symptoms, these will be described separately, although it is to be understood that they may appear at the same time. Gastro-intestinal Symptoms. — These usually consist in a stomatitis, gastric distress and pains„ vomiting, and especially diarrhea. They may come on very early in the disease and be very intense, and then again chronic. The stools may have mucus or blood. Ulcers in the mouth are very common. Dermatitis. — Skin symptoms, as a rule, come on in the early spring, and are generally manifest over the exposed parts of the body, especially over the extensor surface of the hands and forearm as far as the elbow. They are less common over the face, and rarely present over the dorsum of the feet and chest. They are usually ushered in by blebs containing gela- tinous fluid, which burst and form a crust, underneath which a raw surface appears. The eruption may be dry or wet and has a tendency to fade gradually and disappear and, as a mle, reappear the following spring. Instead of the eruptions there may be only an erythematous condition of the skin of varying intensity. Nervous Symptoms. — ^These vary. It is not at all uncommon for pel- lagra to be ushered in with general neurasthenic symptoms. 'There may be fibrillary and coarse tremors in various parts of the body, weakness of the limbs, and generally increase of reflexes. The mental symptoms vary; the patient may be depressed, refusing to eat and drink, and again may be noisy and maniacal. As a rule, there is present a dull apathetic condition. Chronic delirium or pellagrous mania has been described. In Italian coun- tries pellagrous insanity is quite common, and may be of different kinds. General Symptoms. — ^Fever is uncommon. Examination of the blood has shown a diminished amount of hemoglobin, and often changes which are common in pemicious anemia. Semm diagnosis so far has been negative. Summary of Diagnosis. — A disease occurring mostly in damp or tro- pical countries and among people who eat corn, the symptoms consisting of eraptions on the extensor surface of the hand and exposed parts of the body, accompanied by gastro-intestinal irritation and cerebrospinal symptoms. _ Differential Diagnosis. — ^There should be no difficulty in diagnosing this disease, the presence of the skin emption over the extensor surface of the hands and exposed parts of the body being the most important diagnostic symptom. Clinical Course and Complications. — The disease has a tendency to become chronic, and recurrences are frequent. The mortality is variously estimated in d^erent coimtries, and may be as high as 50 per cent., but in the great majority of cases recovery can be hoped for. INDEX. Abdomen, contour of, 426 contraction of, 423 distention of, 423 enlargement of, 426, 427 examination of, 418 growths in, 441, 442 hernial protrusion of, 424 inspection, 46, 423 landmarks of, 420 movable mass in, 440 movements of, 425 obese, 426 Obrastjow's division of, 443 pain in, 422, 442, 443. See also Pain, ■ abdominal. palpation, 440 pendulous, 426 posterior view, skiagraph of, 636 quadrants of, 419, 420 regions of, 418 viscera in, 420 retracted, 426 scaphoid, 426 size of, 426 skin of, 423, 425 spasm of, 1168 succussion sounds originating in, 506 topography of, 418 veins of, diagnostic value, 423, 425 wall of, atrophy of, 424 increased resistance of, 441 relaxation of, gastroptosis from, 511 thickness, 424 Abdominal aorta, aneurism of, 320 reflex, 1017 tension, method of determining, 500, 538 viscera, physical examination of, 28 Abducens nerve, 1038 Abscess, hepatic, 587 after scalp wounds, 588 amebic, 966, 982 carcinoma and, differentiation, 585, 590 chills in, 588 cirrhosis and, differentiation, 580 climate in etiology of, 588 colic and, differentiation, 590 cough in^ 589 differential diagnosis, 590 echinococcus cyst and, differentia- tion, 590 fever in, 589, 690 from dysentery, 588 from gaU-bladder diseases, 588 Abscess, hepatic, from gastric ulcer, 588 gastro-intestinal tract in, 588 in amebic dysentery, 966, 982 in cholelithiasis, 612 malaria and, differentiation, 590 pain in, 588 pleurisy with effusion and, differen- tiation, 152 pneumothorax from, 161 hepatopulmonary, in amebic dysentery, 966 in endocarditis, 256 in varicella, 908 intermittent fever and, differentiation, 950 localized, precordial pain from, 170 of brain, 1071 of esophagus, pneumothorax from, 161 of lung, 121. See also Pulmonary ab- scess. of mediastinum, 322 perinephritic, 695 appendicitis and, differentiation, 542 course, 700 differential diagnosis, 700 laboratory diagnosis, 699 pain in, 697 physical signs in, 697 pyelitis and, differentiation, 688, 700 secondary, 697 suprarenal growths and, differentia- tion, 688 typhhtis with colonic impaction and, differentiation, 688 peritonsillar, 722 pulmonary, 121. See also Pulmonary retropharyngeal, 403 stomach, 487 subdiaphragmatic, 76, 586. See also Peritonitis, subphrenic. subphrenic, pneumothorax and, differ- entiation, 166 Acclimation fever, 767 Acetic acid and potassium ferrocyanid test for albumin, 646 in gastric contents, 469 Acetone in gastric contents, 470 Acetonuria, 656 diabetic, 656 febrile, 656 Achilles jerk, 1017 tendon, neuralgia of, 1150 AchiUodynia, 1150 1195 1196 INDEX. Achlorhydria, 466 Acid-fast bacilli, 794 Acidity of gastric contents, clinical sig- nificance, 468 total, 464, 465 Acrocyanosis, 1151 Acromegaly, 1156 Acroparesthesia, 1150 Actinomyces in urine, 703 Actinomycosis, 919 of thorax, bronchiectasis and, differ- entiation, 102 pulmonary, 130, 920 carcinoma and, diffarentiation, 922 differential diagnosis, 922 echinococcus cyst and, differentia- tion, 922 syphUis and, differentiation, 922 tuberculosis and, differentiation, 818, 922 sputum in diagnosis, 82, 922 Acute anterior poliomyelitis, 843 infectious diseases, 715 Addison's disease, 702 differential diagnosis, 703 Adenitis, cervical, tuberculous, 822 in varicella, 908 pulmonary tuberculosis and, 38 Adenoma of brain, 1060 Adhesions, intestinal obstruction, 526 a;-ray diagnosis, 74 Adiposis dolorosa, 1154 tuberosa simplex, 1011 Agglutinins, 20 Albimiin colloidal coefficient in appendi- citis, 539 in cancer, 501 in diabetes, 998 in endocarditis, 258 elimination, anemia and, 355 in lu'ine, 643. See also Albuminuria. Albuminometer, Esbach's, 647 Albuminous sputum, 77, 80 Albuminuria, 643 acetic acid and potassium ferrocyanid test for, 646 alimentary, 644 Boston's pipet test for, 645 cyclic, 614, 615 Esbach's quantitative test, 646 extrarenal causes, 644 heat and nitric acid test for, 646 Heller's test for, 646 in diphtheria, 871 in pancreatic cyst, 625 in pyeUtis, 687 in variola, 904 intermittent, 644 orthostatic, 644, 645 parasitic, 645 pipet test for, 645 postural, 644 prostatic, 645 remittent, 644 renal, 643 tests for, 645 Albuminuria, toxic, 644 traumatic, 644 Albumosuria, Bence-Jones, 1004 Alcohol Uver, 576, 598. See also Cir- rhosis, atrophic. AUochiria, 1023 Allotriophagia, 430 Aloin-turpentine test for blood in feces, 515 Alternating pulse, 198 Amaurotic family idiocy, 1153 Amboceptor control in Noguchi reaction, 347 Amebic abscess of liver, 982 of lung, 130, 988 dysentery, 963. See also Dysentery, amebic. Amenorrhea in pulmonary tuberculosis, 810 Amoeba coh in sputum, 82 Amphoric resonance, 61 tinkle, 72 Amyloid disease in puhnonary tubercu- losis, 819 leukemia and, differentiation, 371 of intestine, 536 of Uver, 593 fatty infiltration and, differentia^ tion, 592 outhne of hver in, 595 of spleen, 627 outline of spleen in, 594 kidney, 680 nephritis and, differentiation, 672 Amyotonia congenita, 1173 Amyotrophic lateral sclerosis, 1090 Anaemia infantum, 380 lymphatic leukemia and, differen- tiation, 381 myeloid leukemia and, differentia- tion, 381 sarcoma of kidney and, differentia- tion, 381 Anamnesis, taking of, 24 Anatomy, morbid, diagnosis and, 18 Anemia, 351 idiopathic, 361. See also Anemia, pro- gressive pernicious. of maMgnant disease, purpura of, 384 of malnutrition, lymphatic leiikemia and, differentiation, 372 parasitic, 355 progressive pernicious anemia and, differentiation, 365 pernicious, 351 ankylostomiasis and, differentiation, 979 laboratory findings, 375 sclerosis in, 1095, 1096 splenic anemia and, differentiation, 382 symptoms, 374 primary, 351 progressive pernicious, 361 differential diagnosis, 365 gastric atrophy and, differentia- tion, 365 INDEX. 1197 Anemia, progressive pernicious, gastric carcinoma and, differentiation, 365 mineral poisoning and, differen- tiation, 365 parasitic anemia and, differentia- tion, 365 secondary anemia and, differentia- tion, 358 varieties, 361 secondary, 351, 354 albmnin elimination and, 355 and idiopathic, differentiation, 358 blood in, 375 differential diagnosis, 358 hemorrhage and, 355 in articular rheumatism, 895 in carcinoma of stomach, 501 in peritoneal tuberculosis, 561 in plumbism, 533 inanition and, 355 laboratory findings, 356, 375 parasitic, 355 symptoms, 374 splenic, 381, 632 Banti's disease and, differentiation, 382 leukemia and, differentiation, 371 malaria and, differentiation, 382 myeloid leukemia and, differentia- tion, 382 pernicious anemia and, differentia- tion, 382 pseudoleukemia and, differentiation, 379, 382 with splenomegaly, leukemia and, differ- entiation, 371 Anemias, essential, 374, 375, 376 Aneurism, 310 aortic regm-gitation from, 266 arteriovenous, 311, 321 cardiac, 302 circmnscribed saccular, 310 cirsoid, 310 cough in, 39 cylindroid, 310 dilatation, 310 dissecting, 310 empyema and, differentiation, 160 erosion, 311 false, 311 fusiform, 310 heart position in, 232 hepatic, 321 mycotic, 311 of abdominal aorta, 320 of ascending portion of arch, 315 of descending portion of arch, 315 of inferior mesenteric arteries, 321 of innominate artery, 315 pain of, 170 parasitic, 311 pulmonary, 321 pulsation in, 235 pupillary reactions in, 311 renal, 321 Aneurism, retropharyngeal abscess and, differentiation, 403 splenic, 321 spontaneum, 310 thoracic, 311, 312. See also Thoracic aneurism. traction, 311 true, 310 unilateral flushing, 314 sweating, 314 varicose, 311 varum, 310 with physical signs, 311 with sjonptoms, 311 x-ray diagnosis, 235 Aneurisma aortffi, 311, 312. See also Thoracic aneurism. Aneurismal varix, 311 Angina, gangrenous, in scarlet fever, 858 Ludovici, 403 mahgna, 861. See also Diphtheria. pectoris, 302 case, 303 differential diagnosis, 305 gastralgia and, differentiation, 306 hypertension in, 204 locomotor ataxia and, differentiation, 306 pain of, 171 pseudo-angina and, differentiation, 305 true, 303 without intense pain, 303 pseudomembranous, in scarlet fever, 858 streptococcus, diphtheria and, differ- entiation, 869 ulcerative stomatitis with, 398 vasomotoria, 303 Angioneurotic diseases, 1151 edema, 1151 Angular gyrus, 1029 Anidrosis, 639 Animal parasites, intestinal, 963 of Hver, 979 of lung in sputum, 81 of muscles, 982 parasitic diseases, 946 Anisocytosis, 352 Ankle clonus, 1017 in hysteria, 1181 Ankylostomiasis, 976 leukemia and, differentiation, 979 pernicious anemia and, differentiation, 979 plumbism and, differentiation, 979 Anorexia, 429 in pulinonary gangrene, 119 in yellow atrophy, 603 Anosmia, 1035 Anterior axillary lines, 42 corpora quadrigemiria, lesions of, 1032 Anthracosis, 115 x-ray diagnosis, 75 Anthrax, 914 Antibodies, 20 Antigen control in Noguchi reaction, 347 1198 INDEX. Antitoxins, 20 Anus, spasm in, 1168 Aorta, abdominal, aneurism of, 320 pulsation of, thoracic aneurism and, differentiation, 320 tortuosity of, aneurism and, 236 Aortic area of auscultation, 226 disease, pain from, 170 incompetency, 265. See also Aortic regurgitation. regurgitation, 265 auscultation in, 270 auscultatory percussion in, 270 complications, 272 cor bovinum in, 265 Corrigan pulse in, 269 from aneurism, 266 from chemic irritants, 266 from endarteritis, 266 from endocarditis, 266 from increased arterial tension, 265, 266 from infectious processes, 266 heart shadow in, 233 hypertension in, 204 hjrpertrophy in, 265 in alcoholics, 266 in lead workers, 266 inspection in, 267 mechanic influence of lesion, 265 murmurs of, 270 palpation in, 268 peculiarities of murmur, 246 percussion in, 269 pulmonary incompetency and, differ- entiation, 291 pulse in, 269 tracing in, 213, 271 Quincke's pulse in, 268 skin in, 268 sphygmographic tracing in, 213, 271 stenosis and, differentiation, 275 water-hammer pulse in, 269 with thoracic aneurism, 318 sclerosis, heart shadow in, 234 stenosis from, 272 stenosis, 272 Bright' s disease and, differentiation, 275 calcareous deposits and, differentia- tion, 275 from rheumatic endocarditis, 272 from sclerosis, 272 heart shadow in, 233 mechanic influence of lesion, 272 murmiirs in, 274, 276 pulmonary stenosis and, differentia- tion, 292 pulse in, 273, 275 regurgitation and, differentiation, 275 sphygmographic tracing in, 274 Aortitis, acute, 308 syphilis in, 308 Apex of sphygmographic tracing, 213 Apex-beat, 181 displacement, 182 Apex-beat, double, 183 forcible, 183 in disease, 181 in infancy, 182 systolic recession, 183 Aphasia, 1028 motor, 1028 in apoplexy, 1052 sensory, 1029 Aphthous fever, 936 Apoplexy, 1050 aphasia in, 1052 comphcations^ 1054 contractures m, 1052 differential diagnosis, 1054 encephahtis in, 1051 from embohsm, 1051 from syphilis, 1051 from thrombosis, 1051 hemorrhage in, 1053 in infectious diseases, 1051 in uremia, 1051 of lung, 116 pancreatic, 622 pseudo-bulbar paralysis in, 1053 pupils in, 312 Appendicitis, 535 acute, 536 case, 539 cholecystitis and, differentiation, 541 Dietl's crises and, differentiation, 542 differential diagnosis, 540 dyspnea in, 537 extra-uterine pregnancy and, differ- entiation, 540 hepatic colic and, differentiation, 540, 612 indigestion and, differentiation, 541 intestinal obstruction and, differen- tiation, 542 leukocytosis in, 539 McBurney's point in, 537, 638 neurasthenia and, differentiation, 542 ovaritis and, differentiation, 541 pain in, 537 pancreatitis and, differentiation, 542 perinephritic abscess and, differentia- tion, 542 peritonitis and, differentiation, 541 pyosalpinx and, differentiation, 541 renal cohc and, differentiation, 540, 612 tenderness in, 538 tongue in, 538 tuberculous peritonitis and, differen- tiation, 542 catarrhal, 536 chronic, 636, 542 carcinoma of cecum and, differentia- ' tion, 543 tuberculosis of cecum and, differen- tiation, 543 complications, 544 interstitial, 536 mortahty, 644 obliterative, 536 INDEX. 1199 Appendicitis, parietal, 636 perforating, 536 recurrent, 536, 543 ulcerative, 536 urine colloidal albumin in, 539 urine in, 539 Appetite in gastric diseases, 429 perverted, 429 Apyrexia, 717 Arc de cercle in hysteria, 1184 Argyll-Robertson pupU in general paresis, 1190 in tabes dorsalis, 1104 Arhythmia, 172, 194 respiratory, 198 Arhythmic dyspnea in heart disease, 173 Arsenical neuritis, 1146 Arterial disease, symptoms, 175 murmurs, 228 sclerosiSj 308 aneurism from, 311 cerebral, 308 hypertension in, 203 mitral stenosis after, 283 palpation of artery in, 191 peripheral, 309 pulmonary, 309 pulse tracing in, 214 renal, 308 x-ray diagnosis, 236, 310 Arteries, coronary, sclerosis of, 309 diseases of, 308 remote, pulsation over, 185 size of, palpation to determine, 192 syphilis of, 833 Arteriocapillary fibrosis, 308. See also Arterial sclerosis. Arteriosclerosis, 308. See also Arterial Arteriovenous aneurism, 311, 321 Arthritis deformans, 1158 Heberden's nodes in, 1160 senile form, 1160 StrumpeU-Marie type, 116 vertebral form, 1161 von Bechterew's type, 1161 glycosuria in, 653, 993 gonorrheal, 897 and tuberculous, differentiation, 899 articular rheumatism and, differen- tiation, 897 polyarthritis in, 898 transitory, 898 rheumatoid, 1158 syphihtic and rheumatic, differentia- tion, 829 tuberculous, 821 and gonorrheal, differentiation, 899 articular rheumatism and, differen- tiation, 896 Ascaris in bladder, 985 in sputvun, 82 lumbricoides, 974 Ascending paralysis, 1086 Ascites, 564 caput medusae in, 567 Ascites, causes, 565 chylous, 566, 570 dilatation and, differentiation, 508 flatness in, 567 intestinal obstruction and, differentia- tion, 527 ovarian cyst and, differentiation, 569 overdistended bladder and, differentia- tion, 569 polyhydramnios and, differentiation, 569 purulent, 566 sanguineous, 566 serous, 566 true, 566 tympanites and, differentiation, 569 Asiatic cholera, 734. See also Cholera Asiatica. Aspergillosis of lungs, 130, 927 sputmn evidence, 82 Aspergillus fumigatus in urine, 703 niger in sputum, 82 Aspirating in cerebrospinal meningitis, 841 in mitral regurgitation, 281 pericardium, 245 Association fibers of brain, 1013 Asthma, 96 blood in, 98 bronchitis and, 96 chronic, x-ray diagnosis, 73 clinical types, 96 edema of larynx and, differentiation, 100 emphysema and, differentiation, 100 gastric, 96 hay, 939. See also Autumnal catarrh. irritants as cause, 96 laryngeal affections and, differentiation, 100 nervous, 96 reflex, 96 secondary, 96 spasm of glottis and, differentiation, 100 sputum in, 80, 85, 98 uremic, in interstitial nephritis, 675 Ataxia, 1023 Friedreich's, 1097 gastric crises of, gastralgia and, differ- entiation, 480 hereditary cerebellar, Friedreich's ataxia and, differentiation, 1099 in tabes dorsalis, 1103 in tumors of cerebellum, 1068, 1069 locomotor, 1099. See also Tabes dor- Ataxic gait, 1023 multiple nem-itis, 1145 paraplegia, 1095 Atelectasis, pulmonary, 120 Atheroma, 308. See also Arterial sclerosis. Athetosis in brain diseases, 1044 Atonia in tumors of cerebellum, 1068 Atony, gastric, 477. See also Dilatation, gastric. Atrophy, gastric, 424 progressive pernicious anemia and, differentiation, 365 in syringomyeUa, 1093, 1094 1200 INDEX. Atrophy, muscular, 1132 optic, 1037 in tabes dorsalis, 1105 primary neurotic, 1132 progressive muscular, 1088, 1089 yellow, hepatic, 603 hypertrophic, cirrhosis and, differ- entiation, 604 phosphorus-poisoning and, differ- entiation, 597, 604 Atropin test in meningeal and cerebral conditions, 1126 Auditory nerve, 1041 Aura, hysteric, 1184 Auricular complex of electrocardiogram, 220 fibrillation, 196 flutter, 197 hypertrophy, 295 Auscultation, 63 stethoseopic, 64 Auscultatory percussion, 59 Autointoxication, pulse in, 189 Automatism, epileptic ambulatory, 1047 Autumnal catarrh, 939 bronchitis in, 90 AxiUary hues, 42 pulsation, 185 regions, 44 Babinski reflex, 1018 BacUlary index, 350 Bacillus perfringens, 739 satillitis, 739 Back, division of, to locate kidney, 638 regional division of, 637 Bacteria in blood, 390 in feces, 518 in sputum, 83 Bacterial emiilsions for opsonic index, 350 vacciaes, opsonic index and, 349 Bacteriolysis in diagnosis, 22 Baoteriuria, 703 Balantidium coli, 967 in sputum, 82 BaUance's abdominal regions, 418 Banti's disease, 628 pseudoleukemia and, differentiation, 379 splenic anemia and, differentiation, 382 Barrel-shaped chest, 48 Basedow's disease, 1154. See also Exoph- thalmic goiter. Basophiles, 359 BasophiUc degeneration, 352 Bedbug in transmitting acute anterior poliomyelitis, 844 plague, 787 Bedside observations, 29 Beef tape-worm, 968 Bell tympany, 61 in pneumothorax, 164 Bence-Jones albumosuria, 1004 Beriberi, 1147 Beta-oxybut3Tic acid in urine, 657 Biceps clonus, 1017 paralysis, 1139 Big-jaw, 919 Bilateral acting functions, brain centers for, 1030 Bile acids in urine, 655 in typhoid fever, 751 in vomit, 473 Bile-ducts, carcinoma of, 437, 613 catarrh of, 608, 609 common, carcinoma of, pain of, 437 obstruction of, 609 rupture of, in choleUthiasis, 612 diseases of, jaundice in, 604 obstruction of, 605, 608 stenosis of, 605 BUe-pigments in urine, 655 Bilharzia hsematobia, 961 in sputum, 82 Bihary calculi, 608. See also Cholelithiasis. Bilious typhoid, 764 BUiousness, taste in, 430 Birth palsy, 1138 Bismuth mixtures for gastro-intestinal fluoroscopy, 453 Black death, 787 sputum, 78 vomit in yellow fever, 769 Bladder, 703 diseases, 703 i-ray evidences, 634, 637 distention of, ascites and, differentiation, 569 floating spleen and, differentiation, 684 gall-bladder distention and, differen- tiation, 684 hydronephrosis and, differentiation, 683, 684 ovarian cyst and, differentiation, 684 hemorrhage from, 640 in tabes dorsalis, 1101 nerve center of, 1086 neuroses of, 710. See also Neuroses of bladder. parasites of, 985 tuberculosis of, 705, 820 K-ray of, 634, 637 Blastomycosis, pulmonary, 130, 923 Blepharitis in measles, 878 Blepharospasm, 1167 Blindness, figure, 1029 in tabes dorsaUs, 1105, 1107 letter, 1029 word, 1029 Blood, 325 alkalinity of, 338 bacteria in, 390 coagulation of, 327 cell movements, 328, 329 collection of, 326 for Widal reaction, 344 cover-glasses for, 325, 342 cryoscopy of, 341 cultvire in diagnosis, 22 INDEX. 1201 Blood, Daland's lancet for collecting, 326 diseases, 351 eosin-hematoxylin-methylene-blue stain for, 342 examination, 30, 325 fat in, 341 fixing, 342 freezing-point, 341 fresh, study of, 326 glucose in, 341, 652 glycogen in, 340 hematin, 330 hemoglobin, 329 in feces, 515. See also Feces, blood in. in urine, 640 in vomit, 473 laboratory examination, 325 lancet for collecting, 326 leukemic, differences of, 374 microscopic study, 325 normal, laboratory findings, 375 olein in, 341 paknitin in, 341 parasitology of, 390 passage of, through heart, 225 peripheral, alkalinity of, 338 pigments, 329 slides for, 325, 342 smears, 327 specific gravity of, 329 spectroscopic study, 330 staining of, 342 stearin in, 341 vomiting of, 433 Wright's staining of, 343 Blood-corpuscles, counting, 334 solution for preserving, 335 Thoma-Zeiss method of counting, 334 washed, for opsonic index, 350 Blood-fluke, 961 Blood-lancet, Daland's, 326 Blood-pressure, 200 altitude and, 203 arterial tonus and, 200 auscultatory determination, 208 diastolic, 200 digestion and, 203 excitement and, 203 exercise and, 203 factors modifying, 201 heart action and, 200 indicator for, 205. See also Sphyg- momanometer. Kearcher's instrument for determining, 210 maintenance of, 200 mean, 200 obesity and, 203 posture and, 201 sphygmomanometer for, 205. See also Sphygmomanometer. standard for, 201 systolic, 200 unit system for, 201 vasomotor activity and, 200 Blood-vessels, diseases of, 168, 308 76 Blood-vessels, diseases of, x-ray diagnosis, 229 pulsation of, 172 walls of, condition of, 192 Bloody sputum, 78, 397 Blotting-paper test for hemoglobin, 334 . Boas-Oppler bacillus in gastric contents, 471 Boggs' coagulometer, 328 Boston-Kocher sign in Graves' disease, 1155 Boston's pipet test for albumin, 645 Bouveret ulcer, 744 Bovine tuberculosis, 795 Bowles' stethoscope, 224 Brachial neuralgia, 1148 neuritis, 1136 palsy, 1138. See also Paralysis, brachiai. plexus, 1136 Brachiahs anticus paralysis, 1139 Bradycardia, 189 Brain abscess, 1071 adenoma of, 1060 anatomy, 1012 carcinoma of, 1060 centers, 1013 crying, 1030 eating, 1030 for bUateral acting functions, 1030 laughing, 1030 motor, 1027 psychic, 1029 sensory, 1027 speech, 1030 subcortical, 1030 swallowing, 1030 visual, 1029 cholesteatoma of, 1060 compression of, 1073 contusion of, 1076 cortex of, 1012 transmission of sensation to, 1022 cysts of, 1058, 1059, 1060 diseases, 1042 symptoms, 1042, 1043, 1044, 1045 endothelioma of, 1059 fibroma of, 1060 ghoma of, 1058 gummata of, 1059 injuries, 1072, 1076 from skuU fracture, 1073, 1074, 1075 insanity and, 1077 terminal effects, 1077 lipoma of, 1060 localization in, 1027 parasitic diseases of, 991 pia of, 1012 psammoma of, 1060 sarcoma of, 1058 silent area of, 1065 substance, injuries to, 1076 syphiloma of, 1059 tumors and, differentiation, 1071 tuberculoma of, 1059 tumors, 1058 cortical, 1062 1202 INDEX. Brain tumors, frontal, 1062 in motor area, 1063 in occipital area, 1065 in sensory area, 1064 in temporal lobe, 1065 influence on surrounding structures, 1061 of fourth ventricle, 1065 of lateral ventricle, 1065, 1066 of third ventricle, 1065, 1066 paralysis from, 1051 pupils in, 312 subcortical, 1062, 1065 syphilitic lesions and, differentiation, 1071 ventricles of, 1012 Break-bone fever, 884. . See also Dengue. Breast-pang, 302. See also Angina ■pectoris. Breasts, neuralgia of, 1149 Breathing, abdominal, 425 bronchial, 64 bronchovesicular, 65 harsh, 35 normal, 64 vesicular, 66 cardiac, 68 systolic, 68 Breath-sovmds, increased, regions where heard, 68 normal, 64 Bright's disease, 661. See also Nephritis. Brinton's bile test in tjrphoid fever, 751 Broadbent's sign, 183 Broca's convolution, 1028 Brodie-Russell coagulometer, Boggs' modi- fication, 328 Bromidrosis, 638 Bronchi, diseases of, 37, 87 a;-ray evidence, 73, 75 Bronchial asthma, 96. See also Asthma. breathing, 64 casts in sputum, 80 percussion, 60 stenosis, 103 Bronchiectasis, 100 actinomycosis of thorax and, differen- tiation, 102 bronchitis and, differentiation, 94 coughing in, 100 empyema and, differentiation, 102- puhnonary cavity and, differentiation, 102 tuberculosis and, differentiation, 818 sputiim in, 101 thoracic aneurism and, 102 s-ray diagnosis, 75 Bronchitis, acute, 87 bronchopneumonia and, differentia- tion, 90 in asthma, 96 mLiary tuberculosis and, differentia- tion, 90 pleurisy with effusion and, differen- tiation, 89 pulmonary tuberculosis and, differ- entiation, 90 Bronchitis, acute, sputum in, 84, 89 capillary, 107. See also Bronchopneit- monia. chronic, 91 and fetid, differentiation, 94 bronchiectasis and, differentiation, 94 gangrene and, differentiation, 94 in men past middle age, 91 of young females, 91 pulmonary tuberculosis and, differen- tiation, 93 sputum in, 84, 93 varieties, 91 croupous, 94 fetid, 91 and chronic, differentiation, 94 pulmonary gangrene and, differentia- tion, 120 sputum in, 85 fibrinous, 94 in acute infectious colds, 91 in hay-fever, 90 in influenza, 91, 790 in measles, 91, 878 in rubeUa, 878 in scarlet fever, 858 in tjrphoid fever, 742 in whooping-cough, 91 infectious, 90 mucous, 94 plastic, 94 staphylococcus, 84 streptococcus, 80 with myocarditis, 299 with pulmonary emphysema, 127 Bronchopneumonia, 107 bronchitis and, differentiation, 90 cerebral type, 107 in diphtheria, 871 in influenza, 793 case, 110 in measles, 847 in rubella, 848 in scarlet fever, 858 leukocytosis in, 110 lobar pneumonia and, differentiation, 112, 786 ordinary type, 108 primary, 107, 108 pulmonary tuberculosis and, differentia- tion, 803 secondary, 109 sputum in, 85, 110 suffocative, 107 with remittent fever, 107 x-ray diagnosis, 74 Bronchorrhea, 84, 91 Bronchoscope in stenosis, 103 Jackson's, 448 Bronchoscopy, position of patient and second assistant for, 450 Bronchovesicular breathing, 65 Browning's spectroscope, 330, 331 Brown-Siquard paralysis, 1115 Brudzendski's sign in meningitis, 840 Bubonic plague, 787 INDEX. 