il^eference Hibxavp AN i\dp:x of DIFFERENTIAL DIAGNOSIS Ol' MAIN S^'^I1'T()MS I'lllNTKD IS ESOLAND BY JOHN WRIGHT AXn SONS LTD.. BHISTOL PKHFACK TO THE SECOND EDITION Little need be said by way of preface to the second edition of this worlv • ti.e jrratity.ng sale of the first edition and the necessity there has been to reprint it several t.mes ,s .sufficient evidence tliat the book is one wliiel, the medical profession welcomes and ajipreciates. In this edition every article has been re^■ised and several new ones have been added. The elaborate- nuicx. which has been nmeh appreciated, has l,een made if possible, even more complete, and at the same time it has been simplified in some particulars : the relative importance of the entries in it are indicated more clearlv perhaps than was the case in the first edition, by the use of three deorees of type The dlustrations are nearly doubled in number ; the coloured plates especiallv havng been mcreased from sixteen to thirty-seven, and neither time nor expensV has been spared m the endeavour to make them characteristic of the conditions they represent. The size of the type- en.ployed is larger than before, m response to sug-vestions Irom readers, and consequently the pages have had to be enlarged also It became a question, therefore, whether the book should be published m tvvo .•olumes ; in the belief, however, that in a work in which numerous cross-references ire unavoidable it is advantageous to confine it within one cover, it has been lec.ded to keep it as a single book. The general character of the volume remains "tJierwise unchanged. It is hoped that this second edition will be as widelv welcomed as was the first • .nd that It will prove even more helpful in its primary purpose, namelv, to be of .SS.S anec in arriving at the diagnosis of the exact cause of particular symptoms. Cordial thanks are extended to many helpers who. whilst not eoutrihutinrv vritten articles to the volume, have n,-verthelcss assisted g.vatlx- u, ^ ariuus wavs^ specially to Dr. J). S. Davies. Mr. C. Thurstan Holland. Dr. A. C. .Jordan Dr" t' Vanier Laeey Dr. T. M. L.,.,. ,), ,,„dsay Locke, Professor Rutherlbrd Moriso.K '.r .Malcolm Morns. 1),-. II. J{. Xcuham, Dr. G. W. Nicholson. Dr. .1. II HylTc.l • .-. S. CillHi-t Scot.. Dr. W. P. Saunders, Dr. A. Reudle Short. Dr. Hugh Walsham" )r. S. A K. \\,isoM : .,lso to the ]{nyal Society of M,.lieinr. I|,.. (;„nio„ Mnsenn, •uys Jlosp.tal, ,1„. Sonll, K.-.t.-n, fVv.r ]|.,s,.„al. and ll„. London .School .,r ropieal M.-d,,.,,,,.. Also ,.. tl„. publishers and proprietors of various journals and ••r..t hea s lor unl-nhng courtesy n, giving laeilities lor the use of copyright material ■ un illnsi rations. Jli;ui'.i;Kr l''Hi-'.Neu. Liindiin. I''rliniiui/. I!) 1 7. Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/indexofdifferentOOfren PREFACE TO THl-L FIRST EDmON Tins book is a treatise on the application ot differential diagnosis to all the main signs and symptoms of disease. It aims at being of practical utility to medical men whenever difficulty arises in deciding the precise cause of any particular symptom of which a patient may complain. It covers the whole ground of medicine, surgery, gynaecology, ophthalmology, dermatology, and neurology. Whatever the disease from which a patient is suffering, the importance of diagnosing it as early as possible can hardly be over-rated. The present volume deals with diagnosis from a standpoint which is different from