1203 Buccal cavity, hemorrhage from, 397 Buhl's disease, 942 Bulbar paralysis, acute, chronic bulbar palsy and, differentiation, 1078 asthenic, chronic bulbar palsy and, differentiation, 1079 chronic, 1077 acute bulbar palsy and, differentia- tion, 1078 myasthenia gravis and, differentia- tion, 1079 Bulimia, 429 Burdach's tract, 1020 Butyric acid, test for, 469 Cachexia, cretinoid, 1153 malarial, 954 Caisson disease, 1110 Calcareous deposits, aortic stenosis and, differentiation, 275 Calcification in tuberculosis, 793 Calcified tubercles, radiograph of, 815 Calcium oxalate in urine, 657 Calculus, bUiary, 609. See also Chole- lithiasis. hepatic, intestinal cohc and, differen- tiation, 694 nephrolithiasis and, differentiation, 694 vesical calculus and, differentiation, 694 pancreatic, 624 renal, 690. See also Nephrolithiasis. ureteral, x-ray diagnosis, 635 vesical, hepatic calculus and, differen- tiation, 694 intestinal colic and, differentiation, 694 nephroUthiasis and, differentiation, 694 Calf of leg, cramps in, 1168 Calmette's ophthahnotuberculin reaction, 807 Cammidge's pancreatic reaction, 617 Camp fever, 758. See also Typhus fever. Cancer. See Carcinoma. Capillary bronchitis, 107. See also Bron- chopneumonia. pulse, 185 Capsule, internal, locaUzation of fibers in, 1031 Caput medusae, 425 in ascites, 567 in atrophic cirrhosis, 600 Carbohydrates, digestion of, 468 in urine, 652 Carbon disulphid, polyneuritis from, 1146 monoxid, polyneuritis from, 1146 Carbonic-acid hemoglobin, 330 Carcinoma cells, 559 colonic, pancreatic carcinoma and, dif- ferentiation, 624 duodenal, 546 gastric, 498 case, 501 coffee-groimd vomit in, 499 Carcinoma, gastric, colloidal albumin in, 501 compUcations, 504 cyanogen in urine of, 501 gastric contents in, 500 gastritis and, 490, 498, 502 pain in, 436, 499 progressive pernicious anemia and, differentiation, 365 secondary, 498 anemia in, 501 splenitis and, differentiation, 631 ulcer and, differentiation, 495, 502 in etiology, 498 vertigo in, 499 vomiting in, 433, 499 x-ray diagnosis, 460 green, leukemia and, differentiation, 371 hepatic, 579 abscess and, differentiation, 585, 590 case, 583 cirrhosis and, differentiation, 585 colonic carcinoma and, differentia^ tion, 584 differential diagnosis, 584 from cholehthiasis, 580 omental carcinoma and, differentia- tion, 584 pain in, 437, 581 pyloric carcinoma and, differentiar tion, 584 sarcoma and, differentiation, 586 suprarenal carcinoma and, differen- tiation, 585 intestinal, 546 carcinoma of gall-bladder and, differ- entiation, 547 of head of pancreas, and differen- tiation, 547 diarrhea in, 546 dysentery and, differentiation, 547 fecal impaction and, differentiation, 547 floating kidney and, differentiation, 547 hydronephrosis and, differentiation, 547 intussusception and, differentiation, 547 pain in, 546 x-ray diagnosis, 461 Lobstein's, 664 of bile-ducts, 613 of brain, 1060 of cecum, appendicitis and, differentia- tion, 543 of colon, hepatic carcinoma and, differ- entiation, 584 of common duct, pain of, 437 of esophagus, 417 pneumothorax from, 161 x-ray diagnosis, 409 of gall-bladder, intestinal carcinoma and, differentiation-, 547 of head of pancreas, intestinal carci- noma and, differentiation, 547 1204 INDEX. Carcinoma of kidney, 700 of mediastinum, 323 omental, hepatic carcinoma and, differ- entiation, 584 pancreatic, 623 colonic carcinoma and, differentia- tion, 624 pain in, 437 pyloric carcinoma and, differentia- tion, 624 splenitis and, differentiation, 631 peritoneal, 559 peritonitis and, differentiation, 562 tuberculosis of peritoneum and, differ- entiation, 562 pulmonary, 123 actinomycosis and, differentiation, 922 pyloric, hepatic carcinoma and, differ- entiation, 584 pancreatic carcinoma and, differen- tiation, 624 rectal, 546 suprarenal, hepatic carcinoma and, dif- ferentiation, 585 Carcinomatous pleurisy, 154 Cardiac cycle, 224, 225 dulness, boundaries, 178 end of stomach, position of, 508 orifice, relaxation of, 479 thrombosis, 293 vesicular breathing, 68 Cardialgia, 436, 480. See also Gasiralgia. Cardiograph, 216 Cardiopulmonary murmur, 228 Cardiospasm, 479 Carotid pulsation, 184 Caseation in tuberculosis, 793 Casts in feces, 517 in sputum, 80 Cat, endemic hemorrhage in, 988 tapeworm, 970 Catarrh, apical, pulmonary tuberculosis and, differentiation, 818 autumnal, 939. See ■ also Autumnal catarrh. bronchial, pulmonary tuberculosis and, differentiation, 818 dry, 91, 93 gastric, chronic, 488. See also Gastri- tis, chronic. gastroduodenal, pancreatitis and, differ- entiation, 620 gastro-intestinal, 725. See also Enter- itis, catarrhal. nasal, 33 of bile-ducts, 608, 609 of respiratory tract, tuberculosis and, 797 of stomach, acute, 482. See also Gas- tritis, acute. suffocative, 107 Catarrhal dyspepsia, chronic, 488. See also Gastritis, chronic. fever, epidemic, 788. See also Inflvsnza. pneumonia, 107. See also Broncho- pneumonia. Cauda equina, 1082 tumors of, 1112 Caudate nucleus, 1012 lesions in, 1030 Cavities, pulmonary, x-ray diagnosis, 75 Cecum, carcinoma of, appendicitis and, differentiation, 543 tuberculosis of, appendicitis and, differ- entiation, 643 ■ CeUuUtis in scarlet fever, 858 Centers, brain, lOlS, 1027 Central pains, 1023 Cephalodynia, 931 Cerebellar artery, inferior, involvement in bulbar palsy, 1078 tract, direct, 1019 Cerebello-pontile angle, tumors of, 1071 Cerebehum, 1012, 1033 anatomy, 1033 functions, 1034 lesions of, 1034 tumors of, 1067-1070 Cerebral atheroma, 308 hemorrhage, hypertension in, 204 in heart disease, 174 localization, 1027 peduncle, hemorrhage in, 1053 lesions in, 1031 tumors of, 1066 pneumonia, 776 type of ulcerative endocarditis, 262 vomiting, 433 Cerebrospinal fever, 835, 1124. See also Meningitis, cerebrospinal. Cerebrum, 1012 Cervical cord, enlargement of, 1081 myehtis of, 1108 sympathetic, irritation of, 1139 Cervico-brachial neuritis, 1137 Cestodes, 967 ChaUcosis, 115 sputum in, 86 Chalk-plugs of tonsilhtis, 720 Chancre, 826 Charcot joints in tabes dorsalis, 1105, 1106 Charcot - Marie - Tooth - Hoffman - Sachs atrophy, 1132 Chemical methods of diagnosis, 21 Chest abnormalities, 48 gastroptosis from, 511 auscultation, 63 back of, landmarks of, 41 percussion, 56 barrel-shaped, 48 diagnostic significance of special signs, 60 divisions of, 42 emphysematous, 48 enlargement, 49 examination in child, 64 flat type, 48 fluctuations over, 55 in pleurisy, 49 in thoracic aneurism, 49 inspection, 45 landmarks of, 40 INDEX. 1205 Chest, lines of, 42 mensuration in heart disease, 223 movements, 49 of two halves, 131 new-growths and, 49 normal, 48 palpation, 52 perciission, 55 auscultatory, 59 deep, 58 interpretation, 57 results, 57 superficial, 58 tjrmpany in, 58 with patient ia bed, 56 physical examination of, 40 regional anatomy, 42 resonance, 57 shape, 47 spasm of, 1168 tactile fremitus, 52 Chest-wall, inspection of, 47 Cheyne-Stokes respiration, 51 in heart disease, 173 Chicken-breast, 1003 Chicken-pox, 907. See also Varicella. ChHblain, 1151 Chlorids in urine, 648 Chloro-anemias, 351 Chloroma, leukemia and, differentiation, 371 Chlorophyl in feces, 517 Chlorosis, 373 laboratory findings, 375 symptoms, 374 Choked disc, 1036 in tumors of cerebeUmn, 1067 Cholecystitis, appendicitis and, differentia- tion, 541 calculous, 609. See also Cholelithiasis. in typhoid fever, 755 Cholelithiasis, 609 abscess and, differentiation, 590 appendicitis and, differentiation, 540, 612 coUc in, renal colic and, differentiation, 612 differential diagnosis, 612 gastralgia and, differentiation, 480, 612 hepatic abscess in, 612 carcinoma from, 580 intermittent fever and, differentiation, 951 intestinal colic and, differentiation, 612, 694 obstruction in, 612 jaundice in, 610 lead-workers' coHc and, differentiation, 612 pain of, 437 peritonitis in, 612 rupture of bile-duct with, 612 sweating in, 611 ' uterine coUc and, differentiation, 612 without colic, 609 Cholera Asiatica, algid stage, 736 | Cholera Asiatica, asphyxic type, 735 case, 737 cholera morbus and, differentiation, 549, 738 cutaneous complications, 737 first stage, 736 foudroyant type, 735 mild type, 734 premonitory, 734 reaction stage, 736 rice-water stools in, 737 usual type, 735 infantum, 544, 618. See also Enteritis, catarrhal. morbus, 548 Asiatic cholera and, differentiation, 549, 738 nostras, 548 sicca, 735, 736 Cholerine, 734 Cholesteatoma of brain, 1060 Cholesterinemia in chronic nephritis, 672 Cholesterinuria, 659 Choluria, 655 Chorea, 1169 electric, 1169 gravidarum, 1170 habit, 1167 hemiparalytic type, 1170 Henoch's, 1169 Huntington's, 1171 minor, 1169 Sydenham's, 1169 Chromidrosis, 637 Chvostek's sign of tetany, 1165 Chylous effusion, 571 Chyluria, 640 filariasis and, differentiation, 961 Ciliary muscles, reactions of, 1037 Ciliospinal center, 1138 Cimex lectularis conveying plague, 787 Circulatory apparatus in history-taking, 26 diseases, 168 Circumflex nerve, paralysis of, 1139 Circumscribed pleurisy, precordial pain of, 169 Cirrhosis, alcohohc, 576, 598 atrophic, 595, 598 blood in, 600 caput medusse in, 600 case, 600 differential diagnosis, 602 renal disease and, differentiation, 602 valvular disease and, differentiation, 602 biliary, 576 fatty, 598 gUssonian, 602 hypertrophic, 575 abscess and, differentiation, 579 carcinoma and, differentiation, 685 Hanot's, 576 yellow atrophy and, differentiation, 604 Laennec's, 598. See also Cirrhosis, atrophic. 1206 INDEX. Cirrhosis of lung, 113 sjrphUitic, 598 with splenomegaly, 628 Cirsoid aneurism, 310 Clarke's column, 1019 Classification of diseases, diagnosis and, 22 Claudication, intermittent, 1110 Clavicular regions, 42 Claw-hand, 1089, 1141 of leprosy, 835 Click, mucous, 70 Clonus, ankle, 1017 in hysteria, 1181 biceps, 1017 patellar, 1017 triceps, 1017 Clubbing of fingers and toes in valvular disease, 278, 279 Coagulation of blood, 327 Coagulometer, Boggs', 328 Brodie-Russell's, Boggs' modification, 328 Wright's, 327 Cobra venom reaction in syphilis, 828 Cocainization of larynx, 407 Coccygodynia, 1150 Cochlear nerve, 1041 Coflfee-ground feces, 515 vomitus, 434 in gastric carcinoma, 499 Cog-wheel respiration, 68 in incipient phthisis, 806 Coin-test, 61 in pneumothorax, 164 Cold in head, 33 Colds, acute infectious, bronchitis in, 91 CoUc, hepatic. See Cholelithiasis. intestinal, cholelithiasis and, differentia- tion, 612, 694 gastralgia and, differentiation, 480 nephrolithiasis and, differentiation, 694 vesical calculus and, differentiation, 694 lead, 530. See also Plumbism. cholelithiasis and, differentiation, 612 renal, appendicitis and, differentiation, 540, 612 hepatic colic and, differentiation, 612 in nephrolithiasis, 692 uterine, choleUthiasis and, differentia- tion, 612 CoUtis, mucous, 528 Colles' law, 825 Colloidal nitrogen in m-ine as aid in diag- nosis of cancer of internal organs, 501 Colon, carcinoma of, hepatic carcinoma and, differentiation, 584 pancreatic carcinoma and, differen- tiation, 624 dilatation of, 523. See also Dilatation of colon. displacement of, 522 ectasia of, 623. See also Dilatation of colon. Colon, hepatic flexure of, dislocation, gaa- troptosis and, 511 relation of, to anterior area of abdomen, 576 Coloptosis, 522. See also Enteroptosis. Coma, 1072 Common bile-duct, obstruction of, 609 rupture of, in cholelithiasis, 612 Compensatory emphysema, 72 Complexion in heart disease, 180 Compression of brain, 1073 of cord, 1114 Compsomyia maceUaria, 991 Congestion of limgs, 104 passive, splenic, leukemia and, differen- tiation, 371 Congo-red test for free hydrochloric acid, 467 Conjunctivitis in measles, 878 Constipation, acute, habitual constipa- tion from, 534 choleUthiasis from, 610 habitual, 534 significance, 514 x-ray diagnosis, 461 Constitutional diseases, 992 Consumption of bowel, 723 Contracted kidney, secondary, 668. See also Nephritis, chronic. Contractures, hysteric, 1183 in apoplexy, 1052 in syringomyeUa, 1093 Contusion of brain, 1076 Conus meduUaris, 1082 Convolution, Broca's, 1028 Convulsions, focal, 1044 in brain diseases, 1044 in cerebellar tumors, 1070 in hysteria, 1183 in yellow atrophy, 603 Jacksonian, 1044 Copper, polyneuritis from, 1146 test for glycosuria, 654 Coprolalia, 1168 Cor bovinum in aortic regurgitation, 265 Coronary sclerosis, 309 Corpora quadrigemina, lesions of, 1032 Corpus caUosum, 1012 Corrigan pulse, 189, 199 Hawke's method, 269 in aortic regurgitation, 269 Cortex of brain, 1012 transmission of sensation to, 1022 Coryza, erysipelas and, 889 in syphilis, 830 Costal respiration, 50 Costiveness, 534 Costo-abdominal respiration, 49 Cotton-holding forceps, 407 Cough, 38 ear, 39 in anevu-ism, 39 in heart disease, 39, 172 purpura after, 384 reflex, 39 stomach, 39 INDEX. 1207 Cough, tooth, 39 Cover-glasses, 326 for staining blood, 342 preparation of, 325 Cowpox, 906 Cracked-pot sound, 61 in pleurisy, 146 in pneumothorax, 164 in pulmonary tuberculosis, 812 Cramp, muscular, in diabetes mellitus, 997 of calves, 1168 writer's, 1168 Cranial nerves, 1035 cerebellar tumors and, 1069 diseases of, 1035 eighth, 1041 eleventh, 1042 fifth, 1039 first, 1035 fourth, 1038 glossopharyngeal, 1042 ninth, 1042 paralysis of, 1035 in tabes dorsalis, 1104 partial, 1048 total, 1048 second, 1035 seventh, 1040 sixth, 1038 tenth, 1042 third, 1037 twelfth, 1042 Cremasteric reflex, 1017 Crepitus redux, 70 Cretinism, 1153 Cretinoid cachexia, 1153 Croup, false, 34. See also Laryngitis, spasmodic. membranous. See Diphtheria. spasmodic, 34. See also Laryngitis, spasmodic. true. See Diphtheria. Croupous bronchitis, 94 pneumonia, 113. See also Pneumonia, lobar. Crural nerve, anterior, paralysis of, 1141 Crus, lesions in, 1031 tumors of, 1066 Crying center, 1030 epileptic, 1047 Cryoscopy, 341 Cultural diagnosis, 20 Cultures of nasopharynx discharges, 32 Currant-jelly sputum, 78 Curschmann's spirals in sputum in asthma, 98 Cutaneous parasites, 989 Cyanosis from valvular disease, spleen in, 627 in heart disease, 173 Cychc vomiting, 435 Cyclops, 989 Cylindroid aneiirism, 310 Cyst, hydatid, 973, 979. See also Hydatid cyst. of brain, 1058, 1059, 1060 Cyst of Uver, 979-981 pleurisy with effusion and, differen- tiation, 152 of lung, pleurisy with effusion and, dif- ferentiation, 152 of spinal cord, 1111 ovarian ascites and, differentiation, 569 splenic tumor and, differentiation, 632 pancreatic, 625 Cysticercus, 985 cellulosae in brain, 1007 in brain, 991 of eye, 990 Cystinuria, 659 Cystitis, acute, 706 aspergillus in urine in, 703 bacteriuria in, 703 case, 708 chronic, 709 irritability and, differentiation, 711-713 neuroses and, differentiation, 711-713 of pregnancy and, differentiation, 711-713 phlegmonous, 706 Daland's blood-lancet, 326 Dare's hemoalkaUmeter, 339 Deafness in scarlet fever, 860 in tabes dorsahs, 1105 Decinormal hydrochloric acid solution, 334 Decubitus in typhoid fever, 757 Deep sensibiUty, 1019 Degeneration, amyloid, of spleen, 627 basophilic, 352 electric reactions of, 1083 fatty, of newborn, 942 of cord, secondary, 1086 of erythrocytes, 352 of- heart, fatty, 299 of liver, fatty, 593 with enlargement, 591 of wasting diseases, 1095 Deglutition gurgle, 444 Deiters' nucleus, 1033 Dehrium, 1072 in fever, 716 in heart disease, 174 Deltoid paralysis, 1139 Dementia, paralytic, 1189 Dengue, 884 Dentition, enteritis in, 727 Dermacentor occidentahs, 933 Dermatitis in pellagra, 1193 Dermatobia noxiahs, 991 Dermatomyositis, muscular rheumatism and, differentiation, 932 , i ' Desquamation of tongue^yepiithelial, 392 ' Deviation of complement in diagiiosis, 22 Diabetes insipidus, 1000 i - ' meUitus, 992 ;" ' acute, 994 * \ > after shock, 995 aural symptoms, 996 blood changes, 999 case, 999 1208 INDEX. Diabetes mellitus, chronic, 994 circulatory symptoms, 997 colloidal albumin, 998 coma in, 997 cutaneous symptoms, 996 digestive symptoms, 996 gastric crises in, 997 infantile, 992 muscular cramps in, 997 nervous symptoms, 997 ocular symptoms, 996 oral symptoms, 995 pancreatic, 992 phosphatic, 992 respiratory symptoms, 996 sexual weakness in, 997 temperament in, 997 thirst in, 995 urine in, 656 myocarditis in, 297 phosphatic, 649 Diacetic acid in urine, 656 Diagnosis, bacteriolysis in, 22 blood culture in, 22 chemical, 21 classification of diseases and, 22 cultural, 20 definition, 17 deviation of complement in, 22 equipment for, 17 hasty, 19 laboratory as aid in, 23 morbid anatomy and, 18 opsonic index in, 21 Rontgen-ray, 19. See also Rontgen- ray diagnosis. scheme for, 23, 24, 25 serum, 20 system in making, 23 Diaphoresis, hypotension in, 205 Diaphragm, diseases of, x-ray diagnosis, 73, 75 hernia of, eventration and, differentia- tion, 76 pneumothorax and, differentiation, 76, 166 x-ray diagnosis, 76 movement of, abscess and, 76 hernia and, 76 hydatid cyst and, 76 normal, 75 pleuritic adhesions and, 76 tuberculosis and, 76 orthodiagraphic measurement of, 76 paralysis of, 1141 abdominal movements in, 425 spasm of, 1167 Diaphragmatic pleurisy, 156 respii-gjtion, 49 Diarrhea, dyspeptic, acute, 548 ehminative, 725 from dietetic errors, 725 from drugs, 726 mycotic, 725. See also Enteritis, catar- rhal. nervous, 545, 726 Diarrhea of children, 725. See also Enteri- tis, catarrhal. premonitory, 734 significance, 514 summer, 725. See also Enteritis, catar- rhal. toxic, 725 Diastolic blood-pressure, 200 heart-sound, 224 doubling of, 227 Diazo-reaction, 661 in measles, 874 Dibothriocephalus in bladder, 985 latus, 969 Dicrotic pulse, 199 wave of sphygmograph tracing, 214 Diet, scurvy and, 386 Dietl's crises, appendicitis and, differen- tiation, 542 Digestion, blood-pressure and, 203 Digestive system, diseases of, 392 Dilatation aneurism, 310 gastric, 504 acute, 504 ascites and, differentiation, 508 auscultation in, 506 auscultatory percussion in, 506 differential diagnosis, 508 gastroptosis and, differentiation, 608 gastroscopy in, 506 hypomotility and, differentiation, 478 laboratory diagnosis, 507 megalogastria and, differentiation, 508 peristalsis in, 426 pneumothorax and, differentiation, 166 tympanites and, differentiation, 508 vomiting of, 434 x-ray in, 482 of colon, 523 differential diagnosis, 525 intestinal obstruction and, differen- tiation, 527 tympanites in, 523 of esophagus, 416. See also Esophagvs, dilatation. of heart, 299, 300 hypertrophy and, 295, 310 hypertrophy with, 310 pericarditis and, differentiation, 243 plem-isy with effusion and, differentia- tion, 153 with slight alteration in heart wall, 310 with thinning of wall, 309 Diphtheria, 861 albmninuria in, 871 bacillus in sputum, 84 in lu-ine, 868 bacteriology, 862, 863 bronchopneimionia in, 871 case, 867 conjunctival, 861 cough of, 40 diazo-reaction, 868 differential diagnosis, 868 dysphagia in, 871 INDEX. 1209 Diphtheria in domestic animals, 864 laboratory diagnosis, 868 laryngeal, 861, 866 malignant, 861 mild, 861, 864 myocarditis in, 871 nasal, 861, 865 nephritis in, 871 neuritis in, 871 ocular complications, 871 otitis media ia, 871 pharyngeal, 861, 865 pharyngitis and, differentia,tion, 868 scarlet fever and, differentiation, 869 strabismus in, 871 streptococcus angina and, differentia- tion, 869 tonsillar, 861, 864 tonsiUitis and, differentiation, 720, 868, 869 transmission, 863 wound, 862, 866 Diphtheric paralysis, 1146 stomatitis, 399 Diphtheritis, 861. See also Diphtheria. Diplegia, 1054^1057 Diplococci in sputum, 84 DipyUdium caninum, 971 Dislocation of vertebra, 1113 Diver's palsy, 1110 Diverticulum of esophagus, 413 Dizziness ia braia diseases, 1043 Dog, endemic hemorrhage in, 988 hydrophobia in, 908 tape-worm, 971, 973 Dohle's inclusion bodies in scarlet fever, 854 Doremus-Hinds' ureometer, 651 Dorsodynia, 931 Double murmur in aortic stenosis, 274 Dracontiasis, 989 Dracunculus medinensis, 989 Dropsy in heart disease, 173 of pericardium, 250 of pleurae, 135. See also Hydrotharax. Drowsiness in gastric diseases, 438 Drug eruptions of mouth and gums, 401 purpura, 385 Dry catarrh, 91, 93 pleurisy, chronic, 156 fibrinous, 137 rales, 69 Dubini's disease, 1169 Duchenne-Erb paralysis, 1138, 1139 Dudgeon sphygmograph, 211 Dull tympany, 61 Dulness on percussion, 58 over chest, 60 Duodenal fluid, 521 tube, 520 Einhom's, 520 Gross', 520 ulcer, 518 gastric ulcer and, differentiation, 521 a;-ray diagnosis, 519 Duodenum, carcinoma of, 546 Dura arachnoid, 1012 Dysbasia arteriosclerotica, cc-ray diagno- sis, 237 Dysentery, 727 amebic, 963 abscess in, 966 case, 964 chronic dysentery and, differentiation, 966 feeding experiments, 963 bacillary, acute, 728 bacillus in blood, 730 catarrhal, acute, 729 chronic, 733 amebic dysentery and, differentiation, 966 carcinoma of intestine and, differ- entiation, 547 , tuberculous enteritis and, differentia- tion, 734 hepatic abscess from, 588 pseudomembranous, 731 case, 732 tuberculous, 723 typhoid fever and, differentiation, 755 Dyspepsia, atonic, 477 catarrhal, chronic, 488. See also Gas- tritis, chronic. nervous, gastralgia and, 480 Dysphagia in diphtheria, 871 Dyspnea, 50 in gastric diseases, 437 in heart disease, 173 stridulous, 35 Dystrophy, muscular, 1129 differential diagnosis, 1131 facio-scapulo-humeral form, 1131 infantile form, 1131 pseudo-hypertrophic, 1129, 1130 Ear cough, 39 physical examination of, 27 Eating center, 1030 function in tumors of cerebellum, 1069 Ecchymoses in endocarditis, ulcerative, 256 Echinococcus disease, 973, 979, 986 hepatic. See Hydatid cyst. of brain, 1061 of kidney, 985 of lungs, 130 actinomycosis and, differentiation, 922 EcholaKa, 1168 Ectasia of colon, 523. See also Dilatation of colon. Eczema, angioneurotic, 1151 cutaneous, in erysipelas, 890 erysipelas and, differentiation, 891 in heart disease, 180 in pharyngitis, 402 labial, 392 nodosum in erysipelas, 891 of larynx, asthma and, differentiation, 100 1210 INDEX. Eczema of lungs, 105 hydrothorax and, differentiation, 106 in lobar pneumonia, 786 in scarlet fever, 859 Effusion, chylous, 571 pseudochylous, 571 Egophony, 72 in pleurisy, 148 Eighth cranial nerve, 1041 Einhom's duodenal pump, 520 Einthoven thread galvanometer, 217 Elastic tissue in sputum, 80 Electric chorea, 1169 reactions of degeneration, 1083 Electrocardiogram, 217 auricular complex, 220 leads, 220 pathologic alterations in, 222 physiologic mammaUan, 220 time relationship, 222 Eleventh cranial nerve, 988 Emaciation in fever, 717 EmboUc plugging of vessel, aneurism from, 311 Embolism, apoplexy from, 1051 heart disease and, 172 ia typhoid fever, 757 pulmonary, 117 Embolus, fat, 117 Emotion, blood-pressure and, 203 Emphysema, asthma and, differentiation, 100 chest in, 48 compensatory, 72 heart shadow and, 232 pulmonary, 124. See also Pulmonary emphysema. small-lunged, 129 a-ray diagnosis, 73 Emphysematous lung tissue, radiograph of, 815 Emprosthotonos in tetanus, 911 Empyema, 158 aneurism and, differentiation, 160 circumscribed, bronchiectasis and, dif- ferentiation, 102 in lobar pneumonia, 786 in scarlet fever, 859 necessitatis, 158 of pericardium, 245 pleural effusion and, differentiation, 160 pulsating, 158 thoracic aneurism and, differentia- tion, 320 x-Tny diagnosis, 74 Encapsulated pleurisy, 155 Encephahtis, acute, 1056 in apoplexy, 1051 Encephalopathy, lead, 532, 1145 Endarteritis, aortic regurgitation from, 266 chronica deformans, 308. See also Arte- rial sclerosis. obliterating, 833 syphiUtic, 833 Endemic hemoptysis, 130 Endocardial murmurs, hemic, 227 Endocarditis, 251 chronic, 262 colloidal albumin coefficient in, 258 in articular rheumatism, 895 in pulmonary tuberculosis, 819 in scarlet fever, 859 in typhoid fever, 757 infectious, 254. See also Endocarditis, ulcerative. malignant, 254. See also Endocarditis, ulcerative. myocarditis from, 296 pericarditis and, differentiation, 254 recurrent mahgnant, 260, 261 simple acute, 251 aortic regm-gitation from, 266 woolly heart sound in, 253 syphiUtic, 832 tricuspid regurgitation from, 287 stenosis from, 290 ulcerative, 255 abscesses in, 256 care, 268 cerebral type, 262 cutaneous hemorrhages in, 256 ecchymoses in, 256 gastro-intestinal symptoms, 256 in lobar pneumonia, 786 miliary tuberculosis and, differentia- tion, 260, 801 miurmurs of, 257 nervous symptoms, 256 ocular symptoms, 256 recurrent endocarditis and, differen- tiation, 260, 261 typhoid fever and, differentiation, 260 form, 256 varieties, 255 urine in, 258 Endocardium, diseases of, 251 Endolaryngitis, acute, 34 Endoneurium, 1133 Endothelioma of brain, 1059 Ensiform and umbiUcal fine, 440, 443 Entamceba histolytica in lungs, 130 in sputum, 82 Enteralgia, 545 Enteritis, catarrhal, 544, 725 in rubella, 878 nervous, 726 in heart disease, 174 in pulmonary tuberculosis, 818 phlegmonous, 725 tuberculous, 723 case, 724 dysentery and, differentiation, 734 Enteroptosis, 522 peristalsis in, 426 a;-ray diagnosis, 461, 523 Enterospasm, 529 Enxiresis, nocturnal, 713 paralytic, 714 Eosin-hematoxyUn-methylene-blue stain for blood, 342 Eosinophiles, 359 Eosinophilia, 360 INDEX. 1211 Epiconus, 1082 Epicritic sensory system, 1019 Epidemic catarrhal fever, 788. See also Influenza. meningitis, 835 pupils in, 312 Epigastric angle, 42 neuralgia, 545 pain, 442 pulsation, 185, 441 Epilepsy, 1044, 1045 ambulatory automatism in, 1047 catatonic state in, 1047 cry of, 1046, 1047 delusions in, 1047 dreamy state, 1047 in heart disease, 174 laughing in, 1047 major, 1046 maniacal, 1047 minor, 1046 myoclonus, 1169 narcolepsy in, 1047 nocturnal, 1047 psychic, 1046 sleeping in, 1047 status epilepticus, 1047 Epileptic equivalents, 1046 Epinem-ium, 1133 Epistaxis in typhoid fever, 749 in whooping-cough, 884 Epithehoma, benigh cystic, pseudoleu- kemia and, differentiation, 379 syphilis and, differentiation, 829 Erb's sign of tetany, 1165 Erosion aneurism, 311 Eruptions, drug, of mouth and gums, 401 syphilis and, differentiation, 829 Erysipelas, 887 cellulocutaneous, 887 diazo-reaction in, 258 differential diagnosis, 891 eczema and, differentiation, 891 edema in, 890 erythema and, differentiation, 891 in coryza, 889 in puerperium, 889 in varicella, 908 leukocytosis in, 890 line of demarcation in, 890 migratory, 887 neonatorum, 887 nephro-, 887 phlegmonous, 887 pneumo-, 887 relapsing, 887 urticaria and, differentiation, 891 Erythema, erysipelas and, differentiation, 891 in variola, 903 rubella and, differentiation, 878 scarlatiniform, 851 Erythrocytes, 352 counting of, 337 degeneration of, 352 in feces, 517 Erythrocytes in secondary anemia, 357 pipet for counting, 335 solution for preserving, 335 stained, 352 Erythromelalgia, 1150, 1151 Esbach's albuminometer, 647 solution, 647 Esophagismus, 416. See also Esophagus, spasm of. Esophagitis, 409 acute, 412 chronic, 412 cough of, 40 Esophagoscope, Jackson's, 448 Esophagoscopy, 404, 448 anesthesia for, 407 in carcinoma, 417 in diverticulum, 414 in esophagitis, 412 in spasm, 417 in stricture, 415 in ulcer, 413 retrograde, 404 Esophagus, 404 abscess of, pneumothorax from, 161 carcinoma of, 417 pneumothorax from, 161 x-ray diagnosis, 409 constrictions of, 405 dilatation of, 416 esophagoscopy in, 408 x-ray diagnosis, 409 diseases of, 409 esophagoscopy in, 404, 408 a;-ray diaignosis, 408 displacements of, x-ray diagnosis, 408 diverticulum of, 413 x-ray diagnosis, 409 esophagoscopy and, 404 foreign bodies in, 408 hemorrhage from, 410 length of, at different ages, 405 lumen of, 405 movements of, i-ray and, 409 physical examination of, 28 position of, 405 spasm of, 416 stricture and, differentiation, 416 x-ray diagnosis, 409 stenosis of, 414. See also Esophagus, stricture of. stricture of, 414 auscultation in, 444 esophagoscopy in, 408, 415 pressure from without and, differen- tiation, 416 spasm and, differentiation, 416 x-ray diagnosis, 408 technic of examination, 404 ulcer of, 412 Essential anemias, blood in, 375 symptoms, 374 Estivo-autumnal fever, 947, 951 algid form, 951 bilious form, 952 cardialgic form^ 951 1212 INDEX. Estivo-autumnal fever, choleraic form, 951 comatose form, 951 dysenteric form, 951 hemorrhagic form, 951 pnemnonic form, 952 Ether pneimionia, 773 Euchlorhydria, 466 Eustrongylus in urine, 986 Eventratio diaphragmatica, hernia and, differentiation, 76 Ewald-Boas' test-breakfast, 462 Exanthemata, vomiting of, 434 Exercise, blood-pressure and, 203 dyspnea after, in heart disease, 173 purpura after, 384 Exophthalmic goiter, 1154 Boston-Kocher sign in, 1155 hjrpotension in, 205 Exophthahnos in heart disease, 180 Exploratory puncture of pericardium, 245 Extracardial murmurs, 227 Extracerebellar tumors, 1070 Extrasy stole, 195 Extra-uterine pregnancy, ruptured, appen- dicitis and, differentiation, 540 Exudates, examination of, 31 Eyes, cysticercus of, 990 filariasis of, 990 in hysteria, 1187 in neurasthenia, 1176 parasites of, 990 physical examination of, 27 Eye-strain, nausea and, 432 Face, motor neuroses of, 1166 physical examination of, 27 tics of, 1166 Facial hemiatrophy, progressive, 1158 nerve, 1040 paralysis, 1041 Facio-scapulo-humeral dystrophy, 1131 Fallopian tubes, tuberculosis of, 820 False croup, 34. See also Laryngitis, spasmodic. Family history, 26 idiocy, amaurotic, 1153 spastic paralysis, 1092 Farcy, 913 Fasciola hepatica, 974, 981 Fasciolopsis Buski, 974 Fat emboli, 117 in blood, 341 Fatty acids in sputum, 87 cirrhosis, 599 degeneration of heart, 299 of liver, 593 leukemia and, differentiation, 371 with enlargement, 591 of newborn, acute, 942 kidney, 668. See also Nephritis, chronic. stools, 616. See also Feces, fatty. Faught's formula for estimating normal blood-pressure, 201 Febris recurrens, 764. See also Relapsing fever. Fecal impaction, carcinoma and, differ- entiation, 547 of splenic flexure, 632 Feces, 514 baciUi in, 518 biliary acids in, 517 bilious, 516 blood in, 515 microscopic, 517 tests for, 515 casts in, 517 chlorophyl in, 617 clay-colored, 616 coffee-ground, 515 collection, 514 color, 615 consistency, 614 erythrocytes in, 517 examination of, 31 fatty, 518, 616 acids in, 517 tests for, 616 green, 517 hematoidin crystals in, 517 intestinal sand in, 518 macroscopic study, 517 microscopic study, 617 mucoid, 517 odor, 514 pus in, 518 reaction of, 517 red, 617 rice-water, in cholera asiatica, 737 sago granules in, 617 starch in, 617 FehUng's test for glycosuria, 663 Fermentation, gastric, pain of, 437 test for glycosuria, 654 Ferments in gastric contents, 468 in sputum, 87 Festination in paralysis agitans, 1172 Fever, 715 atypical type, 717 defervescence stage, 718 delirium in, 716 fastigium of, 718 intermittent type, 717 invasion stage, 718 inverse type, 717 remittent type, 717 spotted, 835 Fibers in sputum, 80 Fibrillation, auricular, 196 Fibrinous coagula in sputum, 80 pleurisy, dry, 137 pneumonia, 113. See also Pneumonia, fibrinous. Fibroid induration of lung, 113 phthisis, 819 x-ray diagnosis, 75 Fibroma of brain, 1060 of cord, 1111 of nerves, 1142 Fibrosis, arteriocapillary, 308. See also Arterial sclerosis. Fiedler's disease, 937 INDEX. 1213 Fifth cranial nerve, 1039 tics in distribution of, 1166 Figure blindness, 1029 Filaria bronchialis, 82 in sputum, 82 Filarial fever, 959 Filariasis, 959 of eye, 990 of lungs, 988 Filatoff's sign in scarlet fever, 850 Fingers, capillary pulse of, 185 in heart disease, 180 spasm in, 1168 First cranial nerve, 1035 Fish worm, 969 Flagellate, 967 Flatulence, 436 in heart disease, 174 Flea in plague, 787 Flint murmur, 271 Floating kidney, carcinoma of intestine and, differentiation, 547 spleen, 626 Flukes, 974 hver, 981 Flutter, auricular, 197 Fly in transmission of acute anterior polio- myelitis, 843 in trypanosomiasis, 958 Focal convulsion, 1044 Food, regurgitation of, 430 Foot-and-mouth disease, 936 Foot-drop in plumbism, 531 Forceps, cotton-holding, for oocainization of larynx, 407 Forcible apex-beat, 183 Fourth cranial nerve, 1038 ventricle, tumors of, 1065 Fracture of base of skull, brain injury, 1074 of vaiilt of skuU, brain injury, 1073 of vertebra, 1113 Free hydrochloric acid, Congo-red test, 467 Gunzberg's test for, 467 Freezing-point of blood, 341 of urine, 341 Fremitus, tactUe, 52 Frenum, ulcer of, 394 Friction murmurs, 71 Friedlander's bacillus in pus from pul- monary abscess, 84 in sputum, 84 pneumonia, 781 Friedreich's ataxia, 1097 sign, 62, 249 Frontal lobe, tumors of, 1062 Frontocerebellar fibers, 1031 Functional murmurs, mitral regurgitation and, 282 Fungi in sputum, 82 in urine, 703 Fungoid disease of lung, 130 Fusiform aneurism, 310 Gait, hemiplegic, 1052 in tumors of cerebellum, 1068, 1069 Gait, unilateral spastic, 1052 Gall-bladder, carcinoma of, intestinal car- cinoma and, differentiation, 547 diseases, jaundice in, 604 distention of, 590 bladder distention and, differentia- tion, 684 fioatiag spleen and, differentiation, 684 hydatid cyst and, differentiation, 973, 974, 981 hydronephrosis and, differentiation, 683, 684 ovarian cyst and, differentiation, 684 Galloping phthisis, 803 Gall-stone disease, 609. See also Chole- lithiasis. Gangrene of lung, 118. See also Pulmon- ary gangrene. symmetrical, 1151 Gases, regurgitation of, 430 Gastralgia, 436, 480 angina pectoris and, differentiation, 306 ataxic crises and, differentiation, 480 cholehthiasis and, differentiation, 612 hepatic colic and, differentiation, 480 intestinal coHc and, differentiation, 480 nervous dyspepsia and, 480 ulcer and, differentiation, 495, 496 Gastrectasis, atonic, a-ray diagnosis, 459 x-rays diagnosis, 459 Gastric asthma, 96 atrophy, progressive pernicious anemia and, differentiation, 365 carcinoma, 498. See also Carcinoma, gastric. contents, 30, 461 acetic acid in, 469 acetone in, 470 acidity of, 464 chnical significance, 468 total, 465 Boas-Oppler bacillus in, 471 carbohydrate digestion, 468 chemistry of, 464 ferments in, 468 hydrochloric acid in, 466 in carcinoma, 500 lactic acid in, 469. See also Lactic acid in gastric contents. microscopic study, 464, 471 obtaining, 462 profermeiits in, 468 crises in diabetes mellitus, 997 juice, 30, 464. See also Gastric contents. peristalsis, estimation of, 477 ulcer, 491. See also Ulcer, gastric. Gastritis, acute, 482 complications, 485 differential diagnosis, 484 helminthology, 482 laboratory diagnosis, 484, 486 nervous phenomena, 486 pain of, 437 scarlet fever and, differentiation, 484 variola and, differentiation, 484 1214 INDEX. Gastritis, acute, vomiting in, 432 atrophic, chronic, 488 catarrhal, in heart disease, 174 chronic, 488 atrophic, 488 carcinoma and, 490, 498, 602 in measles, 878 laboratory diagnosis, 490 mucous, 488 simple, 488 ulcer and, differentiation, 490 vomiting of, 433 phlegmonous, 487 pseudomembranous, 487 simple chronic, 488 suppurative, acute, 487 toxic, 485 Gastrodynia, 436, 480. See also Gastralgia. Gastro-intestinal phenomena of heart dis- ease, 174 Gastroptosis, 508 auscultation in, 513 dilatation and, differentiation, 508 from chest deformities, 511 from muscular strain, 511 from spinal deformities, 511 hepatic dislocation in etiology, 511 inspection in, 511 palpation in, 611 percussion in, 513 peristaltic movements in, 426 relaxation of abdominal wall in etiology, 511 a;-ray diagnosis, 467, 513 Gastroscope, 446 Jackson's, 446, 448 passing of, 448 Gastroscopy, 446 assistants' duties, 449 contra-indications, 453 extreme right and left positions of in- strument, 452 faulty, 451 in carcinoma, 600 in gastric dilatation, 506 in ulcer, 494 position of patient, 448 technic, 448 Gastrosuccorrhea, hyperchlorhydria and, differentiation, 476 General considerations, 17 paresis, 1189 Geographic tongue, 392 Gerhardt's sign, 63 German measles, 898. See also Rubella. Gigantism, 1158 Gin-drinker's liver, 598. See also Cir- rhosis, atrophic. Glanders, 913 Glandular fever, 937 GUoma of brain, 1068 ependymal, 1065 Ghssonian cirrhosis, 602 Globus hystericus, 1179, 1184 Glomerulonephritis, acute, 661. See also Nephritis, acute. Glomerulonephritis, chronic, 668. See also Nephritis, chronic. Glossina palpaUs, 958 Glossitis, 393 Glosso-l9,bio-laryngeal paralysis, 1077. See also Bulbar paralysis, chronic. Glossopharyngeal nerve, 1042 Glottis, spasm of, asthma and, differentia- tion, 100 Glucose in blood, 341, 652 in sputum, 87 in mrine, 662 Glucosuria, 662, 653 Gluteal nerves, paralysis of, 1141 Glycemia, 652 Glycogen in blood, 340 Glycosiiria, 996 aUmentary, 653, 992 cerebral, 993 collecting urine in test for, 653 copper test for, 664 digestive, 993 Fehhng's test for, 653 fermentation test for, 654 functional, 993 in cyst of pancreas, 625 intermittent, 663, 993 nervous, 653 of arthritis, 653, 993 of gout, 653 of obesity, 653 puerperal, 993 test for, 653 toxic, 992 transitory, 992 traumatic, 993 Glycyltryptophan test in diagnosis of cancer of internal organs, 501 Goiter, exophthalmic, 1154 in heart disease, 180 Goll's tract, 1020 Gonorrheal arthritis, 897. See also Ar- thritis, gonorrheal. stomatitis, 398 Gout, 1006 acute, 1007 atrophic, cirrhosis from, 698 chronic, 1007 differential diagnosis, 1008 glycosuria of, 653 irregular, 1008 poor-man's, 1007 retrocedent, 1007 rheimiatism and, differentiation, 1008, 1009 suppressive, 1007 syphilis and, differentiation, 829 Gowers' tract, 1019, 1020 Grand mal, 1046 Granular degeneration of erythrocytes, 362 Gravel, renal, 690 Graves' disease, 1154. See also Exoph- thalmic goiter. Gross' duodenal tube, 620 Ground itch, 977 Grunt, 72 INDEX. 1215 Guaiac-hydrogen-dioxid test for blood in feces, 615, 516 Giiinea-worm, 989 Gummata, 827, 828 of brain, 1059 Giinzberg's test for free hydrochloric acid, 467 Gurgles, 70 deglutition, 444 Gyrus, angular, 1029 Habit chorea, 1167 migrainous, 1192 neurasthenic, 1175 spasm, 1167 Habitual constipation, 534 Hammerschlag's method for specific grav- ity of blood, 329 Hanburger's auscultation in esophageal constriction, 411 Hanot's hypertrophic cirrhosis, 576 Harrison's curve in rickets, 1003 Harsh breathing, 35 Hasty diagnoses, 19 Hawke's method of eUciting trip-hammer pulse, 269 Hay asthma, 939. See also Autumnal catarrh. Hay-fever, 939. See also Autumnal catarrh. Head, pains in, visceral disease and, 1026 physical examination of, 28 sweating of, 639 tetanus, 1164 Headache in brain diseases, 1042 in yeUow atrophy, 603 sick, 1191 Head's peripheral divisions, 1134 table of referred pains, 1025 Heart, acquired and congenital lesions of, differentiation, 307 action, blood-pressure and, 200 intermittency of, 171 irregularity of, 171 adhesions to, x-ray diagnosis, 232 aneurism of, 302 apex of, 176 base of, 175 block, 174 borders of, 176 circulation through, 225 congenital affections, 306 and acquired lesions of, differentiation, 307 coronary sclerosis, 309 degeneration of, fatty, 299 dilatation of, 309. See also Dilatation of heart. disease, 168 apex-beat in, 181 attitude in, 186 auscultation in, 223 cells, 86 cerebral hemorrhage in, 174 chest measurement in, 223 Heart disease, Cheyne-Stokes respiration in, 173 circumscribed pleurisy and, 169 combined forms, 292 complexion in, 180 cough in, 39, 172 cyanosis in, 173 delirium in, 174 diaphragmatic peritonitis and, 170 dropsy in, 173 dyspnea in, 173 edema in, 180 emboUsm and, 172 enteritis in, 174 / epilepsy in, 174 exophthalmos in, 180 fingers in, 180 fiatulency in, 174 gastric disturbances and, 170, 174 hemorrhagic infarct in, 172 hjrpertension in, 204 hypotension in, 205 kidney in, 174 locaUzed abscess and, 170 myalgia and, 169 nervous phenomena, 173 orthopnea in, 173 pain in, 170 palpation in, 186 percussion in, 223 periostitis and, 170 pleurodynia and, 170 precordium in, 180 pulmonary phenomena, 172 pulse in, 186 sputum in, 86 stethoscope in, 223 Stokes-Adams syndrome in, 174 symptoms suggestive of, 172 throat in, 175 thrombosis and, 172 urine of, 174 voice in, 175 x-ray diagnosis, 229, 230 displacements, x-ray diagnosis, 232 dulness, boundaries, 178 emphysema and, 232 fatty, 299 hypertrophy of, 293 dilatation and, 295, 300 of left ventricle, 233 thoracic aneurism and, differentiar tion, 295 infiltration of, fatty, 299 inspection, 179 landmarks, 177 mobility of, x-ray diagnosis, 232 normal curves of, 231 palpitation of, 171 pain in, 437 pathologic, 232 physical examination of, 28 position of, 232 x-ray to determine, 231, 232 relations of, 177 rupture of, 302 1216 INDEX. Heart, shape of, i-ray diagnosis, 231, 233 size of, 230 x-ray diagnosis, 230, 233 syphilis of, 832 thinning of wall of, 309 topography, 175 valves, areas for auscultating, 236 position, 178 x-ray measurements of, 230 Heart-beat, abnormal, x-ray diagnosis, 232 Heart-block, 190 Heart-sounds, 224 areas of maximum intensity, 226 cycle of, 224, 225 diastoUc, 224 doubUng of, 227 first, 224 in infants, 224 pathologic, 227. See also Murmurs. physiologic variations, 226 second, 224 doubling of, 227 systolic, 224 Heart-valves, sounds of, 226 Heat and nitric acid test for albumin, 646 Heat-apoplexy, 943 Heat-stroke, 943 Heberden's nodes, 1160 Hectic fever in pulmonary tuberculosis, 810 Heel, neuralgia of, 1150 HeUer's test for albumin, 646 Hematin, 330 spectrum of, 331, 332 Hematoidin, 330 crystals in feces, 517 Hematomyeha, 1114 Hematoporphyrinuria, spectrum of, 331 Hematuria, 640 causes, 641 Hemianesthesia in hysteria, 1179 Hemianopsia, 1036 Hemiatrophy, progressive facial, 1158 Hemic murmurs, aortic stenosis murmurs and, differentiation, 276 endocardial, 227 Hemicrania, 1191 Hemidrosis, 637 Hemiplegia, 1048 after fortieth year, 1050 after twentieth year, 1050 from apoplexy, 1050 from birth injuries, 1049 from second year to maturity, 1050 in first two years of life, 1049 in syphilis of nervous system, 1120 Hemiplegia gait, 1052 HemoalkaUmeter, Dare's, 339 Hemochromogen, 329 Hemocytolysis, 330 Hemocytometer, Thoma-Zeiss, 335 Hemoglobin, 329 blotting-paper test for, 334 carbonic acid, 330 spectrum of, 331, 332 estimation of, 332-334 Hemoglobin in secondary anemia, 356 reduced, 330 spectrum of, 331 scale, TaUqvist's, 334 Hemoglobinemia, 330 ' in secondary anemia, 356 Hemoglobinometer, von Fleischl's, 332 Hemoglobinuria, 640 epidemic, 942 in malaria, 956 Hemometer, Sahli's, 333, 334 Hemopericardium, 250 Hemophiha, 382 Hemoptysis, 78 causes, 78 endemic, 130, 988 in pulmonary tuberculosis, 803, 813 in whooping-cough, 884 Hemorrhage, cerebral hypertension in, 204 cutaneous, in ulcerative endocarditis, 256 esophageal, 410 from lung and throat, gastric hemor- rhage and, differentiation, 496 gastric hemorrhage and, differentia- tion, 85 mouth, 397 gastric, lung and throat hemorrhage and, differentiation, 496 pulmonary hemorrhage and, differ- entiation, 85 in atrophic cirrhosis, 599 in cerebral peduncle, 1053 in meduUa, 1053 in pons, 1053 in pulmonary tuberculosis, 818 in thoracic aneurism, 314 in typhoid fever, 756 fever in, 748 into mediastinum, 325 into spinal cord, 1114 into thymus gland, 325 meningeal, 1076 of newborn, hemophilia and, differentia- tion, 384 pancreatic, 622 secondary anemia from 355 Hemorrhagic diseases of newborn, 942 infarct in heart disease, 172 pulmonary, 117 pleurisy, 154 Hemorrhoids from mitral regurgitation, 278 in tricuspid regurgitation, 287 Hemosiderin, 330 in sputum, 86 Hemothorax, 154 Henoch's chorea, 1169 purpura, 385 Hepatic aneurism, 321 coUc, appendicitis and, differentiation, 540 gastralgia and, differentiation, 480 pain of, 437 Hepatitis, suppurative, 587. See also Abscess, hepatic. Hepatoptosis, 573 INDEX. 1217 Hereditary spastic paralysis, 1092 Hernia, diaphragmatic, eventration and, differentiation, 76 pneumothorax and, differentiation, 76, 166 x-ray diagnosis, 76 Hernial projections, abdominal, 424 Herpes labiaUs, 392 Hiccough, 431, 1167 Hinds-Doremus ureometer, 651 Hippocratic succussion splash in pneumo- thorax, 164 Histoplasmosis, 943 History, 25 History-taking, scheme for, 24 Hob-naUed hver, 598 Hodgkin's disease, 376. See also Pseudo- leukemia. Hogs, endemic hemorrhage in, 988 scarlet fever in, 848 tapeworm of, 969 trichina of, 983 Hook-worm disease, 976. See also Anky- lostomiasis. Horse-tick, 764 Hour-glass stomach, 497 a>-ray diagnosis, 459 Himtington'a chorea, 1171 Hutchinson's teeth, 831 Hydatid cyst, 973, 979 abscess and, differentiation, 590 aspiration, 980 diaphragm movements and, 76 gall-bladder distention and, differen- tiation, 973, 974, 981 hydronephrosis and, differentiation, 973, 974, 981 pleural effusion and, differentiation, 981 thrill, 980 Hydrocephalus, external, 1056 internal, 1056 from meningitis, 1128 Hydrochloric acid, free, Congo-red test for, 467 tests for, 466 in gastric contents, 466 solution, decinormal, 334 Hydronephrosis, 681 bladder distention and, differentiation, 683, 684 carcinoma of intestine and, differentia- tion, 547 floating spleen and, differentiation, 683, 684 gall-bladder distention and, differentia- tion, 683, 684 hydatid cyst and, differentiation, 973, 974, 981 ovarian cyst and, differentiation, 683, 684 Hydropericardium, 250 Hydrophobia, 908 in dogs, 908 tetanus and, differentiation, 912 transmitted by dogs, 908 77 Hydrothorax, 135 plem-isy with effusion and, differentia- tion, 153 pulmonary edema and, differentiation, 106 Hymenolepis diminuta, 971 nana, 970 Hyperchlorhydria, 465, 466, 475 continuous, 475 gastric ulcer and, differentiation, 476 gastrosuccorrhea and, differentiation, 476 intermittent, 475 pain of, 437 Hyperemia, hepatic, 686 atrophic, cirrhosis from, 599 of lungs, 104 Hyperesthesia, gastric, 481 Hjrperidrosis, 638 Hyperorexia, 429 Hyperostosis crami, 1158, 1162 Hyperresonant note, 60 Hypertension in angina pectoris, 204 in aortic regurgitation, 204 in arteriosclerosis, 203 in cerebral hemorrhage, 204 in heart disease, 204 in nephritis, 203 in puerperal eclampsia, 204 in toxemia, 204 Hypertonia, congenital, ■ 1054 Hypertrophy, auricular, 295 in aortic regurgitation, 265 of heart, 293 dilatation and, differentiation, 296 of left ventricle, 233 thoracic aneurism and, differentia- tion, 295 with dilatation, 310 of left ventricle, 293 of right ventricle, 294 Hypoacidity, 465 Hypobromite test for urea, 651 Hypochlorhydria, 466 HypoeosinophiUa, 360 Hypogastric neuralgia, 545 Hypoglossus nerve, 1042 Hypoleukocytosis, 360 Hypomotility, gastric atony and, differ- entiation, 478 Hjrpostatic congestion of lungs, 104 Hypotension, 204 Hypotonia in tabes dorsalis, 1103 Hysteria, 1177 ankle clonus in, 1181 arc de cercle in, 1184 aura in, 1184 contractures in, 1085 convulsions in, 1183 grave, purpura in, 384 hemianesthesia in, 1179 major, 1185 minor, 1185 paralysis in, 1182 reflexes in, 1181 sensation in, 1179 1218 INDEX. Hysteria, stigmata of, 1178, 1179 swelling sense in, 1187 taste sense in, 1187 tonic movements in, 1182 tremors in, 1180 visual field in, 1186, 1187 IcTERtrs, 604. See also Jaundice. neonatormn, 615 Idiocy, amaurotic family, 1153 Illuminating gas, polyneuritis from, 1146 Immune opsonins, 349 Impetigo contagiosa, variola and, differ- entiation, 905 Inanition. See Malnutrition. Inclusion bodies of Dohle in scarlet fever, 854 Incompetency. See Regurgitation. Incontinence of urine, 713 Incoordination in tumors of cerebellum, 1067, 1069 Indeterminate r41e, 71 Indicanuria, 660 Indigestion, acute, appendicitis and, differ- entiation, 541 intestinal, acute, 725 Individual cases, investigation of, 23 Indoxyl-potassium sulphate in urine, 660 Indoxyl-sodium sulphate in inrine, 660 Induration of lung, fibroid, 113 Infantile diplegia, 1049, 1054 meningitis, tuberculous, 1125 muscular dystrophy, 1131 spinal palsy, 843. See also Poliomyelitis, acute anterior. Infants, heart-sounds in, 224 Infarct, hemorrhagic, in heart disease, 172 pulmonary, 117 Infectious diseases, 715 apoplexy from, 1051 atrophic cirrhosis from, 599 hypotension in, 204 neuritis in, 1147 probable, 930 purpura of, 384 spleen in, 628 syphiUs and, differentiation, 829 Infiltration of heart, fatty, 299 of hver, fatty, with enlargement, 591 pulmonary tuberculous, serofibrinous pleurisy and, differentiation, 151 Influenza, 788 ambulatory type, 790 apyretic type, 790 bacillus in sputum, 83 bacteriology, 789 bronchitis in, 91, 790 bronchopneumonia in, 793 case, 110 cardiac type, 790 case, 792 complications, 793 gastro-intestinal type, 789 nervous type, 790 pneumonia with, 773, 775 Influenza, respiratory type, 789 rheumatoid type, 790 typhoid type, 789 Infra-axillary regions, 44 Infraclavicular regions, 43 Inframammary regions, 43 Infrascapular regions, 45 Inhalation tubercuUn test, 809 Innominate artery, aneurism of, 315 Insanity, brain injuries and, 1077 general paralysis of, 1189 Inspection, 45 Insufficiency. See Regurgitation. Intention tremor, 1044 Intercostal neuralgia, 1149 Interlobar pleurisy, 155 Intermittency of heart action, 171 Intermittent claudication, lllO fever, 948 abscess and, differentiation, 950 hepatic cohc and, differentiation, 951 pulmonary tuberculosis and, differ- entiation, 950 renal calcuh and, differentiation, 951 urethral fever and, differentiation, 951 pulse, 194 Internal capsule, localization of fibers in, 1031 Interrupted Wintrich phenomenon, 62 Interscapular region, 45 Interstitial pneumonia, chronic, 113 Intestinal animal parasites, 963 cohc, cholelithiasis and, differentiation, 612, 694 nephrohthiasis and, differentiation, 694 fluid, 521 obstruction, 525 acute, 525 appendicitis and, differentiation, 542 ascites and, differentiation, 527 chronic, 525, 526 dilatation of colon and, differentia- tion, 527 from congenital stricture, 526 from intussusception, 525 from new-growths, 526 in choleUthiasis, 612 pancreatitis and, differentiation, 620 peristalsis in, 426, 526 peritonitis and, differentiation, 528 sand in feces, 518 Intestines, 418 amyloid, disease of, 535 bleeding from, 515 carcinoma of, 546. See also Carcinoma, intestinal. diseases of, 514, 518 examination in, 28, 456, 514, 522 x-ray diagnosis, 453, 461 in history-taking, 26 movement of, 426, 526 obstruction of, 525. See also Intestinal obstruction. physical examination of, 28, 456, 514, 522 INDEX. 1219 Intestines, small, caliber of, 426 tuberculosis of, 723 Introduction, 17 Intussusception, intestinal, 525 carcinoma and, differentiation, 547 Investigation of individual cases, 23 Irregular pulse, 194 Irregularity of heart action, 171 Itch, ground, 977 Itching in cirrhosis, 576 in jaundice, 605 Jacksonian convulsions, 1044 Jackson's gastroscope, 446, 448 Jail fever, 758. See also Typhus Jeoer. Jaquet sphygmocardiograph, 214-216 Jaundice, 604 acute febrile, 937 catarrhal, 606 epidemic catarrhal, 937 from blood-cell degeneration, 605 from thrombosis of portal vein, 614 hematogenous, 605 hepatogenous, 6Q5 in choleUthiasis, 610 in pancreatic carcinoma, 624 infectious, 937 itching in, 605 maUgnant, 604 milk secretion in, 606 obstructive, 605 peritonitis in, 605 urticaria in, 605 xanthelasma in, 605 xanthopsia in, 606 Jaworski and Ewald's test for total acid- ity, 465 Jejunal ulcer, 519 Jerky respiration, 68 Jumpers, 1168 Justus' blood-test for syphilis, 828 Kakkb neuritis, 1147 Kala-azar, 957 KarczjTiski-Jaworski test for blood in feces, 515 Kearcher's blood-pressure instrument, 210 KeUing's test for lactic acid, 470 Keratosis follicularis, 990 Kemig's sign in meningitis, 839, 1124 Kidney, amyloid, 680 nephritis and, differentiation, 672 back divisions, to locate, 638 calculi. See Nephrolithiasis. carcinoma of, 700 contracted, secondary, 668. See also Nephritis, chronic. disease, 661 cirrhosis and, differentiation, 602 x-ray diagnosis, 634 dislocation of, gastroptosis from, 511 fatty, 668. See also Nephritis, chronic. floating, carcinoma of intestine and, differentiation, 547 Kidney, heart diseases and, 168, 174 hemorrhage from, 640 large white, 668. See also Nephritis, chronic. parasites of, 985 pelvis of, outUne of, x-ray for, 636 physical examination of, 29 position of, 634 x-ray in determining, 635 relations of, 634 sarcoma of, 700 anaemia infantum and, differentia- tion, 381 small white, 668. See also Nephritis, chronic. syphilis of, 832 topography, 634 tuberculosis of, 685 tumor, splenic enlargement and, differ- entiation, 631 x-ray of, 633 Kjeldahl method, 501 Klumpke paralysis, 1138 Knee-jerk, 1097 Kocher-Boston sign in Graves' disease, 1155 Kophk's spots in measles, 873 Korsakoff's psychosis, 1145 La gkippe, 788. See also Influenza. Labial eczema, 392 Laboratory as aid in diagnosis, 23 examinations, 30 findings, scheme for, 24 Lactic acid in gastric contents, 469 tests for, 470 Lactosuria, 655 Laennec's cirrhosis, 598. See also Cir- rhosis, atrophic. Lamina, interna, 1030 Landry's paralysis, 1086 acute anterior poliomyelitis and, dif- ferentiation, 846 Large white kidney, 668. See also Nephri- tis, chronic. Laryngeal tjrphoid, 756 Laryngismus stridulus, 34. See also Laryngitis, spasmodic. Laryngitis, catarrhal, acute, 34 chronic, 36 edematous, 36 in variola, 902 spasmodic, 34 nervous type, 35 syphiUtic, 36 tuberculous, 35, 818 Larynx, cocainization of, 407 diseases of, 34 asthma and, differentiation, 100 edema of, asthma and, differentiation, 100 inflammation of, 34. See also Laryngitis. obstruction of, abdominal movement in, 425 physical examination of, 27 1220 INDEX. Larynx, spasm of, 35, 1167 stridor in, 35 tuberculosis of, in phthisis, 818 tumors of, 37 Laughing center, 1030 epileptic, 1047 Lead coUc, 530. See also Plumhism. encephalopathy, 532, 1145 line, 532 multiple neuritis, 1145 poisoning, chronic, 530. See also Plum- hism. workers, aortic regurgitation in, 266 myocarditis in, 297 Legs, spasms in, 1168 Leishman-Donovan bodies, 957 Lemniscus, 1020 Lenticular nucleus, 1012 lesions in, 1030 Lepra alba, 895 Leprosy, 833 anesthetic, 834, 835 tubercular, 834, 835 Letter blindness, 1029 Leucinuria, 658 Leukemia, 365 acute, 368 case, 369 amyloid disease and, differentiation, 371 anemia of spleen and, differentiation, 371 ankylostomiasis and, differentiation, 979 blood in, 368, 374 chloroma and, differentiation, 371 chronic, 366 differential count in, 369 erythrocytes in, 368 fatty infiltration of Uver and, differen- tiation, 371, 593 fresh blood in, 368 green cancer and, differentiation, 371 hemoglobin in, 368 laboratory findings, 368, 375 lead poisoning and, differentiation, 371 leukocytes in, 368, 369 leukocytosis and, differentiation, 371 lymphatic, 366, 372 anaemia infantum and, differentiation, 381 anemia of malnutrition and, differ- entiation, 372 Hodgkin's disease and, differentia- tion, 372 pseudoleukemia and, differentiation, 372 malaria and, differentiation, 371 malignant disease of Ijrmphatics and, differentiation, 371 mineral poisoning and, differentiation, 371 murmurs in, 368 myeloid, 365 anaemia infantum and, differentiation, 381 splenic anemia, and, differentiation, 382 Leukemia, nephritis and, differentiation, 371 pseudoleukemia and, differentiation, 379 scorbutus and, differentiation, 390 spleen in, 627 splenic anemia and, differentiation, 371 congestion and, differentiation, 371 splenomegaly and, differentiation, 371 Leukemic blood, 368, 374 Leukocytes, 358 counting of, 338 differential, 359 in disease, 359 in secondary anemia, 357 in urine, 642 lymphogenous, 359 myelogenic, 359 pipet for counting, 335 solution for preserving, 335 Leukocytic cream, 350 Leukocytosis, 359 drug, 359 in appendicitis, 539 in articular rheumatism, 895 in bronchopneumonia, 110 in erysipelas, 890 leukemia and, differentiation, 371 pathologic, 359 physiologic, 359 toxic, 359 Leukocyturia, 642 Leukopenia, 360 Line of demarcation in erysipelas, 890 Lip, capillary pulse of, 184, 185 diseases of, 392 Lipemia, 341 in chronic nephritis, 672 in retinal hemorrhage, 672 Lipoma, adiposis tuberosa simplex and, 1011 of brain, 1060 Lipomatosis universalis, 1009 Lithemia, 1009 Little's disease, 1054 Liver, 572 abscess of, 587. See also Abscess, hepatic. alcohol, 598. See also Cirrhosis, atrophic. amebic abscess of, 966, 982 amyloid disease of, 593 animal parasites of, 979 atrophy of, yellow, 603 phosphorus-poisoning and, differ- entiation, 597 carcinoma of, 579. See also Carcinoma, hepatic. cirrhosis of, hypertrophic, 575. See also Cirrhosis. contour of, 572 cysts, 979-981 pleurisy with effusion and, differen- tiation, 152 diseases, 573 jaundice in, 604 distention of, 590 enlargement of, abdominal movement m, 425 INDEX. 1221 Liver examination, 572 fatty degeneration of, 593 leiikemia and, differentiation, 371 with enlargement, 591 flukes, 9.81 gin-drinker's, 598. See also Cirrhosis, atrophic. heart diseases and, 168 hepatoptosis, 573 hob-nailed, 598 hyperemia of, 586 atrophic cirrhosis from, 599 in hereditary syphiUs, 830 in phosphorus-poisoning, 596 nematodes of, 982 outline of, in amyloid dioease, 595 outUning of, 578 position of, 573 posture and, 577 respiration and, 575 pulsating, in tricuspid regurgitation, 286, 288 relations of, 574r-576 sarcoma of, 585 size of, diminished, 598 eyphHis of, 831 topographic anatomy, 572 tuberculosis of, 595, 820 tumor of, abdominal movement in, 425 splenic enlargement and, differentia- tion, 631 yellow atrophy of, hypertrophic cir- rhosis and, differentiation, 604 phosphorus-poisoning and, differ- entiation, 604 Lobar pneumonia, 113, 770. See also Pneumonia, lobar. Lobstein's cancer, 563 LocaUzation, cerebral, 1027 of fibers in internal capsule, 1031 spinal, 1081 Lockjaw, 910, 1163. See also Tetanus. Locomotion, physiology of, 1102 Locomotor ataxia, 1099. See also Tabes dorsalis. Long up-stroke on sphygmograph tracing, 213 Lower arm brachial palsy, 1138 limbs, spasm in, 1168 LuciUa csesar, 991 serricata, 991 Lugol's solution, 656 as reagent for starch digestion, 469 test for acetone, 656 Lumbago, 930 Lvunbar cord, enlargement of, 1081 myelitis of, 1108 neuralgia, 1150 plexus, diseases of, 1141 Lumpy-jaw, 919 Lung. See also under Pulmonary. fever, 770. See also Pneumxmia, lobar. stone-mason's, 86 a;-ray transparency of, 73, 75, 122 Lymphadenitis, 322 Lymphadenoma, general, 376. See also Pseudoleukemia. Lymphangitis in glanders, 913 Lymphatic leukemia, 372. See also Leukemia, lymphatic. obstruction, filariasis and, differentia- tion, 961 Lymphatics, malignant disease of, leu- kemia and, differentiation, 371 tuberculosis of, 821, 822 Lymphocytes, 359 Lymphocytosis, 361 Lyinphogenous leukocytes, 359 Lysins, 20 Lyssophobia, 909 MacEwbn's sign in meningitis, 840 Macrocyte, 352 Madura-foot, 929 Mahogany flush in pneumonia, 779 Malacia, 429 Maladie des tics, 1168 Malaise with fever, 716 Malaria, 946 atrophic cirrhosis from, 598 estivo-autumnal, 947, 951. See also Eslivo-autumnal fever. hematuria in, 956 hemoglobinuria in, 956 hepatic abscess and, differentiation, 590 intermittent type, 948. See also In- termittent fever. latent, 956 leukemia and, differentiation, 371 myocarditis in, 297 parasite of, arterial sclerosis from, 309 quartan, 947 quotidian, 947 recurrent, 954 remittent, 952, 953. See also Remit- tent fever. spleen in, 628 splenic anemia and, differentiation, 382 tertian, 947 typhoid and, differentiation, 754 Malarial cachexia, 954 pneumonia, 773 Malignant disease, pseudoleukemia and, differentiation, 379 pustule, 914 Malnutrition, anemia of, lymphatic leu- kemia and, differentiation, 372 hemophilia and, differentiation, 383 Pseudoleukemia and, differentiation, 379 Malta fever, 762 Mammary gland, neuralgia of, 1149 region, 43, 419 Mastigophora, 967 Mastitis in mumps, 882 Mastodynia, 1149 Mazamorra, 977 McBumey's point, 537, 538 Measles, 871 bacteriology, 871, 874 blepharitis in, 878 1222 INDEX. Measles, bronchitis in, 91, 878 • bronchopneumonia in, 877 case, 875 conjunctivitis in, 878 diazo-reaction in, 874 experimental, in swine, 872 gastric catarrh in, 878 German, 878. See also Rubella. KopKk's spots in, 873 malignant, typhus fever and, differen- tiation, 762 mitral stenosis after, 283 nephritis in, 878 otitis media in, 878 pneumonia in, 877 rubella and, differentiation, 877, 878 scarlet fever and, differentiation, 857, 876 varicella and, differentiation, 877 variola and, differentiation, 877, 905 Median fillet, 1020 nerve palsy, 1140 Mediastinopericarditis, 240 Mediastinum, abscess of, 322 carcinoma of, 323 diseases of, 322 hemorrhage into, 325 inflammations of, 322 new-growths of, heart position and, 232 thoracic aneurism and, differentia- tion, 320 sarcoma of, 323 tuberculosis of glands of, 322 tumors of, 232, 320, 323 a;-ray diagnosis, 234, 325 x-ray exploration of, 234, 325 Mediterranean fever, 762 Medulla, hemorrhage in, 1053 oblongata, lesions of, 1033 tumors of, 1067 Megaloblast, 352 Megalogastria, gastric dilatation and, dif- ferentiation, 508 i-ray diagnosis, 459 Melanin, 330 M6ni^re's disease, 1043 Meningeal hemorrhage, 1076 Meninges of brain, injuries to, 1075 spinal, diseases of, 1122 tuberculosis of, 819 Meningism, 1127 Meningismus, 1127 Meningitis, acute, lobar pneumonia and, differentiation, 785 atropin test in, 1126 cerebrospinal, 835, 1124 abortive, 837 apoplectic, 836 aspiration in, 841 Brudzendski's sign in, 840 case, 841 epidemic, 835 eruptions, 838 intermittent, 837 Kemig's sign in, 839 MacEwen's sign in, 840 Meningitis, cerebrospinal, malignant, 836 mild, 837 opisthotonos in, 839 ordinary type, 837 paralyses in, 839 photophobia in, 838 Rocky Mountain fever and, differen- tiation, 935 spinal puncture in, 841 tongue in, 839 typhoid state in, 839 typhus fever and, differentiation, 761 ulcerative endocarditis and, differen- tiation, 262 variola and, differentiation, 905 in syphilis of nervous system, 1120 in tjrphoid, 756 purulent, 1124 serous, 1127 cerebral, 1128 cerebrospinal, 1127 circvimscribed, 1111 hydrocephalus from, 1128 syphihtic, 1059 tuberculous, 819, 1125 acute, 802 typhoid and, differentiation, 754 Meningomyehtis, 1108 Menopause, hypotension in, 205 Menorrhagia in pulmonary tuberculosis, 810 Meralgia paresthetica, 1142 Mesenteric aneurism, 321 glands, tuberculosis of, 821 Mesostemal line, 42 Metabolism, chemical studies and, 21 MetaUic tinkle, 72 in pneumothorax, 164 Metatarsal neviralgia, 1150 Methemoglobin, 330 spectrum of, 331, 332 Microblasts, 352 Microcytes, 352 Mid-axillary lines, 42 Midclavicular hnes, 42 Midspinal Une, 42 Migraine, 1191 ophthalmic, 1192 Miliary fever, 936 tuberculosis, 793, 794, 800- See also Tuberculosis, miliary. Milk-sickness, 935 Miotic pupils in tabes dorsalis, 1104 Mitral area of auscultation, 226 incompetency, 276. See also Mitral re- gurgitation. insufficiency, 276. See also Mitral re- gurgitation. regurgitation, 276 aspiration in, 281 auscultation in, 280 clubbing of fingers and toes in, 278, 279 expectoration in, 277, 281 functional mm'murs and, 282 gastro-intestinal catarrh in, 278 INDEX. 1223 Mitral regurgitation, heart shadow in, 233 hemorrhoids from, 278 murmur of, 280 pulse in, 280 stenosis and, difierentiation, 282 stenosis, 283 heaxt shadow in, 233 mm-murs in, 285, 286 paralyses in, 284 regurgitation and, differentiation, 282 Mixed infections, 18 Mobius' sign in Graves' disease, 1166 Moist riles, 69 Monkey hand, 1089 Mononuclear cells, 359 Morbid anatomy, diagnosis and, 18 Morbus coxEe seniUs, 1160 maculosus neonatorum, 385, 942 Morphea, 1152 Mosquito in filariasis, 959 in malaria, 946 in yellow fever, 768 Motility disturbances in brain diseases, 1044 gastric, neuroses of, 476 x-ray diagnosis, 456, 457 Motor aphasia, 1028 in apoplexy, 1052 area of brain, tumors in, 1063 centers of brain, 1027 columns, sclerosis of, unilateral, 1092 functions of cord segments, 1082 neuroses, 1015, 1165. See also Neu- roses, motor. paralysis, 1018 symptoms, 1013 in cerebellar tumors, 1070 systems, 1015 Mountain fever, 933 sickness, 933 Mouth, diseases, 392 drug eruption of, 401 hemorrhage from, 397 physical examination of, 27 Movement, sense of, 1023 Movements in brain diseases, 1044 Mucoid stools, 517 Mucor corymbifer in sputum, 82 Mucous click, 70 Multiple neuritis, 1133, 1142. See also Neuritis, muUipk. sclerosis, 1116 Mumps, 880 mastitis in, 882 nephritis in, 882 orchitis in, 881 otitis media in, 882 ovaritis in, 882 vulvitis in, 882 Murmurs, 227 arterial, 228 cardiopulmonary, 228 deglutition, 444 double, in aortic stenosis, 274 endocardial, 227 extracardial, 227 Murmurs, flint, 271 friction, 71 functional, mitral regurgitation and, 282 murmurs of endocarditis and, differ- entiation, 254 hemic, aortic stenosis murmurs and, differentiation, 276 endocardial, 227 in ansemia infantimi, 380 in anemia, progressive pernicious, 363 secondary, 356 in cirrhosis, 578 in dilatation, 301, 302 in endocarditis, simple acute, 253 ulcerative, 257 in hypertrophy of ventricles, 294 in incipient phthisis, 805 in insufficiency, 228, 229 aortic, 270, 271 mitral, 280 tricuspid, 289 in leukemia, 368 in myocarditis, 297, 298 in nephritis, 663 in obstruction, 229 in pericarditis, acute plastic, 238 callosa, 249 subacute, 243 in pneumopericardium, 251 in pseudoleukemia, 378 in pulmonary incompetency, 291 stenosis, 291 tuberculosis, 812 in relapsing fever, 766 in scorbutus, 388 in splenic anemia, 381 in stenosis, 229 aortic, 273 mitral, 285, 286 pulmonary, 291 in subphrenic peritonitis, 557 in thoracic aneiurism, 317 localization, 228 • point of maximum intensity, 228 rhythm of, 228, 229 vascular, 228 venous, 228 whiff, 228 Muscle, animal parasites of, 982 sense, 1022 Muscular atrophy, distal, 1132 peroneal, 1132 progressive, 1088, 1089 dystrophy, 1129. See also Dystrophy, muscular. strain, gastroptosis from, 511 Musculocutaneous nerves, paralysis of, 1139 Musculospiral paralysis, 1140 Myalgia cervicaUs, 931 heart disease and, 169 lumbahs, 930 of special groups, 931 Myasthenia gravis, chronic bulbar palsy and, differentiation, 1079 Mycetoma, 929 1224 INDEX. Mycosis, intestinal, 914, 915 Mycotic aneurism, 311 MyeUn, 1133 Myelitis, 1107 acute, acute anterior poliomyelitis and, diiierentiation, 846 central, 1108 chronic, 1109 disseminated, 1108, 1109, 1111 in syphilis of nervous system, 1120 of cervical cord, 1108 of lumbar cord, 1108 of thoracic cord, 1108 purpura of, 384 senile, 1110 serous, 1110 subacute, 1109 transverse, 1108 Myelogenic leukocytes, 359 Myelomalacia, 1108 Myelomata, 1004 Myiasis, 990 Myocarditis, 296 in diphtheria, 871 in typhoid fever, 757 Myocardium, diseases of, 293 Myoclonus epilepsy, 1169 Unverricht's type, 1169 Myoidema in pulmonary tuberculosis, 811 Myokimia, 1169 Myositis, rheumatic, 931 Myotonia, 931 congenita, 1172 Myxedema, 1152 operative, 1152 Narcolepsy in epilepsy, 1047 Nasopharynx, diseases of, laboratory ex- amination, 32 Natiform skull in syphilis, 831 Necator Americanus, 977 Neck, physical examination of, 28 spasms of, 1167 sweating of, 639 Nematodes, 959, 974 of liver, 982 of lung, s-ray diagnosis, 75 Nephritis, acute, 661 case, 665 in lobar pneumonia, 786 aortic stenosis and, differentiation, 275 cholesterinemia in, 672 chronic, 668 amyloid kidney and, differentiation, 672 interstitial nephritis and, differentia- tion, 672 desquamative, 668. See also Nephritis, chronic. diffuse chronic, with exudate, 668. See also Nephritis, chronic. exudative, chronic, 668 hemorrhagic, 662 hypertension in, 203 in diphtheria, 871 Nephritis in measles, 878 in mumps, 872 in pregnancy, 662 in scarlet fever, 860 in septicemia, 917 in typhoid fever, 757 in varicella, 908 interstitial chronic, 674 amyloid kidney and, differentia- tion, 672 blood in, 677 case, 677 urine in, 676 non-suppurative, acute, 667 leukemia and, differentiation, 371 Upemia in, 672 mitral stenosis after, 283 myocarditis in, 297 parenchymatous, acute, 661. See also Nephritis, acute. chronic, 668. See also Nephritis, chronic. post-scarlatinal, 860 productive, 664 septic, in scarlet fever, 860 traumatic, 662 tubal, 668. See also Nephritis, chronic. typhus fever and, differentiation, 761 Nephro-erysii)elas, 887 Nephrolithiasis, 690 cohc in, 692 coUapse in, 692 hepatic calculus and, differentiation, 694 intermittent fever and, differentiation, 951 intestinal colic and, differentiation, 694 micturition in, 691 pain in, 691 pelvic, 690 renal, 690 uremic manifestations, 691 vesical calculus and, differentiation, 694 x-ray diagnosis of, 634, 690, 693 Nephrotyphoid, 743, 757 Nerve-cells, 1012 Nerve-fibers, 1012 Nerves, cranial, 1035. See also Cranial nerves. fibroma of, 1142 olfactory, 1035 optic, 1035 peripheral, 1133 spinal, 1135 sympathetic, paralysis of, 1138 tumors of, 1142 Nervous diseases, 1012 phenomena of heart disease, 173 system, anatomy, 1012 diseases of, 1012 in history-taking, 26 motor, 1015 representation in, 1013, 1014 sensory, 1018 syphilis of, 1118. See also Syphilis of nervous system. Neuralgia, 422, 1147 INDEX. 1225 Neuralgia, brachial, 1148 epigastric, 545 hypogastric, 545 idiopathic, 1148 infraorbital, 1039 intercostal, 1149 intestinal, 545 lumbar, 1150 metatarsal, 1150 muscular rheumatism and, differentia- tion, 932 occipital, 1148 of AchUles tendon, 1150 of breasts, 1149 .of heel, 1150 ' of mammary gland, 1149 sacral, 1150 supraorbital, 1039 unusual forms, 1149 Neuralgic pain, precordial, 169 Neurasthenia, 1173 appendicitis and, differentiation, 542 hypotension in, 205 sexual, 1176 Neurasthenic habit, 1175 Neurilemma sheath, 1133 Nem^itis, arsenical, 1146 brachial, 1136 cervico-brachial, 1137 degenerative, 1133 in diphtheria, 871 in pulmonary tuberculosis, 819 interstitial, 1133 kakk6, 1147 multiple, 1133 acute anterior poUomyehtis and, dif- ferentiation, 846 alcohohc, 1144 arsenical, 1146 ataxic form, 1106, 1145 carbon disulphid, 1146 monoxid, 1146 copper, 1146 from infectious diseases, 1147 idiopathic, 1143 illuminating gas, 1146 in plumbism, 1145 lead, 1145 mercuric, 1146 phosphoric, 1146 senile, 1147 toxic form, 1143 optic, 1036 parenchymatous, 1133 simple, 1133 Neuroma, 1142 Neurons, motor, 1015 sensory, 1021 Neuroses, motor, 476, 1165 occupation, 1168 of bladder, 710 cystitis and, differentiation, 711-713 irritabiUty and, differentiation, 711- 713 neurosis of pregnancy and, differen- tiation, 711-713 Neurosis of pregnancy, cystitis and, dif- ferentiation, 711-713 irritability of bladder and, differen- tiation, 711-713 neuroses of bladder and, differentia- tion, 711-713 of stomach, 473 secretory, 475 sensory, 480 traumatic, 1188 Neutrophiles, polymorphonuclear, 359 Newborn, hemorrhagic diseases of, 942 Ninth cranial nerve, 1042 Nitric acid and heat test for albumin, 646 Nitrogen coefficient of Salkowski and Kojo, 501 colloidal, in inline, 501 in blood, 354 in cancer, 501 in gastric contents, 501 Nocturnal enuresis, 713 Noguchi reaction in syphilis, 345, 346 Noma, 399. See also Stomatitis, gan- grenoiis. Normoblast, 352 Normoblastic shower, 352 Nose, discharges from, bacteria in, 32 diseases of, 33 physical examination of, 27 Nucleus, caudate, lesions in, 1030 Deiters', 1033 lenticular, lesions in, 1030 magnoceUularis substantia reticularis, 1033 paracerebellar, 1033 test for fatty stools, 616 vestibularis, 1033 Numbness, 1023 Nummular sputum in pulmonary tuber- ciilosis, 813 Nystagmus in tumors of cerebeUimi, 1069 Obesity, 1009 abdomen in, 426 blood-pressure and, 203 glycosuria of, 653 ObMque up-stroke on sphygmograph trac- ing, 213 Obrastzow's division of abdomen, 443 Obstetric palsy, 1138 Obturator nerve, paralysis of, 1141 Occipital area, tumors in, 1085 neuralgia, 1148 Occupation neurosis, 1168 Ocular movements, associated, paralysis of, 1032 Oculomotor nerve, 1037 paralysis in syphilis, 1037, 1120 OculopupiUary fibers, 1139 Olein in blood, 341 Olfactory nerve, 1035 Oligocythemia, 351 Oliguria, 640 Omentum, carcinoma of, hepatic car- cinoma and, differentiation, 684 1226 INDEX. Omentum, growth of, splenic tumor and, differentiation, 632 Omodynia, 931 Ophthalmic migraine, 1192 Ophthahnoplegia, 1037, 1038 Ophthalmotuberculin reaction, 807 Opisthorchis sinensis, 974 Opisthotonos in cerebrospinal meningitis, 839 in tetanus, 911 Oppenheim's disease, 1173 Opsonic index, 21, 348 bacterial emulsions for, 350 vaccines and, 348, 349 central serum for, 350 patient's serum for, 350 percentage index, 351 technic, 350 washed corpuscles for, 350 Wright's conclusions, 349 Opsonins, 348 immune, 349 Optic atrophy, 1037 in tabes dorsalis, 1105 nerve, 1035 neuritis, 1036 tabes, 1105, 1107 thalamus, 1012 lesions in, 1030 Orchitis in mumps, 881 tuberculous, 820 Organic endocardial murmurs, 227 Ornithodorus moubata, 764 Orthodiagraphic measurement of dia- phragm, 76 Orthopnea in heart disease, 173 Osteitis deformans, 1162 Osteoarthropathy, hypertrophic, 1158 Osteomalacia, 1161 fragilitas rubra with albumosuria, 1004 Osteosarcoma, cranial, 1059 Otitis media in diphtheria, 871 in measles, 878 in mumps, 882 in scarlet fever, 859 in typhoid fever, 757 Ovarian cyst, ascites and, differentiation, 569 bladder distention and, differentia- tion, 684 floating spleen and, differentiation, 684 gall-bladder distention and, differen- tiation, 684 hydronephritis and, differentiation, 683, 684 splenic tumor and, differentiation, 632 tuberculosis, 820 Ovaritis, appendicitis and, differentiation, 541 in mumps, 882 Oxalm-ia, 657 Oxyhemoglobin, 329 change of, into methemoglobin, 332 spectrum of, 331 Oxyuris in bladder, 985 Oxyuris vermicularis, 976 Oyster-shell lesion in syphilis, 827 Pachymeningitis, cerebral, 1122 Paget's disease, 1162 Pain, abdominal, 421, 422, 442, 443 in children, 423 locaUzed, 422 central, 1023 epigastric, 436, 442 not coimected with stomach, 437 from aneurism, 170 from angina pectoris, 171 from aortic disease, 170 from heart disease, 170, 175, 437 from pericardial disease, 170 gastric, 436 in carcinoma, 436 in fermentation, 437 in ulcer, 436 on palpation, 442 hepatic coUc and, 437 in carcinoma of common duct, 437 of liver, 437 of pancreas, 437 of stomach, 436 in cardiac palpitation, 437 in gastritis, 437 in head, visceral disease and, 1026 in hyperacidity, 437 in pancreatic disease, 437 in thoracic aneurism, 437 in throat in heart disease, 175 of gall-stones, 437 precordial, 169 referred, 1023 sense, 1022 Palate, paralysis of, from diphtheria, 1146 spasms of, 1167 Pahnitin in blood, 341 Palpatory percussion, 60 Palpitation, 171 pain in, 437 Pancreas, 616 apoplejcy of, 622 calcuU in, 624 carcinoma of, 623 cyst of, 625 diseases, 618 Cammidge reaction, 617 fatty stools in, 616 pain in, 437 head of, carcinoma of, intestinal car- cinoma and, differentiation, 547 hemorrhage into, 622 Pancreatitis, chronic, 621 gangrenous, 621 hemorrhagic, acute, 618 gastroduodenal catarrh, and, differ- entiation, 620 intestinal obstruction and, differ- entiation, 620 appendicitis and, differentiation, 542 suppurative, 620 Paracentesis in pleurisy, 149 INDEX. 1227 Paracerebellar nuclei, 1033 Paragonimiasis, 988 Paragonimus Westermanii, 974 in lungs, 130 in sputum, 81 Paralysis agitans, 1171 tremors in, 1044 ascending, 1086 biceps, 1139 birth, 1139 brachial, 1134, 1138 brachialis anticus, 1139 Brown-S6quard, 1115 bulbar, 1076. See also Bulbar paralysis. deltoid, 1139 diphtheric, 1146 diver's, 1110 Duchenne-Erb, 1138, 1139 facial, 1040, 1041 from brain tumor, 1051 general, of insane, 1189 glosso-labio-laryngeal, 1077. See also Bulbar paralysis, chronic. hysteric, 1182 in apoplexy, 1050 in cerebrospinal meningitis, 839 in nephritis, 675 infantile spinal, 843. See also Polio- myelitis, acute anterior. Klumpke's, 1138 Landry's, 1086 acute anterior poUomyeUtis and, differ- entiation, 846 median nerve, 1140 motor, 1018 musculospiral, 1140 obstetric, 1138 oculomotor, syphilitic, 1037 of abducens nerve, 1038 of anterior crural nerve, 1141 of associated ocular movements, 1032 of auditory nerve, 1041 of circumflex nerve, 1139 of cranial nerves, 1035, 1048 in tabes dorsahs, ll04 of diaphragm, 1141 abdominal movements in, 425 of eyeball, 1037. See also Ophthalmo- plegia. of glossopharyngeal nerve, 1042 of gluteal nerves, 1141 of hypoglossus nerve, 1042 of limbs, spastic, 1054 of long thoracic, 1139 of motor fifth, 1039 of musculocutaneous nerves, 1139 of obturator nerve, 1141 of oculomotor nerve, 1037 of olfactory nerve, 1035 of optic nerve, 1035 of palate in diphtheria, 1147 of pneumogastric nerve, 1042 of popUteal nerves, 1142 of posterior thoracic, 1139 of spinal accessory nerve, 1042 of sympathetic nerves, li38 Paralysis of trigeminus nerve, 1039 of trochlear nerve, 1038 of uremia, shifting, plumbism and, differ- entiation, 534 of vocal cords in thoracic aneurism, 314 post-diphtheric, plumbism and, differ- entiation, 534 pseudo-bulbar, 1057 apoplexy, 1053 rachitic, 1003 Saturday night, 1140 sciatic, 1142 serratus magnus, 1139 spastic family, 1092 hereditary, 1092 tabes dorsalis and, differentiation, 1107 ulnar, 1140 Paralytic dementia, 1189 Paramyoclonus multiplex, 931, 1169 Parasites, animal, intestinal, 963 of Uver, 979 of lung in sputum, 81 of muscles, 982 cutaneous, 989 of bladder, 985 of brain, 991 of eye, 990 of kidney, 985 of lung, 81, 986 vegetable, in urine, 703 Parasitic anemia, 355 aneurism, 311 diseases, animal, 946 of lungs, 130 Parasitology of blood, 390 Parasternal lines, 42 Paratyphoid fever, 757 serum diagnosis, 20 Widal reaction in, 344 Paresis, general, 1189 Paresthesia, 1023 Parkinson's disease, 1171 Parorexia, 429 Parosmia, 1035 Parotitis, epidemic, 880. See also Mumps. Paroxysmal dyspnea in heart disease, 173 Pastia's sign in scarlet fever, 850 Patellar clonus, 1017 jerk, 1017 Peduncles, cerebral, lesions in, 1031 tumors of, 1066 Pehosis rheumatica, 385, 897 Pellagra, 1192 dermatitis in, 1193 Pelvis of kidney, outline of, s-ray for, 636 Pentose in urine, 655 Pentosuria, 655 Pepsin in gastric contents, 468 Pepsinogen in gastric contents, 468 Percussion, 55 sphygmograph tracing, 213 Perforation in typhoid fever, 756 Periarteritis, gummatous, 833 Pericardial effusion, pleurisy with effusion and, differentiation, 153 Pericarditis, 237 1228 INDEX. Pericarditis, acute plastic, 238 adhesive, 248 callosa, 249 chronic, 248 dry, x-ray diagnosis, 229 endocarditis and, differentiation, 254 external mediastinal, x-ray diagnosis, 230 exudative, x-ray diagnosis, 229 hemorrhagic, 248 in lobar pneumonia, 786 in scarlet fever, 859 in typhoid fever, 757 myocarditis from, 296 obHterative, x-ray diagnosis, 230 pleuropericardial type, 240 purulent, 245 serofibrinous, 240. See also Pericarditis, subacute. subacute, 240 cardiac dilatation and, differentiation, 243 plem-isy and, differentiation, 244 serum diagnosis, 243 Pericardium, air in, 250 aspirating, 245 diseases of, 168, 237 pain due to, 170 x-ray evidences, 229 dropsy of, 250 empyema of, 245 exploratory puncture of, 245 gas in, 250 pus in, 250 Pericystitis, 554 Perihepatitis, 595 Perimetritis, 554 Perinephritic abscess, 695. See also Ab- scess, perinephritic. Periostitis, precordial pain of, 170 Peri-ovaritis, 554 Peripheral atheroma, 309 blood, alkalinity of, 338 nerves, diseases of, 1133 functions, 1134 structure of, 1133 sensation, 1134 Peristalsis, 426 absence of waves, x-ray diagnosis, 456 diminished, 477 in stomach, 439 estimation, 477 intestinal, diminished, 526, 529 reversed, x-ray diagnosis, 457 x-ray and, 456 Peristaltic unrest, 477 Peritoneum, carcinoma of, 559 diseases of, 549 tuberculosis of, 560. See also Tuber- culosis, peritoneal. Peritonitis, acute, appendicitis and, differ- entiation, 541 general, 549 intestinal obstruction and, differen- tiation, 528 locaUzed, 554 Peritonitis, adhesive, appendicitis from, 536 chronic diffuse, 558 general, carcinomatous peritonitis and, differentiation, 562 peritoneal tuberculosis and, differ- entiation, 562 diaphragmatic, precordial pain of, 170 in choleHthiasis, 612 subphrenic, 556 diaphragm movements and, 76 pyopneumothorax and, differentiation, 558 tuberculous, 560, 819 appendicitis and, differentiation, 542 vomiting of, 435 Peritonsillar abscess, 722 Perityphlitis, 536 Pernicious anemia, 351 laboratory findings, 375 progressive, 361. See also Anemia, progressive pernicious. sclerosis in, 1095, 1096 splenic anemia and, differentiation, 382 Peroneal muscular atrophy, 1132 Perspiration, 637 Pertussis, 882. See also Whooping-cough. Pestis ambulans, 788 Petit mal, 1046 Pharyngitis, acute, 401 diphtheria and, differentiation, 868 scarlet fever and, differentiation, 856, 857 chronic, 403 cough of, 40 dry, 403 in variola, 902 sicca, 403 Pharyngocele, 413 Pharynx, cocainization of, 407 physical examination of, 27 spasms of, 1167 Phlebitis, portal, purulent, 614 Phosphates in lu-ine, 649 Phosphorus-poisoning, hver in, 596 yellow atrophy and, differentiation, 597, 604 Photophobia in cerebrospinal meningitis, 838 Phthisis. See Pulmonary tuberculosis. Physical examination, 27 Physiologic mammalian electrocardiogram, 220 Pia of brain, 1012 Pia-arachnoid, inflammation of, 1124 Pica, 430 Pipet test for albumin, Boston's, 645 Piroplasma hominis, 933 Pitch, 57 Plague, 787 bed-bug in transmitting, 787 bubonic form, 787 flea bites in, 787 pneumonic form, 788 septicemic form, 788 Plantar reflex, 1018 INDEX. 1229 Plasmodium falciparum, 947 malarise, 946, 947 in brain, 991 vivax, 947 Plastic bronchitis, 94 pleurisy, acute, 137 primary, 137, 138 secondary, 137, 138 Pleura, adherent, x-ray diagnosis, 76 diseases of, 37, 131 x-ray diagnosis, 73, 76 dropsy of, 135. See also Hydrothorax. examination of, 37 growths of, x-ray diagnosis, 76 thickened, 156 x-ray diagnosis, 76 tuberculosis of, 154, 819 tumors of, pleurisy and, differentiation, 151 Pleural effusions, heart position in, 232 hydatid cyst and, differentiation, 981 x-ray diagnosis, 76 friction-sounds, 71 Pleurisy, 136 adhesive, 156 carciaomatous, 154 chest ia, 49 chronic, 156 serofibrinous and, differentiation, 158 x-ray diagnosis, 157 circumscribed, precordial pain of, 169 clinical forms, 154 diaphragmatic, 156 encapsulated, 141, 155 encysted, 141 pericarditis and, differentiation, 244 fibrinous, 137 hemorrhagic, 154 idiopathic, 138 in typhoid fever, 756 interlobar, 155 partial, 141 pericarditis and, differentiation, 244 plastic, 137, 138 pleuropericarditic type, 240 serofibrinous, 141, 152 abscess of liver and, differentiation, 152 bronchitis and, differentiation, 89 cardiac symptoms, 143 cough in, 142 cracked-pot sound in, 146 cysts of liver and, differentiation, 152 of lung and, differentiation, 152 dilatation of heart and, differentiation, 153 dry adhesive and, differentiation, 158 egophony in, 148 empyema and, differentiation, 160 hydrothorax and, differentiation, 153 in lobar pneumonia, 786 lobar, pneumonia and, differentiation, 161, 785 paracentesis in, 148 pericardial effusion and, differentia^ tion, 153 Pleurisy, serofibrinous, pericarditis and, differentiation, 244 rheumatism and, 142 sequelae, 153 S-Une of flatness in, 147 stage of effusion, 144 resorption, 149 tubercle bacilli and, 141 tuberculous infiltration of lung and, differentiation, 151 tumors and, differentiation, 151 x-ray diagnosis in, 148, 150 subacute, 141. See also Pleurisy, sero- fihrinoiis. tuberculous, 154, 819 with effusion, 141. See also Pleurisy, serofibrinous. with heart displacement, thoracic aneur- ism and, differentiation, 320 Pleuritic adhesions, diaphragm movements and, 76 Pleuritis, 136. See also Pleurisy. purulent, 158. See also Empyema. Pleurodynia, 931 heart disease and, 170 Pleuropericardial pericarditis, 240 Pleurothotonos in tetanus, 911 Pleximeter, 56 Plexus, brachial, 1136 lumbar, diseases of, 1141 sacral, diseases of, 1141 Plugging of vessel, embolic, aneurism from, 311 Plumbism, 530 anemia in, 533 blood in, 533 chronic ankylostomiasis and, differen- tiation, 979 cohc in, 530, 531 encephalopathy in, 532 eyes in, 533 foot-drop in, 531 headaches in, 532 heart in, 533 lead line in, 532 leukemia and, differentiation, 371 muscular rheumatism and, differentia- tion, 534 nervous phenomena, 531 neuritis in, 1145 paralysis of uremia and, differentiation, 534 post-diphtheric paralysis and, differen- tiation, 534 scaphoid abdomen in, 532 urine in, 533 vomitus in, 533 wrist-drop in, 531 Pneumatosis, gastric, 479 Pneumococcus in sputum, 84 Pneumo-erysipelas, 887 Pneumogastric nerve, 1042 Pneumogram, bilateral, 669 Pneumomycosis, sputum evidence, 82 Pneumonia, abdominal distention in, 779 tension in, 779 1230 INDEX. Pneumonia, abortive, 773 bilious, 773 catarrhal, 107. See also Bronchopnevr monia. central, 772 cerebral, 776 croupous, 113, 770. See also Pnev^ monia, lobar. diarrhea in, 775 epidemic, 772 ether, 773 fibrinous, 770. See also Pneumonia, lobar. Friedlander's, 781 in tjrphoid fever, 756 influenza with, 775 interstitial, 113 latent, 772 lobar, 113, 770 abscess with, 786 albuminous sputum in, 781 bacteriology, 774 blood in, 781 bronchopneumonia and, differentia- tion, 112, 785 cardiovascular symptoms, 778 case, 782 complicating other diseases, 775 congestion stage, 770, 778 consolidation stage, 779 cough in, 775, 776, 785 edema with, 786 empyema in, 786 endocarditis in, 786 epidemics of, 774 feces in, 782 gangrene with, 786 gray hepatization in, 771, 780 in measles, 877 invasion stage, 775 mahogany flush in, 779 meningitis and, differentiation, 785 nephritis in, 786 pain in, 775, 776, 785 pericarditis in, 786 pleurisy with effusion and, 151, 785, 786 pneumonic phthisis and, differentia- tion, 784 pulmonary tuberculosis and, differen- tiation, 803 rales in, 779, 780, 781 red hepatization in, 770 sputum in, 781 suppurative, 121 sweating in, 775 tympanites in, 773 typhoid pneumonia and, 745, 771, 785, 786 state in, 785 urine in, 782 malarial, 773 massive, 780 migratory, 872 of children, 773 relapsing, 774 Pneumonia, senile, 773 serous, 773 sputum in, 84, 781 streptococcus, 773 terminal, 773, 775 typhoid, 745, 771, 785, 786 walking, 776 with influenza, 773 a;-ray diagnosis, 74 Pneumonic phthisis, acute, 803 lobar pneumonia and, differentiation, 784 Pneumonitis, 113, 770. See also Pnevr monia, lobar. Pneumonokoniosis, 115 sputum in, 86 Pneimaopericardium, 250 Pneumorrhagia, 116 Pneumothorax, 161 coin-test in, 164 cracked-pot sound in, 164 diaphragmatic hernia and, differentia- tion, 76, 166 dilated stomach and, differentiation, 166 effect on heart, 232 emphysema and, differentiation, 129 from abscess, 161 from bacillus aerogenes capsulatus, 161 coh communis, 161 from carcinoma of esophagus, 161 Hippocratic succussion splash in, 164 metallic tinkle in, 164 pulmonary cavity and, differentiation, 165 subdiaphragmatic, 161 subphrenic abscess and, differentiation, 166 succussion splash in, 72, 164 traumatic, 161 Wintrich's sign in, 164 a;-ray diagnosis, 77 Pneumotyphoid fever, 745, 771, 785, 786 Pocket sphygmomanometer, 207 Faught's, 207 Poikilocyte, 352 Poikilocytosis, 352 Poisoning, lead-, chronic, 530. See also Plumbism. mineral, leukemia and, differentiation, 371 progressive pernicious anemia and, differentiation, 365 phosphorus-, liver in, 596 yellow atrophy and, differentiation, 597, 604 strychnin-, tetanus and, differentiation, 712 Pohoencephalitis, 1038, 1057 Pohomyelitis, acute anterior, 843, 1057 acute myelitis and, differentiation, 846 bedbug in transmission of, 844 dog in transmission of, 843 fly in transmission of, 843 Landry's paralysis and, differentia- tion, 846 INDEX. 1231 Poliomyelitis, acute anterior, multiple neu- ritis and, difierentiation, 846 chronic, 1088, 1089 subacute, 1088, 1089 Pollen as cause of hay-fever, 939 Polyarthritis, hemorrhagic, 894 in gonorrheal arthritis, 898 Polychromatophilia, 352 Polycythemia, 353 altitude effects of, 354 blood changes in, 354 nitrogen content in, 354 drugs in, 354 pathologic, 354 Polyesthesia, 1023 Polyhydramnios, ascites and, differentia- tion, 569 Polymorphonuclear neutrophiles, 359 Polymyositis, trichiniasis and, differentia- tion, 984 Polyneuritis. See Neuritis, multiph. Polyphagia, 429 Polysarcia adiposa, 1009 Polyuria, 639 Pons, hemorrhage in, 1053 lesions in, 1031 tumors of, 1066 Pophteal nerves, paralysis of, 1142 Pork tape-worm, 968 Portal vein, diseases of, 614 Position, sense of, 1023 Posterior axillary lines, 42 corpora quadrigemina, lesions of, 1032 Potassium ferrocyanid and acetic acid test for albumin, 646 Precordial pain not due to heart disease, 169 Precordium, 179 pulsation in apex-beat, 181, 183. See also Apex-beai. Pregnancy, chorea in, 1170 extra-uterine, ruptured, appendicitis and, differentiation, 540 nephritis in, 662 neurosis of, cystitis and, differentiation, 711-713 irritability of bladder and, differen- tiation, 711-713 neuroses of bladder and, differentia- tion, 711-713 pulmonary tuberculosis and, 810 Prendergast's vaccine reaction in typhoid fever, 751 Present iUness in history-taking, 26 Pressure sense, 1022 Previous history, 25 Probable infectious diseases, 930 Proferments in gastric contents, 468 Profeta's law, 825 Projection fibers of brain, 1012 Propepsin in gastric contents, 468 Prostate, tuberculosis of, 705, 820 Proteids in sputum, 87 Protopathic sensory system, 1019 Protozoan disease, 946 Prune-juice sputum, 78 Pruritus in jaundice, 605 Psammoma of brain, 1060 Pseudo-angina pectoris, 171, 303 angina pectoris and, differentiation, 305 Pseudo-bulbar paralysis, 1057 in apoplexy, 1053 Pseudochylous effusion, 571 Pseudohydrophobia, 909 Pseudoleukemia, 376 bacteriology, 377 Banti's disease and, differentiation, 379 epithelioma and, differentiation, 379 leukemia and, differentiation, 379 lymphatic leukemia and, differentia- tion, 372 mahgnant disease and, differentiation, 379 malnutrition and, differentiation, 379 murmurs in, 378 splenic anemia and, differentiation, 379, 382 suppuration and, differentiation, 379 sjT)hilis and, differentiation, 379 tuberculosis and, differentiation, 379 tuberculous adenitis and, differentia- tion, 823 lUceration and, differentiation, 379 Pseudomeningitis, 1127 Pseudo-tabes, 1106, 1145 Pseudotuberculosis, 794, 818 Psilosis, 738 rheumatica, hemophUia and, differen- tiation, 383 Psorospermiasis, 990 Psychic centers, 1029 Psychosis, Korsakoff's, 1145 PtyaUsm, 400 Puerperal eclampsia, hypertension in, 204 glycosuria, 993 sepsis, remittent fever and, differentia- tion, 953 Puerperium, erysipelas in, 889 Pulmonary abscess, 121 amebic, 130, 988 expectoration in, 122 Friedlander's bacillus in pus from, 84,85 sputum in, 85 with lobar pneumonia, 786 a;-ray diagnosis, 74, 122 actinomycosis, 130 aneurism, 321 apoplexy, 116 aspergillosis, 130 atelectasis, 120 atheroma, 309 blastomycosis, 130 carcinoma, 123 cavities, bronchiectasis and, differen- tiation, 102 pneumothorax and, differentiation, 165 radiograph of, 815 a;-ray diagnosis, 75 cirrhosis, 113 collapse, ,120 1232 INDEX. Pulmonary compression, 120 congestion, 104 diseases, 37, 104 x-ray diagnosis, 73 echinococcus disease, 130, 986 edema, 105 in lobar pneumonia, 786 embolism, 117 emphysema, 124 atrophic, 125, 129 compensatory, 124, 125 hypertrophic, 125 x-ray diagnosis, 128 uiterlobular, 124, 125 pneumothorax and, differentiation, 129 senile, 129 thoracic aneurism and, differentia- tion, 129 vesicular, 125 examination, 28 fibroid induration, 113 filariasis, 988 fungoid disease, 130 gangrene, 118 bronchitis and, differentiation, 94 circumscribed, 118 fetid bronchitis and, differentiation, 120 sputum in, 85 with lobar pneumonia, 786 x-ray diagnosis, 74, 120 hemorrhage, gastric, hemorrhage and, 85, 496 in tuberculosis, 818 hemorrhagic infarction, 117 hyperemia, 104 incompetency, 291 neoplasms, 123 x-ray diagnosis, 75 parasites in sputum, 81- parasitic diseases, 130, 986 phenomena in heart disease, 172 relations to heart, 177 sarcoma, 124 stenosis, 291 streptothricosis, 130 syphilis, 832 x-ray diagnosis, 75 tuberculosis, 116 actinomycosis and, differentiation, 818, 922 acute, 803 bronchopneumonia and, differentia- tion, 803 bronohopneumonic type, 803 hemoptysis in, 803 lobar pneumonia and, differentia- tion, 803 pneumonic form, 803 typhoid fever and, differentiation, 803 adenitis and, 38 advanced, 804, 809 amenorrhea in, 810 blood in, 813 cracked-pot sound in, 812 Pulmonary tuberculosis, advanced, feces in, 813 hemoptysis in, 813 menorrhagia in, 810 m\irm\n:s in, 812 myoidema in, 811 pregnancy and, 810 sputum in, 812 urine in, 813 x-ray in, 814 amyloid disease in, 819 apical catarrh and, differentiation, 818 bronchial catarrh and, differentia- tion, 818 ' bronchiectasis and, differentiation, 818 bronchitis and, differentiation, 93 catarrh in etiology, 797 chronic, 804 x-ray diagnosis, 75 endocarditis in, 819 enteritis ia, 818 fibroid, 819 galloping, 803 heart shadow in, 232 hemorrhage in, 818 incipient, 804 bronchitis and, differentiation, 90 cog-wheel breathing in, 806 cutaneous tubercuUn reaction in, 806 fremitus in, 805 inhalation tubercuhn test, 809 murmur in, 805, 806 ophthahno-tubercuhn reaction in, 807 tuberculin reactions in, 806-809 infiltration in, pleurisy and, differen- tiation, 151 initial, 804 intermittent fever and, differentia- tion, 950 laryngeal tuberculosis in, 818 lobar pneimionia and, differentiation, 784 miliary, 802 bronchitis and, differentiation, 90 tuberculosis comphcating, 819 neuritis in, 819 rupture of cavity in, 818 sputum in, 85 streptothricosis and, differentiation, 818 thoracic aneurism and, differentiation, 319 tubercuUn reactions in, 806-809 vomiting of, 435 x-ray diagnosis, 74, 814 Pulmonic area of auscultation, 236 Pulsating empyema, thoracic aneurism and, differentiation, 320 Hver in tricuspid regurgitation, 286, 288 Pulsation, apex, 181. See also Apex-beat. at base, 183 at left of sternum, 183 axillary, 185 capillary, Quincke's, 185 INDEX. 1233 Pulsation, carotid, 184 double, 184 epigastric, 185 in precordium, 181 of blood-vessels, 172 of fingers, 185 of lip, 184, 185 outside precordium, 184 over remote arteries, 185 scapular, 185 supraclavicular, 184 Pulse, 28, 186 alternating, 198 autointoxication and, 189 Corrigan, 189, 199 Hawke's method, 269 dicrotic, 199 equality of, 194 evidence obtained from, 187 force of, 197 frequently, pathologic, 187 physiologic, 187 frequent, 187 high-tension, 191 inequality of, 197 infrequency, pathologic, 189 intermittent, 194 irregular, 194 large, 192 low-tension, 199 physical technic, 186 position of patient and, 186 pressure, 200 quick, 189 rapid, 188 rate of, 187 rhythm, 194 slow, 187, 188 small, 193 tardy, 188 tension, 199 thready, 193 tracing, cUnical significance, 213 water-hammer, 189, 199 Hawke's method, 269 Pulse-rate in fever, 716 Pulse-wave, size of, 192 Pulsus celer, 188 frequens, 187 magnus, 192, 193 paradoxus, 198 parvus, 193 rarus, 188, 189 tardus, 187, 188 Puncture, spinal, in cerebrospinal menin- gitis, 841 Pupillary reactions, 311 symptoms in cerebellar tumors, 1070 Pupils, 1037 reaction of, 311 Purpura, 384, 1151 hsemorrhagica, 384, 385 hemophiUa and, differentiation, 380 Henoch's, 385 scurvy and, differentiation, 390 Pus in feces, 518 78 Pus in urine, 642 organisms in feces, 518 Pustule, malignant, 914 Pyelitis, 685 albuminuria in, 687 baciUuria in, 705 blood in, 687 calculous, 685 x-ray diagnosis, 688 catarrhal, 685 catheterization in, 687 chronic, 686 cystoscopy in, 687 extraneous, 685 mucus in urine in, 687 new-^owths of suprarenals and, differ- entiation, 688 obstructive, 685 parasitic, 686 perinephritic abscess and, differentia- tion, 688, 700 pseudomembranous, 685 severe, 685 suppvu-ative, 685 tuberculous, 685 typhlitis with colonic impaction and, differentiation, 688 urinary sediment in, 643 urine in; 687 Pyeloneplu-itis, 685. See also Pyelitis. Pyemia, 917 articular rheumatism and, differentia- tion, 897 diazo reaction in, 919 Rocky mountain fever and, differentia- tion, 934 Pyloric orifice, relaxation of, 479 stenosis, congenital, 504 gastroscopy in, 500 in gastric dilatation, 504 Pylorospasm, 479 Pylorus, carcinoma of, hepatic carcinoma and, differentiation, 584 pancreatic carcinoma and, differen- tiation, 624 constriction of, by fibrous bands, 504 pressure upon, 504 situation of, 508 Pyonephrosis, 685. See also Pyelitis. Pyopneumopericardium, 250 Pyopneumothorax, 161. See also Pneu- mothorax. encysted, 251 heart position in, 232 pneumopericardium and, differentiation, 251 subphrenic peritonitis and, differentia- tion, 558 rc-ray diagnosis, 77 Pyosalpinx, appendicitis and, differentia- tion, 541 Pyrexia, 716 Pyrosis, 430 Pyuria, 642 clinical significance, 642 microscopic appearance, 642 1234 INDEX. Quartan malaria, 947 Quincke's capillary pulse, 185 Quotidian malaria, 947 Rabies, 908 Rachitic paralysis, 1003 Rachitis, 1001 abdominal enlargement in, 1003 bony changes in, 1003 chicken-breast in, 1003 Harrison's curve in, 1003 muscular changes in, 1003 nervous symptoms, 1003 ribs in, 1003 scorbutus and, differentiation, 390 teeth m, 1003 tenderness in, 1003 x-ray diagnosis, 1003, 1004 R41es, 69 cardiopulmonic, 228 crepitant, 70 dry, 69 indeterminate, 71 intrapleural moist, 71 moist, 69, 71 mucocrepitant, 70 mucous, 70 sibilant, 69 sonorous, 69 subcrepitant, 70 submucous, 70 Rattles, 69. See also Rdks. Ray fungus, 920 Raynaud's disease, 1151 syndrome, 1150 Reactions of degeneration, electric, 1083 of pupils, 311, 1037 Rectal nerve-center, 1086 Rectvmi, carcinoma of, 546 syphiUs of, 832 Rectus muscles of separation, 424 Red blood-corpuscles. See Erythrocytes. sputum, 78 Referred pain, 1023 Reflexes, 1016 abdominal, 1017 Achilles, 1017 Babmski, 1018 biceps, 1017 cremasteric, 1017 in hysteria, 1181 of spinal segments, 1082, 1083 patellar, 1017 plantar, 1018 skin, 1017 superficial, 1017 triceps, 1017 umbiUcus, 1017 vomiting, 435 Regin-gitation, aortic, 265. See also Aor- tic regurgitation. cardiac murmurs in, 228, 229 in gastric diseases, 430 mitral, 276. See also Mitral regurgita- tion. Regurgitation, murmurs of, 228, 229 pulmonary, 291 tricuspid, 286. See also Tricuspid re- gurgitation. Relapsing fever, 764 pneumonia, 774 Remittent fever, bUious, 952 bronchopneumonia with, 107 puerperal sepsis and, differentiation, 953 typhoid fever and, differentiation, 963 Renal aneurism, 321 atheroma, 308 colic, appendicitis and, differentiation, 640 gravel, 690 sand, 690 Representation in nervous system, 1013, 1014 Resonance, 57 Respiration, Cheyne-Stokes, 51 cog-wheel, 68 costal, 50 costo-abdominal, 49 diaphragmatic, 49 difficult, 50 effect on position of liver, 575 frequency, 49 in fever, 716 jerky, 68 normal, 49 unilateral changes in, 61 upper thoracic type, 50 Respiratory apparatus, diseases of, 32 in history-taking, 26 arhythmia, 198 muscles, spasm of, 1167 percussion, 58 tract, upper, obstruction to, abdominal movement in, 425 Retroperitoneal glands, sarcoma of, 563 Retropharyngeal abscess, 403 Rhabditis peUio in urine, 985 Rheumatic myocarditis, 296 Rheumatism, abdominal, 931 acute articular, 892 arthritis and, differentiation, 896, 897 case, 895 endocarditis in, 895 fingers in, 894 gout and, differentiation, 1009 leukocytosis in, 896 pyemia and, differentiation, 897 scurvy and, differentiation, 897 secondary anemia in, 895 S5Tiovial fluid in, 895 articular, chronic, 932 trichiniasis and, differentiation, 984 chronic, gout and, differentiation, 1008 endocarditis and, 252 muscular, 930 dermatomyositis and, differentiation, 932 neuralgia and, differentiation, 932 INDEX. 1235 Rheumatism, muscular, plumbism and, dif- ferentiation, 534 trichiniasis and, differentiation, 984 varieties, 930 myocarditis in, 296, 297 pleurisy and, 138, 142 syphilis and, differentiation, 829 Kheumatoid arthritis, 1158 hydrochloric acid diminished in, 1161 Rhinitis, acute, 32 bacteria in nares in, 32 atrophic, 34 chronic, 32, 33 hypertrophic, 33, 34 syphihtic, 830 Rhonchi, 69. See also Bdles. Rhythm, 194 of murmurs, 228, 229 Ribs, counting, 40, 41 in rickets, 1003 Rice-water stools in cholera asiatica, 737 Rickets, 1001. See also Rachitis. Riegel's test-dinner, 462 Riggs' disease, 396 Right ventricle, hypertrophy of, 294 Rigidity of limbs, congenital spastic, 1054 Rocky Mountain fever, 933 Romberg's sign, 1023, 1103 Rontgen-ray diagnosis, 19 of abnormal heart pulsations, 232 mobility of heart, 232 of abscess of lung, 74 of adherent pleura, 76 of adhesions, 74 of aneurism, 235 of anthracosis, 75 of arteriosclerosis, 236, 310 of atonic gastrectasis, 459 of bladder diseases, 634 of blood-vessel diseases, 229 of bronchial stenosis, 103 of bronchiectasis, 75 of bronchopneumonia, 74 of calculous pyeUtis, 688 of coloptosis, 461 of constipation, 461 of diaphragmatic hernia, 76 of diseases of bronchi, 73 of diaphragm, 73, 75 of lungs, 73, 74 of pleura, 73, 76 of duodenal ulcer, 519 of dysbasia arteriosclerotica, 237 of echinococcus of lungs, 987 of emphysema, 128 of empyema, 74 of enlarged bronchi, 75 of enteroptosis, 523 of esophageal diseases, 408 of gangrene of lung, 74 of gastrectasis, 459 of gastric abnormaUties, 459 carcinoma, 460 of gastro-intestinal diseases, 453 of gastroptosis, 457, 513 of heart adhesions, 232 Rontgen-ray diagnosis of heart diseases, 229, 230 displacements, 232 of hour-glass contraction, 459 of intestinal carcinoma, 461 diseases, 461 of kidney diseases, 635 of mediastinal diseases, 234 tumors, 234, 325 of megalogastria, 459 of miliary tuberculosis, 74 of motihty disturbances, 456 of nephrolithiasis, 690, 693 of pericardial diseases, 229 of pericarditis, 229 of peristaltic disturbances, 456 of pleural effusion, 77 of pleurisy, serofibrinous, 148, 150 of pneumonia, 74 of pneumothorax, 77 of pulmonary abscess, 122 cavities, 75 gangrene, 120 neoplasms, 75 syphilis, 75 of pyopneumothorax, 77 tuberculosis, 74, 75, 814 of renal calculi, 634 diseases, 634 of rickets, 1003, 1004 of shape of heart, 233 of size of heart, 230, 233 of thoracic aneurism, 318 of tumors of pleura, 76 of ureteral calculi, 635 disease, 634 diseases of lung which decrease trans- parency for, 74 which increase transparency for, 73 measurements of heart, 230 of bladder, 637 of ureter, 636 outlining pelvis of kidney by, 636 to determine position of heart, 231, 233 shape of heart, 231 size of heart, 230 Ropy urine in cystitis, 710 Rose fever, 940 Rotheln, 878. See also Rubella. Round-worms, 974 of Hver, 982 Roy's method for specific gravity of blood, Hammerschlag's modification, 329 Rubella, 878 acute infectious fevers in, 878 bronchitis in, 878 bronchopneumonia in, 878 erythema and, differentiation, 878 gastro-intestinal catarrh in, 878 measles and, differentiation, 877, 880 scarlet fever and, differentiation, 878 urticaria and, differentiation, 878 RumpeU-Leede phenomenon in scarlet fever, 851 Rupture of cavity into pleura in phthisis, 818 1236 INDEX. Rupture of heart, 302 of spleen, 632 of thoracic aneurism, from, 116 Rusty sputum, 84 pneumorrhagia Sacral neuralgia, 1150 plexus, diseases of, 1141 Sago granules in feces, 517 SahU's hemometer, 333, 334 St. Anthony's fire, 887. See also :ipe- St. Vitus' dance, 1169 Sajou's cotton-holding forceps for cocain- ization of larynx, 407 SaUva, blood-stained, 397 Salivation, 401 Salkowski and Kojo's test in diagnosis of cancer of "internal organs, 501 Salzer test-meal, 462 Sand, renal, 690 Sarcocystis Miescheri, 990 Sarcoma, eosinophilia in, 360 hepatic, 585 of brain, 1058 of cord, 1111 of kidney, 700 anaemia infantum and, differentia- tion, 381 of mediastinum, 323 of retroperitoneal glands, 563 pulmonary, 124 Sardonic grin in tetanus, 1163 Saturday night palsy, 1140 Saturnism, 530. See also Plumbism. Scapulae, 41 Scapular hues, 42 pulsation, 185 regions, 45 Scarlet fever, 847 angina in, 858 average type, 847, 849 bacteriology, 848 bronchitis in, 858 bronchopneumonia in, 858 cardiac compUcations, 859 case, 853 celluhtis in, 858 deafness in, 860 diazo-reaction in, 854 diphtheria and, differentiation, 869 drug rashes and, differentiation, 856 ear complications, 859 edema of lungs in, 859 empyema in, 859 endocarditis in, 859 Filatoff's sign in, 850 gastritis and, differentiation, 484 gastro-intestinal irritation and, differ- entiation, 856 immunity, 849 in hogs, 849 inclusion bodies of Dohle in, 854 malighant type, 847, 855 measles and, differentiation, 857, 876 Scarlet fever, mUd type, 847, 855 nasal symptoms, 852 nephritis in, 860 ocular manifestations, 852 otitis media in, 859 Pastia's sign in, 850 pericarditis in, 859 pharyngitis and, differentiation, 856, 857 pulmonary complications, 858 relapses, 856 renal complications, 860 rubella and, differentiation, 878 RumpeU-Leede phenomenon in, 851 serous membranes in, 859 sudden death in, 860 tongue in, 852 tonsiUitis and, differentiation, 856 variola and, differentiation, 905 vomiting of, 434 Schistosomum haematobium, 961 in bladder, 985 in sputum, 82 Schmidt's test for fatty stools, 616 Sciatic paralysis, 1142 Sciatica, 1149 Scleroderma, 1152 Sclerosis, amyotrophic lateral, 1090 aortic, heart shadow in, 233 arterial, 308. See also Arterial sclerosis. coronary, 309 diffuse, 1095, 1096 disseminated, 1116 in tuberculosis, 793, 794 lateral, 1091 multiple, 1116 of aortic leaflets, stenosis from, 272 of motor columns, unilateral, 1092 posterolateral, 1095 primary, 1091 subacute combined, 1095, 1096 Scorbutus, 388 diet and, 386 hemophilia and, differentiation, 383 infantile, 389 leukemia and, differentiation, 390 of adults, 387 of infants, 387 purpura and, differentiation, 390 rickets and, differentiation, 390 Screw-worm, 991 Sciurvy, 386. See also Scorbutus. articular rheumatism and, differentia- tion, 897 hemophilia and, differentiation, 383 Second cranial nerve, 1035 Secondary anemia, 354. See also Anemia, secondary. degeneration of cord, 1086 Secretions from nose and throat, 849 Semilunar space, Traube's, 444 Senile tremor, 1172 Sensation, 1019 peripheral, 1134 transmission of, to cerebral cortex, 1022 Sense, muscle, 1022 INDEX. 1237 Sense of movement, 1023 of pain, 1022 of position, 1023 of pressure, 1022 of temperature, 1022 of touch, 1022 Sensibility, 1134 Sensory aphasia, 1029 area, tumors in, 1064 centers of brain, 1027 functions of spinal segments, 1085 irritation, symptoms of, 1023 neurons, 1021 system, 1018, 1021 Sepsis intestinaJis, 916 Septicemia, 916 bacteriology, 916 true, 916 typhoid, 745, 757 Serofibrinous pleurisy, 141. See also Pleurisy, serojOrrinovs. Seropneumothorax, 161. See also Pneu- mothorax. Serous membranes, tuberculosis of, 819 Serratus magnus paralysis, 1139 Serum diagnosis, 20, 344 of paratyphoid fevers, 20 of pericarditis, subacute, 243 of typhoid fever, 20, 751 tests for syphiUs, 345, 1121 Serum-albumin in sputum, 87 Seventh cranial nerve, 1040 spasms in distribution of, 1166 Sexual nerve-center, 1086 neurasthenia, 1176 symptoms ia tabes dorsalis, 1101 Shiga bacillus in feces, 518 Ship fever, 758. See also Typhus fever. Short up-stroke on sphygmograph tracing, 213 Shoulder, spasm of, 1168 Sick headache, 1191 Siderosis, 115 sputum in, 86 Silent area, 1065 Singultus, 1167 Sinus irregularities, 194 Sixth cranial nerve, 1038 Skeleton hand, 1089 Skin, color of, 27 dryness of, 27 moisture of, 27 parasites of, 989 reflexes, 1017 SkuU, base of, fracture of, brain injury in, 1074 physical examination of, 27 vault of, fracture of, brain injury, 1073 Sleeping in epilepsy, 1047 sickness, 957 Shdes, 326 for staining blood, 342 preparation of, 325 S-line of flatness in pleurisy, 147 Small white kidney, 668. See also Neph- ritis, chronic. SmaU-lunged emphysema, 129 Small-pox, 899. See also Variola. Smears, blood, 327 of nasopharynx discharges, 32 SmeU, nerve of, 1035 Smelling sense in hysteria, 1187 Snuffles in syphiUs, 830 Social history, 26 Sodium nitroprussid test for acetone, 656 Softening of brain, 1189 Sounds, diagrammatic representation, 57 egophony, 72 friction, 71 grunt, 72 percussion, interpretation, 57 rdles, 69. See also Rdles. splashing, 71 succussion, originating in abdomen, 506 tinkle, 72 voice, in health, 73 Spasms, 1165 habit, 1167 in fifth nerve distribution, 1166 of abdomen, 1168 of chest, 1168 of diaphragm, 1167 of face, 1166 of fingers, 1168 of glottis, asthma and, differentiation, 100 of larynx, 35, 1167 of legs, 1168 of lower Umbs, 1168 of neck, 1167 of palate, 1167 of pharynx, 1167 of respiratory muscles, 1167 of shoulder, 1168 of toes, 1168 of tongue, 1167 of upper hmbs, 1168 Spastic paralysis, 1092 rigidity of limbs, congenital, 1054 Special considerations, 17 Spectroscope, Browning's, 330, 331 Spectroscopic study of blood, 330 Speech center, 1030 function in tumors of cerebellum, 1069 Sphygmocardiograph, 215 Jacquet, 214, 215, 216 tracing, 215, 216 Sphygmograph, 211 Dudgeon, 211 paper for, 212 technic, 211 tracing of, 212, 213, 214, 215, 216 Sphygmomanometer, 205 Faught's, 205 pocket, 207 in high pressure, 207 in rapid pulse, 206 in slow pulse, 206 pocket, 207 Stanton's, 206 imiform method, 206 Spina bifida, 1116 1238 INDEX. Spinal accessory nerve, 1042 column, 41 sprain of, 1113 cord, anatomy, 1080 cervical enlargement of, 1081 compression of, 1114 cysts of, 1111 diseases of, 1080 fibroma of, 1111 functions of, 1081 hemorrhage into, 1114 injuries, 1113, 1114 lumbar enlargement, 1081 sarcoma of, 1111 tumors of, 1111 deformities, gastroptosis from, 511 degeneration, electric reactions of, 1083 secondary, 1086 locahzation, 1081 muscular atrophy, progressive, 1088, 1089 nerves, injuries to, 1135 pachymeningitis, 1122 palsy, infantile, 843. See also Polio- myelitis, acute anterior. puncture in cerebrospinal meningitis, 841 roots, 1080 segments, 1081 motor functions of, 1082 reflex functions, 1082, 1083 sensory functions of, 1085 sympathetic system, pressure of thora- cic aneurism on, 314 Spine, typhoid, 756 Spirillum of Vincent, 398 Spirochseta duttoni, 764 Spirochete in sputum, 85 Splashing sound, 71 Spleen, 625 acute tumor of, 630 amyloid degeneration of, 627 anemia of, leukemia and, differentiation, 371 Banti's disease of, 628 congestion of, passive, leukemia and, differentiation, 371 diseases of, 626 displacement, 626 enlargement of, 626 abdominal movement in, 425 causes, 626 differential diagnosis, 631 floating, 626 in acute infections, 628 in cyanotic congestion from valvular disease, 627 in hereditary syphihs, 830 in leukemia, 627 in malaria, 628 in subacute suppuration, 629 in typhoid fever, 742, 756 movable, bladder distention and, differ- entiation, 684 gall-bladder distention and, differen- tiation, 684 Spleen, movable, hydronephrosis and, dif- ferentiation, 683, 684 ovarian cyst and, differentiation, 684 new-growths of, 629 outhne of, in amyloid disease, 594 palpation of, 626 position of, 626, 630 relations of, 625 rupture of, 632 size, 625 topography, 625 tumor of, abdominal movement in, 425 differential diagnosis, 632 Splenic anemia, 381, 632. See also Anemia, splenic. aneurism, 321 fever, 914 puncture, 957 Splenitis, 630 acute hyperplastic, 630 suppurative, 630 gastric carcinoma and, differentiation, 631 pancreatic carcinoma and, 631 Splenomegaly, 632 anemia with, leukemia and, differentia- tion, 371 cirrhosis with, 628 Spondylose rhizom61ique, 1161 Spotted fever, 835. See also Meningitis, cerebrospinal. Sprain of spinal column, 1113 Sprue, 738 Sputum, 77 actinomycosis evidence in, 82 albuminous, 77, 80 amoeba coh in, 82 animal parasites of lung in, 81 ascarides in, 82 aspergillus in, 82 bacillus pyocyaneus in, 78 bacteria in, 83 balantidium coli in, 82 biUiarzia in, 82 black, 78 bloody, 78, 397 bronchial casts in, 80 spirals in, 80 casts in, 80 characteristics, 77 chemic study, 87 collection, 77 color, 78 constituents of, organic, 87 organized, 80 creamy, 78 currant-jelly, 78 density, 77 diphtheria bacilli in, 84 diplococci in, 84 elastic tissue in, 80 entamoeba histolytica in, 82 examination of, 30 fatty acids in, 87 ferments in, 87 fibers in, 80 INDEX. 1239 Sputum, fibrinoiis coagula in, 80 filaiia in, 82 fluidity, 77 Friedlander's bacilli in, 84 fungi in, 82 glucose in, 87 hemorrhagic, 397 hemosiderin in, 86 in asthma, 80, 58, 98 in bronchitis, acute, 84, 89 chronic, 84, 93 fibrinous, 95 putrid, 85 in bronchopneumonia, 85 in chalicosis, 86 in disease, 77 in gangrene of lung, 85 in heart disease, 86 in pneumonia, 84 in pneumonokoniosis, 86 in pulmonary tuberculosis, 85 in siderosis, 86 in stonemason's lung, 86 in stycosis, 86 influenza bacilli in, 83 Uquid, 78 microscopic study, 80 mucopurulent, 79 mucor corymbifer in, 82 mucous, 79 nummular, 79 odor, 77 paragonimus Westermanii in, 81 pneumococci in, 84 pneumomycosis evidence in, 82 proteids in, 87 prune-juice, 78 quantity, 77 reaction, 78 red, 78 rusty, 84 schistosomum haematobium in, 82 serous, 79 serum-albimiin in, 87 specific gravity, 78 spirochete in, 85 tsenia echinococcus in, 82 tenacity, 77 trichomonas in, 82 tubercle baciUi in, 83, 85 yellow, 78 Stains for blood, 342 for fat in blood, 341 for glycogen in blood, 340 Stanton's sphygmomanometer, 206 Staphylococcus bronchitis, 84 Starch digestion, 468, 469 degree of, test, 468 in feces_, 617 Status epilepticus, 1047 Stearin m blood, 341 Stegomyia calopus, 768 SteUwag's sign in Graves' disease, 1155 Stenocardia, 302. See also Angina pectoris. Stenosis, aortic, 272. See also Aortic stenosis. Stenosis, bronchial, 103 mitral, 283. See also Mitral stenosis. murmurs of, 229 of bile-ducts, 605 of esophagus, auscultation in, 444 i-ray diagnosis, 408 pulmonary, 291 tricuspid, 290 Sternal pulsation, 183 regions, 43 Sternocostal route for aspirating peri- cardium, 247 Sternum, pulsation at, 183 Stethoscope, Bowies', 224 for auscultatory percussion, 69 in heart diseases, 223 Stethoscopic auscultation, 64 Stigmata of hysteria, 1178, 1179 Stokes-Adams syndrome in heart disease, 190 Stomach, 418 abscess, 487 atony of, 477 auscultation of, 444 boundaries of, 443 carcinoma of, 498. See also Carcinoma, gastric. catarrh of, acute, 482. See also Gas- tritis, acute. chronic, 488. See also Gastritis, chronic. coats of, 427 cqntents, 461. See also Gastric con- tents. cough, 39 dilatation of, 504. See also Dilatation, gastric. diseases, 473 age and, 428 appetite in, 429 constipation in, 438 deglutition gurgle in, 444 diarrhea in, 438 drowsiness in, 438 dyspnea in, 437 examination in, preparation for, 456 exercise and, 428 gastroscopy in, 446. See also Gas- troscopy. hiccough in, 431 history, 427, 428 local affections and, 428 mental strain and, 428 nausea in, 431 occupation and, 428 other diseases and, 427 overwork and, 428 pain in, 436, 442 pressure on sympathetic nerve-supply and, 429 previous diseases and, 428 pyrosis in, 430 regurgitation in, 430 relaxation of abdominal muscles and, 429 sex and, 428 1240 INDEX. Stomach diseases, signs, s-ray and, 456 succussion splash in, 444, 445 taste in, 430 tenderness on palpation, 442 thirst in, 430 vomit in, 471 vomiting in, 432 x-ray evidences, 453 disturbances, precordial pain from, 170 examination of, 427, 438 exploratory area of, 452 fermentation in, pain of, 437 fining of, 453 form of, 454 abnormalities in, x-ray diagnosis, 459 hemorrhage from, pulmonary and throat hemorrhages and, differentiation, 85, 496 hour-glass, 497 hyperesthesia of, 481 hypomotiUty of, atony and, differentia- tion, 478 in history-taking, 26 inspection of, 438 motility of, neuroses of, 476 x-ray diagnosis, 456 movements, 426 neurosis of, 473. See also Neurosis of stomach. orifices of, relaxation, 479 outlining by auscultatory percussion, 444, 447 palpation of, 440 percussion-note of, 444 peristalsis in, 439 estimation, 477 physical examination of, 28 pneimiatosis of, 479 position of, 454, 508, 609 in adults, 443 in children, 445, 446 topography of, 508 tympany of, 61, 444 ulcer, 491. See also Ulcer, gastric. wall of, 427 Stomach-tube, 462 Stomatitis, aphthous, 395 thrush and, differentiation, 927 catarrhal acute, 394 diphtheric, 399 epidemic, 936 erythematosa, 394 fetid, 396 follicular, 395 fungous, 925. See also Thrush. gangrenous, 399 gonorrheal, 398 hepatic, 395 mercmal, 401 mineral, 401 mycotic, 925. See also Thrush. ulcerative, 396 with angina, 398 vesicular, 395 with tonsilhtis, 720 Stomoxys calcitrans, 843 Stonemason's lung, 86 Stools. See Feces. Strabismus in diphtheria, 871 Strangulation, intestinal, 525 Strawberry tongue in scarlet fever, 852 Streptococcus angina, diphtheria and, differentiation, 869 bronchitis, 84 pneumonia, 773 Streptothricosis, 923 pulmonary, 130 tuberculosis and, differentiation, 818 Stricture, appendicitis from, 536 of esophagus, 414. See also Esophagus, stricture of. of intestine, congenital, 526 Stridor, 35 Strongyloides intestinalis, 979 StrumpeU-Marie type of arthritis defor- mans, 1161 Strychnin-poisoning, tetanus and, differen- tiation, 912 Stupor, 1072 Stycosis, sputimi in, 86 Subcortical centers of brain, 1030 Subdiaphragmatic abscess. See Peritoni- itis, subphrenic. pneumothorax, 161 Subphrenic abscess, pneumothorax and, daEferentiation, 166 Succussion, 71 sounds originating in abdomen, 506 splash, 71, 164, 444, 445 Suffocative catarrh, 107 Sugar in urine, quantitative estimation, 654 Sulphates in in-ine, 650 Sulphur in urine, 650 Summer diarrhea, 725. See also Enteritis, catarrhal. Simstroke, 943 Suppuration, pseudoleukemia and, differ- entiation, 379 Supraclavicular pulsation, 184 regions, 42 Suprarenals, carcinoma of, hepatic car- cinoma and, differentiation, 585 in Addison's disease, 702 new-growths of, perinephritic abscess and, differentiation, 708 pyehtis and, differentiation, 708 typhhtis with colonic impaction and, differentiation, 708 Suprascapular regions, 44 Swallowing center, 1030 function in cerebellar tumors, 1069 Sweat, blue, 638 brown, 638 cessation of, 639 color and odor, 637 green, 638 red, 638 secretions, disturbances of, 1152 yellow, 638 Sweating, 637 disease, 936 in aneurism, 314 INDEX. 1241 Sweating in jaundice, 605 of head and neck, 639 profuse, 639 Sydenham's chorea, 1167 Symmetrical gangrene, 1151 Sympathetic cervical, irritation of, 1139 fibers, 1139 system, paralysis of, 1138 spinal, pressure of thoracic aneurism on, 314 Synovial membranes, tuberculosis of, 821 Syphilis, 823 acquired, 826 acute infections and, differentiation, 829 cobra venom reaction in, 828 differential diagnosis, 829 epitheUoma and, differentiation, 829 Justus' blood-test for, 828 oyster-shell lesion, 827 rheimiatism and, differentiation, 829 skin eruptions and, differentiation, 829 small-pox and, differentiation, 825, 827, 829 tonsillar epithehoma and, differentia- tion, 829 tuberculosis and, differentiation, 829 Weil's cobra venom reaction in, 828 aneurism from, 311 apoplexy from, 1051 atrophic cirrhosis from, 598 bacteriology, 824 contagion of, 824 gout and, differentiation, 829 hereditary, 829 auditory manifestations, 831 coryza in, 830 Hutchinson's teeth in, 831 hver in, 830 natiform skull in, 831 ocular manifestations, 831 spleen ia, 830 Hutchinson's teeth in, 831 inmiunity, 825 in newborn, 830 inoculation with, 825 Justus' blood-test for, 828 malignant, 828 myocarditis in, 297 Noguchi reaction in, 345, 346 oculomotor paralysis from, 1037 of arteries, 833 of brain, tumors and, differentiation, 1071 of heart, 832 of kidney, 832 of liver, 831 hydatid cyst and, differentiation, 973 of lung, 832 actinomycosis and, differentiation, 922 i-ray diagnosis, 75 of nervous system, 1118 cerebrospinal involvement, 1120 hemiplegia- in, 1120 meningitis in, 1120 SyphiUs of nervous system, myelitis in, 1120 Noguchi reaction in, 345, 346 oculomotor palsy in, 1120 serum tests for, 345, 1121 Wassermann reaction, 345 of rectum, 832 of testicles, 832 primary lesions, 823 pseudoleukemia and, differentiation, 379 secondary lesions, 824 serum tests for, 345, 1121 snuffles in, 830 tabes dorsahs and, 1099 tertiary lesions, 824 transmission of, 825 variola and, differentiation, 905 visceral, 831 Wassermann reaction, 345 Weil's reaction, 828 Syphiloma of brain, 1059 Syringomyeha, 1093 System in diagnosing, 23 Systolic blood-pressure, 200 heart-sound, 224 vesicular breathing, 68 Tabes, diabetic, 997 dorsaUs, 1099 angina pectoris and, differentiation, 306 Argyll-Robertson pupil in, 1104 ataxia in, 1103 bladder symptoms, 1101 cervical, 1105 Charcot joints in, 1105, 1106 crises in, 1104 deafness in, 1105 early, 1106 girdle sense, 1099, 1101 hereditary, 1105 hypotonia, 1103 juvenile, 1105 late, 1106 locomotion in, 1102 miotic pupils in, 1104 nimibness in, 1100 optic, 1105, 1107 atrophy in, 1105 pain in, 1100 paralysis of cranial nerves in, 1104 paresis and, differentiation, 1107 pathology, 1100 physiology of locomotion in, 1102 pupillary phenomena in, 1104 pupils in, 312 purpura after, 384 rectal symptoms, 1101 reflex disturbances, 1101 Romberg's sign in, 1103 sacral, 1105 sensation in, 1101 sexual symptoms, 1101 syphihs and, 1099 1242 INDEX. Tabes dorsalis, trigeminal involvement, 1104 trophic phenomena in, 1105 vasomotor phenomena in, 1105 vomiting in, 434 Tachycardia, 187 causes of, 189 Tsenia echinococcus, 973 in lungs, 130 in sputum, 82 Madagascariensis, 972 marginata, 971 sa^inata, 968 soEum, 968 TaUqvist's hemoglobin scale, 334 Tapeworms, 967 beef, 968 dog, 971, 973 pork, 968 Tarsalgia, 1150 Taste, acid, 430 in fevers, 430 in gastric diseases, 430 in hysteria, 1187 offensive, 430 Temperature, axilla, 715 determination, 715 mouth, 715 normal, 715 rectal, 715 sense, 1022 vaginal, 715 Temporal lobe, tumors in, 1065 Tension, abdominal, method of determin- ing, 500, 538 of pulse, 199 Tenth cranial nerve, 1042 Tentorium cerebelli, 1012 Terminal pneumonia, 773, 776 Tertian malaria, 947 Test-breakfast, Ewald-Boas', 462 Test-dinner, Riegel's, 462 Testicles, syphilis of, 832 tuberculosis of, 820 Test-meals, 461 Ewald-Boas', 462 oil, 751 Riegel's, 462 Salzer, 462 Tetanus, 910, 1163 acute, 910, 911 bacteriology, 910 cephaUc, 910, 912, 1164 chronic, 910, 912 head, 1164 hydrophobia and, differentiation, 912 immunity, 910 neonatorum, 910 sardonic grin in, 1163 strychnin-poisoning and, differentia- tion, 912 tetany and, differentiation, 912 Tetany, 1164 tetanus and, differentiation, 912 Thickened pleura, 156 Third cranial nerve, 1037 Third ventricle^ tumors of, 1065, 1066 Thirst in gastric diseases, 430 Thoma-Zeiss counting chamber, 337 hemocytometer, 334, 335 Thomsen's disease, 1172 Thoracic aneurism, 311, 312 abnormal aortic pulsation and, differ- entiation, 320 aortic regurgitation with, 318 auscultation in, 317 auscultatory percussion in, 317 bronchiectasis and, differentiation, 102 cardiac hypertrophy and, differentia- tion, 295 case, 318 chest deformity in, 49, 315 cough in, 314 dysphagia in, 314 dyspnea in, 314 emphysema and, differentiation, 129 hemorrhage in, 314 inspection, 315 mediastinal growths and, differentia- tion, 320 multiple, 316 murmurs in, 317 pain in, 313, 437 palpation in, 316 paralysis of vocal cords in, 314 percussion in, 317 peripheral arteries in, 316 pleurisy with heart displacement and, differentiation, 320 pressure on spinal sympathetic sys- tem, 314 pulmonary tuberculosis and, differen- tiation, 319 pulsating empyema and, differentia- tion, 320 pupils in, 312 rupture of, pneumorrha^a from, 116 sphygmographic tracing in, 318 tracheal tugging in, 317 with symptoms, 312 a;-ray diagnosis, 318 cord, myelitis of, 1108 long, paralysis of, 1139 regions, 44 type of respiration, 50 Thorax, actinomycosis of, bronchiectasis and, differentiation, 102 new-growths of, chest and, 49 physical examination of, 28 posterior veiw, skiagraph of, 636 Thread-worm, 976 Thready pulse, 193 ThrUls in heart disease, 186 Throat diseases, 32 Thrombosis, apoplexy from, 1051 cardiac, 293 cavernous sinus, ophthalmoplegia in, 1038 heart disease and, 172 in tjrphoid fever, 757 of portal vein, 614 Thrush, 925 INDEX. 1243 Thrush, aphthae and, differentiation, 927 Thymus gland, disease of, 325 hemorrhage into, 325 tumors of, 325 Tic, 1165 convulsif, 1168 douloureaux, 1039, 1166 in fifth nerve distribution, 1166 of face, 1039, 1166 Tidal wave of sphygmograph tracing, 213 Tinkle, amphoric, 72 metaUic, 72 Toes, spasm in, 1168 Toisson's mixture, 335 Tongue, desquamation of, epithelial, 392 diseases of, 392 geographic, 392 in scarlet fever, 852 spasms, 1167 Tongue-swaUowing, 394 Tonic movements in hysteria, 1182 TonsiUitis, acute, 718 catarrhal, 719 stomatitis with, 720 chalk-plugs in, 720 chronic, 723 diazo-reaction in, 721 follicular, 720 diphtheria and, differentiation, 720, 868, 869 scarlet fever and, differentiation, 856 necrotic, 722 parenchymatous, 721 phlegmonous, 722 TonsUlotyphoid fever, 744 Tonsils, epithelioma of, syphUis and, dif- ferentiation, 829 Tooth cough, 39 Tormina ventricuU, 477 TorticoUis, 931, 1167 Total acidity, Jaworski and Ewald's test, 460 test for, 465 Touch sense, 1022 Toxemia, 916 hypertension in, 204 Tracheal tugging in thoracic aneurism, 317 Tracheobronchial lymph-nodes, tubercu- losis of, 821 Tracheobronchoscopy in stenosis, 103 Traction aneurism, 311 diverticulum of esophagus, 413 Traube's semilunar space, 444 Traumatic neuroses, 1188 Trematodes, 974 Trembles, 935 Tremors, fibrillary, 1044 in brain diseases, 1044 in hysteria, 1180 intention, 1044 senile, 1172 Treponema paUidum, arterial sclerosis from, 309 Triceps clonus, 1017 reflex, 1017 Trichinella spiralis in blood, 984 Trichiniasis, 979, 982 polymyositis and, differentiation, 984 rheumatism and, differentiation, 984 Trichomonas in sputum, 82 Trichuris trichiuria, 979 in urine, 985 Tricuspid area of auscultation, 226 regurgitation, 286 anorexia, 287 ascites in, 287 cyanosis in, 288 dyspnea in, 287 heart shadow in, 233 hemorrhoids in, 287 mechanic influence of lesion, 286 murmur of, 289 nausea in, 287 pulsating Uver of, 286, 288 vomiting in, 287 stenosis, 290 Trigeminus nerve, 1039 in tabes dorsalis, 1104 motor neuroses in distribution of, 1166 spasms in its distribution, 1166 Trismus, 910, 1163. See also Tetanus. Trochlear nerve, 1038 Trophic diseases, 1150, 1152 phenomena, 1150 in tabes dorsalis, 1105 Trousseau's s3anptom of tetany, 1165 Trypanosomiasis, 957 Tsetse fly, 958 Tubercle bacillus, 793 in blood, 796, 801, 802, 806, 813 in feces, 518, 801, 806 in sputum, 85 in urine, 801, 802, 806, 813 staining, 83 development of, 794 diapedesis of, 794 elementary, 794 fully developed, 794 nodular, 794 proUferation, of 794 Tuberculin reaction, cutaneous, 806 test, 808 inhalation, 809 Tuberculoma of brain, 1059 Tuberculosis, 793 acute, 800 albuminous sputum in, 806, 813 atrophic cirrhosis from, 598 bacteriology of, 793, 794 bovine, 795 calcification in, 793 radiograph of, 815 caseation in, 793 chronic, 796 case, 798 catarrh of respiratory tract and, 797 heart in, 233 heredity and, 797 diapedesis in, 794 diaphragm movements and, 76 diazo-reaction in, 813 distribution of lesions, 794 1244 INDEX. Tuberculosis, gastric symptoms in, 804 hepatic, 595 hypotension in, 204 incipient, 804 intestinal, 723 laboratory diagnosis, 812 laryngeal, in pulmonary tuberculosis, 818 mdUary, 793, 794, 800 acute, typhoid and, differentiation, 753 bronchitis and, differentiation, 90, 829 endocarditis and, differentiation, 260 general, 801 endocarditis and, differentiation, 801 meningeal, 802 of peritoneum, 560 puhnonary, 802, 819 typhoid form, 801 s-ray diagnosis, 74 of bladder, 705, 820 of cecum, appendicitis and, differentia- tion, 543 of cervical lymph-nodes, 822 of Fallopian tubes, 820 of kidney, 685 of hver, 820 ' of mediastinal lymph-glands, 322 of meninges, 819 of mesenteric glands, 821 of ovaries, 820 of peritoneum, 819 of pleura, 154, 820 of prostate, 705, 820 • of serous membranes, 819 of synovial membranes, 821 of testicles, 820 of tracheobronchial lymph-nodes, 821 of ureters, 705, 820 peritoneal, 558, 819 anemia in, 561 carcinomatous peritonitis and, differ- entiation, 562 miliary, 560 peritonitis and, differentiation, 562 typhoid state in, 561 pleurisy and, 141 proHferation stage, 794 ■ pseudoleukemia and, differentiation, 379 pulmonary, 116, 803. See also Pul- monary tubercuhsis. sclerosis in, 793, 794 sputum in, 816 syphilis and, differentiation, 829 Tumors, brain, 1058. See also Brain tumors. extracerebeUar, 1070 in motor area, 1063 in occipital area, 1065 in sensory area, 1064 in temporal lobe, 1065 of Cauda equina, 1112 of cerebeUo-pontile angle, 1071 of cerebellum, 1067. See also Cere- bellum, tumors of. of cerebral peduncles, 1066 Tumors of crus, 1066 of diira covering occipital bones, 1071 of fourth ventricle, 1066 of frontal lobe, 1062 of larynx, 37 of lateral ventricle, 1065, 1066 of lungs, 123 of medulla oblongata, 1067 of nerves, 1142 of pleurae, pleurisy and, differentiation, 151 of pons, 1066 of spinal cord, 1111 of thu-d ventricle, 1065, 1066 of vermis, 1111 of vertebra, 1112 Twelfth cranial nerve, 1042 Tympanites, chronic, ascites and, differ- entiation, 569 gastric dilatation and, differentiation, 508 in dilatation of colon, 523 Tympany, 58 baU, 61 duU, 61 of stomach, 61, 444 Typhlitis, 536 with colonic impaction, perinephritic abscess and, differentiation, 688 pyelitis and, differentiaion, 688 suprarenal growths and, differen- tiation, 688 Typhoid carriers, 741 fever, 739 abdominal complications, 755 afebrile, 743 of aged, 743 alkahnity of blood in, 751 atypical temperature, 748 bacteriology of, 739 bile in, 751 bilious, 746 blood in, 750 bone complications, 757 Brinton's bile test in, 751 bronchitis in, 742 carriers, 741 case, 752 cerebral, 744 cholecystitis in, 755 circulatory sjrmptoms, 749, 747 constipation in, 742, 749 decubitus in, 757 defervescence stage, 739, 748 development stage, 746 diarrhea in, 748 dysentery and, differentiation, 755 ear complications, 757 embolism in, 757 endocarditis and, differentiation, 260 endocarditis in, 757 epistaxis in, 749 eruption in, 743 eruptive stage, 759 eye comphcations, 757 fastigium of, 739, 746 INDEX. 1245 Typhoid fever, gastrointestinal symptoms, 748, 755 heart-sounds in, 742 hemorrhage in, 748, 756 hypotension in, 204 in children, 745 incubation stage, 746 invasion stage, 739 inverse t3rpe, 748 kidneys in, 743 laryngeal, 744, 756 latent, 743 limgs in, 745 malaria and, differentiation, 754 meningeal sjonptoms, 756 meningitis and, 754, 756 mild form, 743 miliary tuberculosis and, differentia- tion, 753 myocarditis in, 757 nephritis in, 757 nervous symptoms, 742, 749, 756 occult blood in, 752 otitis media in, 757 perforation in, 748, 756 pericarditis in, 757 physical signs, 749 pleurisy in, 756 pneumonia in, 756 Prendergast's vaccine reaction in, 751 principal complaint, 746 pulmonary tuberculosis and, differ- entiation, 803 pulse in, 742 relapses, 762 ' remittent fever and, differentiation, 953 renal comphcations, 757 respiratory symptoms, 749, 756 season and, 741 septicemia of, 757 serum diagnosis, 20 severe form, 742 skin in, 757 spleen in, 742, 756 throat ulcers in, 744 thrombosis in, 757 tongue in, 742 tonsils Iq, 744 t3rphus and, differentiation, 753, 762 ulceration of mouth in, 744 usual form, 742 vaccine test for, 751 varieties, 742 walking, 743 Widal reaction in, 344, 743, 750 influenza, 789 pneumonia, 771, 786 lobar pneumonia and, differentiation, 784 septicemia, 745 spine, 756 state in cerebrospinal meningitis, 839 in lobar pneumonia, 785 in peritoneal tuberculosis, 561 Typhus fever, 758 Typhus fever, case, 761 cerebrospinal meningitis and, differ- entiation, 761 measles and, differentiation, 762 nephritis and, differentiation, 761 preeruptive stage, 759 tjrphoid fever and, differentiation, 762 uremia in, 761 variola and, differentiation, 905 Tyrosinuria, 658 Tyrotoxicon, 916 UrFELMANN's test for lactic acid, 470 Ulcer, Bouveret, 744 duodenal, 518 gastric ulcer and, differentiation, 521 a;-ray diagnosis, 519 gastric, 491 carcinoma and, differentiation, 495, 502 carcinoma from, 498 case, 494 duodenal ulcer and, differentiation, 521 gastralgia and, differentiation, 495, 496 gastritis and, differentiation, 490 gastroscopyin, 494 hepatic abscess from, 588 hyperchlorhydria and, differentiation, 476 pain of, 436, 492 perforating, 491 simple, 491 vomiting of, 433, 493 jejunal, 519 typhoid, in bowel, 739 in mouth, 744 on nasal septum, 744 Ulceration, pseudoleukemia and, differen- tiation, 379 Ulnar paralysis, 1140 UmbUicus reflex, 1017 Uncinariasis, 976. See also Ankylosto- miasis. Undulant fever, 762 Unverricht's type of myoclonus, 1169 Upper arm tjrpe of brachial palsy, 1138, 1139 limbs, spasm in, 1168 Up-stroke on sphygmograph tracing, 213 Urea, 651 Uremia, apoplexy in, 1051 in typhus fever, 761 shifting paralysis of, plumbism of, dif- ferentiation, 534 vomiting of, 435 Uremic asthma in interstitial nephritis, 675 Ureometer, Doremus-Hinds, 651 Ureters, calcuU in, a;-ray diagnosis, 635 diseases of, x-ray diagnosis, 634 tuberculosis of, 705, 820 a;-ray of, 636 Urethral fever, intermittent fever and, differentiation, 951 1246 INDEX. Uric acid, 652 Urinary system, diseases of, 634 ia history-taking, 27 tract, injury to, irritability after, cysti- tis and, differentiation, 711- 713 neiu'oses and, differentiation, 711- 713 Urine, acetone in, 656 acid, 647 actinomyces in, 703 albumin in, 643. See also Albuminuria. alkalinity of, 648 amphoteric, 648 aspergillus fumigatus in, 703 bacillus typhosus in, 704 beta-oxybutyric acid in, 656, 657 bile acids in, 655 bile-pigments in, 655 blood in, 640 calciimi oxalate in, 657 carbohydrates in, 652 chlorids in, 648 cholesterin in, 659 collection of, 639 in testing for glycosuria, 653 colloidal nitrogen in, as aid to diagnosis in cancer of internal organs, 501 cryoscopy of, 341 cystin in, 659 decrease of, 640 diacetic acid in, 656 diazo-reaction, 661 examination of, 30, 639 excessive, conditions causing, 639 freezing-point of, 341 fungi in, 703 glucose in^ 652. See also Glycosuria. hemoglobm in, 640 incontinence of, 713. See also Incon- tinence of urine. indican in, 660 indigo in, 661 indoxyl-potassium sulphate in, 660 indoxyl-sodium sulphate in, 660 lactose in, 655 leucin in, 658 leukocytes in, 642 milky, 640 neutral, 648 oxaUc acid in, 657 pentose in, 655 phosphates in, 649 pus in, 642 quantity, 639 reaction of, 647 ropy, in cystitis, 710 specific gravity, 647 sugar in, quantitative estimation, 654 sulphates in, 650 sulphur in, 650 suppression of, 640 tubercle bacilU in, 705 tyrosin in, 658 urea in, 651 uric acid in, 652 Urine, vegetable parasites in, 703 Urticaria, 1151 erysipelas and, differentiation, 891 jaundice in, 705 rubella and, differentiation, 878 Uterine coHc, choleUthiasis and, differen- tiation, 612 Vaccine reaction, Prendergast's, in ty- phoid fever, 751 Vaccines, bacterial, opsonic index and, 348, 349 Vaccinia, 906 Valvular disease, 265 cirrhosis and, differentiation, 602 compUcations, 292 clubbing of fingers and toes in, 278, 279 cyanosis from, spleen in, 627 VariceUa, 907 measles and, differentiation, 877 variola and, differentiation, 906 Varicose aneurism, 311 Variola, 899 albumimu:ia in, 904 bacteriology, 901 black, 899 cerebrospinal fever and, differentiation, 905 confluent, 899 constipation in, 905 cough in, 902 cutaneous features, 902, 903, 904 discrete, 899 eruption in, 903 erythema in, 903 gastritis and, differentiation, 484 hematuria in, 904 hemorrhagic, 899 immunity, 900 impetigo contagiosa and, differentia- tion, 905 joints in, 904 laryngitis in, 902 macule of, 903 measles and, differentiation, 877, 905 mUd, 900 morbilliform erythema in, 903 nervous symptoms, 901 ocular phenomena, 904 papule of, 903 parasitology, 900 pharyngitis m, 902 pulse in, 904 respiratory symptoms, 902 scarlatiniform erythema in, 903 scarlet fever and, differentiation, 905 secondary fever, 902 sputum in, 905 syphiUs and, differentiation, 825, 827, 829 tjrphus fever and, differentiation, 905 varicella and, differentiation, 906 vesicles of, 903 vomiting, 434 INDEX. , 1247 Varioloid, 900 Vasculax murmurs, 228 Vasomotor activity, blood-pressure and, 200 diseases, 1150 phenomena, 1150 in tabes dorsalis, 1105 Vegetable parasites in urine, 703 Veins of abdomen, diagnostic value, 423, 424 portal diseases of, 614 Venoms, purpura after, 385 Venous hmn, 228 Ventricle, left, of heart, enlargement of, 233 Ventricles of brain, 1012 tumors of, 1065 of heart, hj^iertrophy of, 293, 294 Ventricular complex of electrocardiogram, 221 Vermis of cerebeUimi, 1033 tumors of, 1070 Vertebra, diseases of, 1112 dislocation of, 1113 fractiu-e of, 1113 prominens, 41 tumors of, 1112 Vertebral column. See Spinal column. Vesical bleeding, 640 Vesicular breathing, 66 Vestibular nerve, 1041 Vincent's bacillus, 398 Visceral disease, areas of referred pain, 1023-1026 syphihs, 831 Vision, nerve of, 1035 Visual centers, 1029 field in hysteria, 1186, 1187 Vocal cords, paralysis of, in thoracic aneur- ism, 314 Voice in heart disease, 175 sounds in health, 73 Vomit, bile in, 473 black, in yellow fever, 769 blood in, 473 coflfee-ground, 434, 499 in gastric diseases, 471, 499 Vomiting, cerebral, 434 cyclic, 435 gastric causes, 472 hepatic causes, 472 in acute infections, 472 in drug intoxications, 472 in shock, 472 intestinal causes, 472 nervous, 472, 479 of blood, 433, 473 pancreatic causes, 472 physiologic, 472 purpura after, 384 reflex, 435 renal causes, 472 stercoraceous, 473 types of, 432 Von Bechterew tsrpe of arthritis defor- mans, 1161 Von Fleischl's hemoglobinometer, 332 Von Graefe's sign in Graves' disease, 1155 Von Pirquet's cutaneous tuberculin re- action, 806 Vulvitis in mumps, 882 Walking pneumonia, 776 Wassermann reaction for syphilis, 345 Water-hammer pulse, 189, 199 Hawke's method, 269 in aortic regurgitation, 269 Waxy kidney, 680. See also Amyloid kidney. Weil's cobra venom reaction in syphihs, 828 disease, 937 Wernicke's zone, 1028 Whiff murmur, 228 White blood-corpuscles. See Leukocytes. kidney, small, 668. See also Nephritis, chvOTViC Whooping-cough, 39, 882 bronchitis in, 91 cardiac comphcations, 884 epistaxis in, 884 gastro-intestinal irritation, 884 hemoptysis in, 884 mitral stenosis after, 283 Widal reaction, 334 in typhoid fever, 344, 743, 750 Williams' sign, 76 Winckel's disease, 942 Wintrich's sign, 62 in pneimiothorax, 164 interrupted, 62 "Witzelsucht," 1063 Woley's blood-pressure chart, 202 Woolly heart sound in endocarditis, 253 Wool-sorter's disease, 914, 915 Word blindness, 1029 Worms, fish, 969 guinea-, 989 round-, 974 of liver, 982 screw-, 991 tape-, 967 thread-, 976 Wright's coagulometer, 327 conclusion on opsonic index, 349 determination of opsonic index, 351 staining of blood, 343 Wrist-drop in plumbism, 531 Writer's cramp, 1168 Wry-neck, 931, 1167 Xanthelasma in jaimdice, 605 Xanthopsia in jaundice, 606 Xiphocostal route for aspirating pericar- dium, 246 X-ray. See Rdntgennray. Yellow atrophy of hver, acute, 603 hypertrophic cirrhosis and, differ- entiation, 604 phosphorus-poisoning and, differ- entiation, 597, 604 1248 INDEX. Yellow fever, 767 albuminuric, 767 dengue and, differentiation, 886 melano-albumimu'ic, 767 mosquito transmission, 768 non-albuminuric, 767 photophobia in, 768 Yellow fever, secondary, 769 vomiting of, 434 sputum, 78 Zone, Wernicke's, 1028 Zymogen in gastric contents, 468 SAUNDERS' BOOKS on GYNECOLOGY and OBSTETRICS W. B. SAUNDERS COMPANY WEST WASHINGTON SQUARE PHILADELPHIA 9. HENRIETTA STREET COVENT GARDEN, LONDON SAUNDERS' ANNOUNCEMENTS HAVE AN ANNUAL CIRCULATION OF OVER 5.000,000 TTHE recent growth of our foreign business necessitated some further provision * for bringing our new books before the English-speaking profession abroad. 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For this reason diagnosis is featured, and the relations of obstetric con- ditions and accidents to general medicine, surgery, and the specialties brought into prominence. Regarding treatment : You get here the very latest advances in this field, and you can rest assured every method of treatment, every step in operative technic, is just right. Dr. De Lee's twenty-one years' experience as a teacher and obstetrician guarantees this. Worthy of your particular attention are the descriptive legends under the illus- trations. These are unusually full, and by studying the pictures serially with their detailed legends, you are better able to follow the operations than by referring to the pictures from a distant text — the usual method. Dr. M. A. Hanna, University Medir.al College, Kansas City " I am Irank in stating that I pri?,e it more highly than any other volume in my obstetric library, which consists of practically aU the recent books on that subject." Prof. W. Stoeckel, Jnel, Germany "Dr. DeLee's Obstetrics deserves the greatest recognition. The text and the 913 very beau- tiful illustrations prove that it is written by an obstetrician of ripe experience and of exceptional teaching ability. It must be ranked with the best works of our hterature." Dr. George L. Brodhead, New York Post- Graduate Medical School " The name of the author is in itself a sufficient guarantee of the merit of the book, and I congratulate him, as well as you, on the superb work just published." G YNECOLOG Y AND OBSTETRICS. Norris' Gonorrhea in Women Gonorrhea in Women. By Charles C. Norris, M. D., Instructor in Gynecology, University of Pennsylvania. With an Introduction by John G. Clark, M. D., Professor of Gynecology, University of Penn- sylvania. Large octavo of 520 pages, illustrated. Cloth, ^6.00 net. A CLASSIC Dr. Norris here presents a work that is destined to take high place among pubhcations on this subject. He has done his work thoroughly. He has searched the important literature very carefully, over 2300 references being utilized. This, coupled with Dr. Norris' large experience, gives his book the stamp of authority. The chapter on serum and vaccine therapy and organotherapy is particularly valuable because it expresses the newest advances. Every phase of the subject is considered : History, bacteriology, pathology, sociology, prophylaxis, treatment, gonorrhea during pregnancy, parturition and puerperium, and all other phases. Pennsylvania Medical Journal " Dr. Norris has succeeded in presenting most comprehensively the present knowledge of gonorrhea in women in its many phases. The present status of serum and vaccine therapy is given in detail." American Text-Book (jf Gynecology Second Revised Edition American Text-Book of Gynecology. Edited by J. M. Baldy, M. D. Imperial octavo of 718 pages, with 341 text-illustrations and 38 plates. Cloth', ^6.00 net. American Text-Book qf Obstetrics Second Revised Edition The American Text-Book of Obstetrics. In two volumes. Edited by Richard C. Norris, M. D. ; Art Editor, Robert L. Dickinson, M. D. Two octavos of about 600 pages each ; nearly 900 illustrations, includ- ing 49 colored and half-tone plates. Per volume : Cloth, ;^3.50 net " As an authority, as a book of reference, as a ' working book ' for the student or practi- tioner, we commend it because we believe there is no better." — American Journal of thb Medical Sciences. SAUNDERS' BOOKS ON Ashton's Practice of Gynecology The Practice of Gynecology. By W. Easterly Ashton, M. D., LL.D., Professor of Gynecology in the Medico-Chirurgical College, Philadelphia. Handsome octavo volume of i lOO pages, containing 1058 original line drawings. Cloth, 1^6.50 net; Half Morocco, ;^8.00 net. NEW (5th) EDITION The continued success of Dr. Ashton's work is not surprising to any one knowing the book. The author takes up each procedure necessary to gynecologic step by step, the student being led from one step to another, just as in studying any non-medical subject, the minutest detail being explained in language that cannot fail to be understood even at first- reading. Nothing is left to be taken for granted, the author not only telling his readers in every instance what should be done, but also precisely how to do it. A distinctly original feature of the book is the illustrations, numbering 1058 line drawings made especially under the author's personal supervision from actual apparatus, living models, and dissections on the cadaver. From its first appearance Dr. Ashton's book set a standard in practical medical books ; that he has produced a work of unusual value to the medical practitioner is shown by the demand for new editions. Indeed, the book is a rich store-house of practical information, presented in such a way that the work cannot fail to be of daily service to the practitioner. Howard A. Kelly, M. D. Professor of Gynecologic Surgery, Johns Hopkins University. " It is different from anything that has as yet appeared. The illustrations are particularly clear and satisfactory. One specially good feature is the pains with which you describe so many details so often left to the imagination." Charles B. Penrose, M. D. Formerly Professor of Gynecology in the University of Pennsylvania " I know of no book that goes eo thoroughly and satisfactorily into all the details of every- thing connected with the subject. In this respect your book differs from the others." George M. Edebohls, M. D. Professor of Diseases of Women, New York Post-Graduate Medical School " A text-book most admirably adapted to teach gynecology to those who must get thels biowledge, even to the minutest and most elementary details, from books." GYNECOLOGY AND OBSTETRICS Bandler's Medical Gynecology Medical Gynecology. By S. Wyllis Bandler, M. D., Adjunct Professor of Diseases of Women, New York Post-Graduate Medical School and Hospital. Octavo of 790 pages, with 150 original illus- trations. Cloth, $5.00 net ; Half Morocco, ^6.50 net. NEW (3d) EDITION— 60 PAGES ON INTERNAL SECRETIONS This new work by Dr. Bandler is just the book that the physician engaged ijs general practice has long needed. It is truly the practitioner' s gynecology — planned for him, written for him, and illustrated for him. There are many gynecologic conditions that do not call for operative treatment ; yet, because of lack of that special knowledge required for their diagnosis and treatment, the general practi- tioner has been unable to treat them intelligently. This work not only deals with those conditions amenable to non-operative treatment, but it also tells how to recognize those diseases demanding operative treatment. Americem Journal of Obstetrics "He has shown good judgment in the selection of his data. He has placed most emphasis on diagnostic and therapeutic aspects. He has presented his facts in a manner to be readily grasped by the general practitioner." B&ndler's Vaginal Celiotomy Vaginal Celiotomy. By S. Wyllis Bandler, M. D., New York Post-Graduate Medical School and Hospital. Octavo of 450 pages, with 148 original illustrations. Cloth, $5.00 net; Half Morocco, $6.50 net. SUPERB ILLUSTRATIONS -^ The vaginal route, because of its simplicity, ease of execution, absence of shock, more certain results, and the opportunity for conservative measures, con- stitutes a field which should appeal to all surgeons, gynecologists, and obstetricians. Posterior vaginal celiotomy is of great importance in the removal of small tubal and ovarian tumors and cysts, and is an Important step in the performance of vaginal myomectomy, hysterectomy, and hysteromyomectomy. Anterior vaginal celiotomy with thorough separation of the bladder is the only certain method of correcting cystocele. The Lancet, London " Dr. Bandler has done good service in writing this book, which gives a very clear descrip- tion of all the operations which may be undertaken through the vagina. He makes out ^ strong case for these operations." SAUNDERS' BOOKS ON Kelly and Noble's Gynecology and Abdominal Surgery Gynecology and Abdominal Surgery. Edited by Howard A, Kelly, M. D., Professor of Gynecology in Johns Hopkins University ; and Charles P. Noble, M. D., formerly Clinical Professor of Gyne- cology in the Woman's Medical College, Philadelphia. Two imperial octavo volumes of 950 pages each, containing 880 illustrations, some in colors. Per volume: Cloth, |8.00 net ; Half Morocco, ;^9.50 net. TRANSLATED INTO SPANISH WITH 880 ILLUSTRATIONS BY HERMANN BECKER AND MAX BRODEL In view of the intimate association of gynecology with abdominal surgery the editors have combined these two important subjects in one work. For this reason the work will be doubly valuable, for not only the gynecologist and general prac- titioner will find it an exhaustive treatise, but the surgeon also will find here the latest technic of the various abdominal operations. It possesses a number of valuable features not to be found in any other publication covering the same fields. It contains a chapter upon the bacteriology and one upon the pathology of gyne- cology, dealing fully with the scientific basis of gynecology. In no other work can this information, prepared by specialists, be found as separate chapters. There is a large chapter devoted entirely to medical gynecology written especially for the physician engaged in general practice. Heretofore the general practitioner was compelled to search through an entire work in order to obtain the information desired. Abdominal surgery proper, as distinct from gynecology, is fully treated, embracing operations upon the stomach, upon the intestines, upon the liver and bile-ducts, upon the pancreas and spleen, upon the kidneys, ureter, bladder, and the peritoneum. The illustrations are truly magnificent, being the work of Mr. Hermann Becker and Mr. Max BrSdel. American Journal of the Medical Sciences " It is needless to say that the work has been thoroughly done : the names of the authors and editors would guarantee this ; but much may be said in praise of the method of presen- tation, and attention may be called to the inclusion of matter not to be found elsewhere." GYNECOLOGY AND OBSTETRICS Webster's Text-:Book qf Obstetrics A Text-Book of Obstetrics. By J. Clarence Webster, M. D. (Edin.), F. R. C. p. E., Professor of Obstetrics and Gynecology in Rush Medical College, in affiliation with the Univei'sity of Chicago. Octavo volume of 767 pages, illustrated. Cloth, ^5.00 net; Half Morocco, $6.50 net. BEAUTIFULLY ILLUSTRATED In this work the anatomic changes accompanying pregnancy, labor, and the puerperium are described more fully and lucidly than in any other text-book on the subject. The exposition of these sections is based mainly upon studies of frozen specimens. Unusual consideration is given to embryologic and physiologic data of importance in their relation to obstetrics. Buffalo Medical Journal '.' As a practical text-book on obstetrics for both student and practitioner, there is left very little to be desired, it being as near perfection as any compact work that has been published." Webster's Diseases of Women A Text-Book of Diseases of Women. By J. Clarence Webster, M. D. (Edin.), F. R. C. P. E., Professor of Gynecology and Obstetrics in Rush Medical College. Octavo of 712 pages, with 372 text-illustra- tions and 10 colored plates. Cloth, ;^7.oo net ; Half Morocco, ^^8.50 net. Dr. Webster has written this work especially for the general practitioner, dis- cussing the clinical features of the subject in their widest relations to general practice rather than from the standpoint of specialism. The magnificent illus- trations, three hundred and seventy-two in number, are nearly all original. Howard A. Kelly. M. D. Professor of Gynecologic Surgery, Johns Hopkins University. " It is undoubtedly one of the best works which has been put on the market within recent years, showing from start to finish Dr. Webster's well-known thoroughness. The illustrations are also of the highest order." SAUNDERS BOOKS ON Hirst's Text-Book of Obstetrics The New (7th) Edition A Text- Book ot Obstetrics. By Barton Cooke Hirst, M.D., Professor of Obstetrics in the University of Pennsylvania. Handsome octavo of 1013 pages, with 89S illustrations, 53 of them in colors. Cloth, ^5.00 net ; Half Morocco, {^6.50 net. INCLUDING RELATED GYNECOLOGIC OPERATIONS Immediately on its publication this work took its place as the leading text-book on the subject. Both in this country and in England it is recognized as the most satisfactorily written and clearly illustrated work on obstetrics in the language. The illustrations form one of the features of the book. They are numerous and the most of them are original. In this edition the book has been thoroughly revised. Recognizing the inseparable relation between obstetrics and certain gynecologic conditions, the author has included all the gynecologic operations for complica- tions and consequences of childbirth, together with a brief account of the diagnosis and treatment of all the pathologic phenomena peculiar to women. OPINIONS OF THE MEDICAL PRESS Biitish Medical Joumstl " The popularity of American text-boolts in this country is one of the features of recent years. The popularity is probably chiefly due to the great superiority of their illustrations over those of the English text-books. The illustrations in Dr. Hirst's volume are far more numerous and far better executed, and therefore more instructive, than those commonly found in the works of writers on obstetrics in our own country." Bulletin of Johns Hopkins Hospital "The work is an admirable one in every sense of the word, concisely but comprehensively written.'' The Medical Record, New York " The illustrations are numerous and are works of art, many of them appearing for the first time. The author's style, though condensed, is singularly clear, so that it is never necessary to re-read a sentence in order to grasp the meaning. As a true model of what a modern text- book on obstetrics should be, we feel justified in affirming that Dr. Hirst's book 's v/ithout a rival." • DISEASES OF WOMEN. HirstV Diseases of Women A Text-Book of Diseases of Women. By Barton Cooke Hirst, M. D., Professor of Obstetrics, University of Pennsylvania ; Gynecolo- gist to the Howard, the Orthopedic, afld the Philadelphia Hospitals. Octavo of 745 pages, with 701 original illustrations, many in colors. Cloth, ^5.00 net; Half Morocco, $6.t,o net. THE NEW (2d) EDITION WITH 701 ORIGINAL ILLUSTRATIONS The new edition of this work has just been issued after a careful revision. As diagnosis and treatment are of the greatest importance in considering diseases of women, particular attention has been devoted to these divisions. To this end, also, the work has been magnificently illuminated with 701 illustrations, for the most part original photographs and water-colors of actual clinical cases accumu- lated during the past fifteen years. The palliative treatment, as well as the radical operative, is fully described, enabling the general practitioner to treat many of his own patients i^ithout referring them to a specialist. An entire sec- tion is devoted to r, full description of all modern gynecologic operations, illumi- nated and elucidatsd by numerous photographs. The author's extensive ex- perience renders this work of unusual value. OPINIONS OF THE MEDICAL PRESS Medical Record, New York " Its merits can be appreciated only by a careful perusal. . . . Nearly one hundred pages are devoted to technic, this chapter being in some respects superior to the descriptions in many other text- boks." Boston Medical and Surgical Journal "The author has given special attention to diagnosis and treatment throughout the book, and has produced a practical treatise which should be of the greatest value to the student, the general practitioner, and the specialist." Medical News, New York " Office treatment is given a due amount of consideration, so that the work will be as useful to the non-operator as to the specialist," lo SAUNDERS' BOOKS ON- GET i» • THE NEW THE BEST /\ HI 6 n C Si H STANDARD Illustrated Dictionary New (7th) Edition— 5000 Sold in Two Months The American Illustrated Medical Dictionary. A new and com- plete dictionary of the terms used in Medicine, Surgery, Dentistry, Pharmacy, Chemistry, Veterinary Science, Nursing, and kindred branches ; with over lOO new and elaborate tables and many handsome illustrations. By W. A. Newman Borland, M.D., Editor of "The American Pocket Medical Dictionary." Large octavo, 1107 pages, bound in full flexible leather. I'rice, ^4.50 net ; with thumb index, #5.00 net. IT DEFINES ALL THE NEW WORDS— MANY NEW FEATURES The American Illustrated Medical Dictionary defines hundreds of the newest terms not defined in any other dictionary — bar none. These new terms are live, active words, taken right from modern medical literature. It gives the capitalization and protjunciation of all words. It makes a feature of the derivation or etymology of the words. In some dictionaries the etymology occupies only a secondary place, in many cases no derivation being given at all. In the ' 'American Illustrated ' ' practically every word is given its derivation. Every word has a separate paragraph, thus making it easy to find a word quickly. The tables of arteries, muscles, nerves, veins, etc. , are of the greatest help in assembling anatomic facts. In them are classified for quick study all the necessary information about the various structures. Every word is given its definition — a definition that defines in the fewest pos- sible words. In some dictionaries hundreds of words are not defined at all, refer- ring the reader to some other source for the information he wants at once. Howard A. Kelly, M. Ti., Johns Hopkins University, Baltimore "The American Illustrated Dictionary is admirable. It is so well gotten up and of such convenient size. No errors have been found in my use of it." J. Collins Wsrren, M. D., LL.D., F.R.C.S. (Hon.), Hm-vard Medical School " I regard it as a valuable aid to my medical literary work. It is very complete and oi convenient size to handle comfortably. I use it in preference to any other." GYNECOLOGY AND. OBSTETRICS Penrose's Diseases of Women Sixth Revised Edition A Text-Book of Diseases of Women. By Charles B. Penrose, M. D., Ph. D., formerly Professor of Gynecology in the University of Pennsylvania ; Surgeon to the Gynecean Hospital, Philadelphia. Oc' tavo volume of 550 pages, with 225 fine original illustrations. Cloth, ^3.75 net. ILLUSTRATED Regularly every year a new edition of this excellent text-book is called for, and it appears to be in as great favor with physicians as with students. Indeed, this book has taken its place as the ideal work for the general practitioner. The author presents the best teaching of modern gynecology, untrammeled by anti- quated ideas and methods. In every case the most modern and progressive technique is adopted and made clear by excellent illustrations. Howard A. Kelly, M.D.. Professor of Gynecologic Surgery, Johns Hopkins University, Baltimore. " I shall value very highly the copy of Penrose's ' Diseases ofWomen ' received. I have already recommended it to my class as the best book." Davis' Operative Obstetrics operative Obstetrics. By Edward P. Davis, M.D., Professor of Obstetrics at Jefferson Medical College, Philadelphia. Octavo of 483 pages, with 264 illustrations. Cloth, $5.50 net; Half Morocco, $7.00 net. INCLUDING SURGERY OF NEWBORN Dr. Davis* new work is a inost practical one, and no expense has been spared to make it the handsomest work on the subject as well. Every step in every operation is described minutely, and the technic shown by beautiful new illustra- tions. Dr. Davis' name is sufficient guarantee for something above the mediocre. t2 SAUNDERS' BOOKS ON Dorland's Modern Obstetric^/* Modern Obstetrics: General and Operative. By W. A. Newman Borland, A. M., M. D., formerly Professor of Obstetrics at Loyola University, Chicago, Illinois. Handsome octavo volume of 797 pages, with 201 illustrations. Cloth, $4.00 net. Second Edition, Revised and Greatly Enlar{(ed In this edition the book has been entirely rewritten and very greatly enlarged. Among the new subjects introduced are the surgical treatment of puerperal sepsis, infant mortality, placental transmission of diseases, serum-therapy of puerperal sepsis, etc. By new illustrations the text has been elucidated, and the subject pre- sented in a most instructive and acceptable form. Journal of the American Medical Association " This work deserves commendation, and that it has received what it deserves at the hands of the profession is attested by the fact that a second edition is called for within such a short time. Especially deserving of praise is the chapter on puerperal sepsis," Davis' Obstetric and Gynecologic Nursing Obstetric and Gynecologic Nursing. By Edward P. Davis, A. M., M. D., Professor of Obstetrics in the Jeliferson Medical College and Philadelphia Polyclinic ; Obstetrician and Gynecologist, Philadelphia Hospital. 1 2mo of 480 pages, illustrated. Buckram, ;^ 1,7 5 net. NEW (4th) EDITION Obstetric nursing demands some knowledge of natural pregnancy, and gyne- cologic nursing, really a branch of surgical nursing, requires special instruction and training. This volume presents this information in the most convenient form. This third edition has been very carefully revised throughout, bringing the subject down to date. The Lancet, London " Not only nurses, but even newly qualified medical men, would learn a great deal by a perusal of this book. It is written in a clear and pleasant style, and is a work we can recom- mend." GYNECOLOGY AND OBSTETRICS. ^3 Kelly and CuUen's Myomata of the Uterus Myomata of the Uterus. By Howard A. Kelly, M. D., Professor of Gynecologic Surgery at Johns Hopkins University; and Thomas S. CuLLEN, M. B., Associate in Gynecology at Johns Hopkins University. Large octavo of about 700 pages, with 388 original illustrations, by August Horn and Hermann Becker. Cloth, ^7.50 net ; Half Morocco, $g.C)0 net. ILLUSTRATED BY AUGUST HORN AND HERMANN BECKER This monumental work, the fruit of over ten years of untiring labors, will remain for many years the last word upon the subject. Written by those m6n who have brought, step by step, the operative treatment of uterine myoma to such perfection that the mortality is now less than one per cent., it stands out as the record of greatest achievement of recent times. Surgery, Gynecolo^, and Obstetrics " It must be considered as the most comprehensive work of the kind yet published. It will always be a mine of wealth to future students.' ' CuUen's Adenomyoma of the Uterus Adenomyoma of the Uterus. By Thomas S. Cullen, M. B. Octavo of 275 pages, with original illustrations by Hermann Becker and August Horn.. Cloth, JJS5.0O net; Half Morocco, $().^o net. " A good example of how such a monograph should be written. It is an excellent work, worthy of the high reputation of the author and of the school from which it emanates." — The Lancet, London. Cullen's Cancer of the Uterus Cancer of the Uterus. By Thomas S. Cullen, M. B. Large octavo of 693 pages, with over 300 colored and half-tone text-cuts and eleven lithographs. Cloth, JJS7.S0 net ; Half Morocco, ^8.50 net. " Dr. Cullen's book is the standard work on the greatest problem which faces the surgical world to-day. Any one who desires to attack this great problem must have this book." — Howard A. Kelly, M. D., Johns Hopkins University. 14 SAUNDERS' BOOKS ON Schaffer and £d|(ar's Labor and Operative Obstetrics Atlas and Epitome of Labor and Operative Obstetrics. By Dr. O. Schaffer, of Heidelberg. Edited, with additions, by J. Clifton Edgar, M. D., Professor of Obstetrics and Clinical Midwifery, Cornell University Medical School, New York. With 14 lithographic plates in colors, 139 text- cuts, and III pages of text. Cloth, J2.00 net. In Saunders' Hand-Atlases. Schaffer and Edgar's Obstetric Diagnosis and Treatment Atlas and Epitome of Obstetric Diagnosis and Treatment. By Dr. O. Schaffer, of Heidelberg. Edited, with additions, by J. Clifton Edgar, M. D., Professor of Obstetrics and Clinical Midwifery, Cornell University Medical School, New York. With 122 colored figures on 56 plates, 38 text- cuts, and 315 pages of text. Cloth, $3.00 net. Saunders' Hand-Atlases. Schaffer and Norris' Gynecology Atlas and Epitome of Gynecology. By Dr. O. Schaffer, of Heidel- berg. Edited, with additions, by Richard C. Norris, A. M., M. D., Gynecologist to Methodist Episcopal and Philadelphia Hospitals. With 207 colored figures on 90 plates, 65 text-cuts, and 308 pages of text. Cloth, J3. 50 net. In Saunders' Hand- Atlas Series. Galbraith's Four Epochs of Woman's Life New (2d) Edition The Four Epochs of Woman's Life : A Study in Hygiene. By Anna M.. Galbraith, M. D., Fellow of the New York Academy of Medicine, etc. With an Introductory Note by John H. Musser, M. D., University of Pennsylvania. l2mo of 247 pages. Cloth, Ji.jo net. Birmingham Medical Review, England " We do not, as a rule, care for medical books written for the instruction of the public. But we must admit that the advice in Dr. Galbraith's work is, in the main, wise and wholesome." Garrigues' Diseases of Women Third Edition A Text=Book of Diseases of Women. By Henry J. Garrigues, M. D., Gynecologist to St. Mark's Hospital, New York City. Octavo of 756 pages, illustrated. Cloth, )j(4. 50 net ; Half Morocco, ;?6. 00 net. GYNECOLOGY -AND OBSTETRICS. 15 Schaffer and Webster's Operative Gynecology Atlas and Epitome of Operative Gynecology. By Dr. O. Schaf- fer, of Heidelberg. Edited, with additions, by J. Clarence Webster, M.D. (Edin.), F.R.C.P.E., Professor of Obstetrics and Gynecology in Rush. Medical College, in affiliation with the University of Chicago. 42 colored lithographic plates, many text-cuts, a number in colors, and 138 pages of text. In Saunders' Hand- Atlas Series. Cloth, $3.00 net. Much patient endeavor has been expended by the author, the artist, and the lithographer in the preparation of the plates of this atlas. They are based on hundreds of photographs taken from nature, and illustrate most faithfully the various surgical situations. Dr. Schaffer has made a specialty of demonstrating by illustrations. Medical Record, New York " The volume should prove most helpful to students and others in grasping details usually to be acquired only in the amphitheater itself." De Lee*s Obstetrics for Nurses Obstetrics for Nurses. By Joseph B. De Lee, M.D., Professor of Obstetrics in the Northwestern University Medical School ; Lecturer in the Nurses' Training Schools of Mercy, Wesley, Provident, Cook County, and Chicago Lying-in Hospitals. i2nio volume of 508 pages, fully illustrated. Cloth, ^2.50 net. THE NEW (4th) EDITION While Dr. De Lee has written his work especially for nurses, yet the prac- titioner will find it useful and instructive, since the duties of a nurse often devolve upon him in the early years of his practice. The illustrations are nearly all original, and represent photographs taken from actual scenes. The text is the result of the author's many years' experience in lecturing to the nurses of five different training schools. J. Clifton Edgar, M. D., Professor of Obstetrics and Clinical Midwifery, Cornell University , New York. " It is far and away the best that has come to my notice, and I shall take great pleasure in recommending it to my nurses, and students as well." l6 SAUNDERS' BOOKS ON GYNECOLOGY AND OBSTETRICS. American Pocket Dictionary New (8th) Edition The American Pocket Medical Dictionary. Edited by W, A. Newman Borland, A. M., M. D. 677 pages. ;gi.oo net; with patent thumb index, $\.2^ net. James W. Holland. M. D., Professor of Medical Chemistry and Toxicology at tke Jefferson Medical College, Philadelphia. " I am struck at once with admiration at the compact size and attractive exterior. J can recommend it to our students without reserve." Cragin's Gynecology. New (7th) Edition Essentials of Gynecology. By Edwin B. Cragin, M. D., Professor of Obstetrics, College of Physicians and Surgeons, New York. Crown octavo, 232 pages, 59 illustrations Cloth, ;^i.oo net. In Saunders' Question- Compend Series. The Medical Record, New York " A handy volume and a distinct improvement- of students' compends in general. No author who was not himself a practical gynecologist could have consulted the student's needs so thoroughly as Dr. Cragin has done." Ashton's Obstetrics. New (rth) Edition Essentials of Obstetrics. By W. Easterly Ashton, M. D., Professor of Gynecology in the Medico-Chirurgical College, Phila- delphia. Revised by John A. McGlinn, M. D., Assistant Professor of Obstetrics in the Medico-Chirurgical College of Philadelphia. i2moof 2 87 pages, 109 illustrations. Cloth, ^i. 00 net. In Saunders' Question- Compend Series. Southern Practitioner "An excellent little volume ccAtaining correct and practical knowledge. An admir- able compend, and the best condensation we have seen." Barton and Wells' Medical Thesaurus A Thesaurus of Medical Words and Phrases. By Wilfred M. Barton, M. D., Assistant to Professor of Materia Medica and Therapeutics, Georgetown University, Washington, D. C. ; and Walter A. Wells^ M. D., Demonstrator of Laryngology, George- town University, Washington, D. C. i2mo of 534 pages. Flex- ible leather, ^2.50 net; with thumb index, ^3.00 net. Macfarlane's Gynecology for Nurses second Edition A Reference Hand-Book of Gynecology for Nurses. By Cath- arine Macfarlane, M. D., Gynecologist to the Woman's Hospital of Philadelphia. 32mo of 150 pages, with 70 illustrations. Flexible leather, ^1.25 net. A. M. Seabrook. M. D., Woman's Medical College of Philadelphia. " It is a. most admirable little book, covering in a concise but attractive way the subject from the nurse's standpoint."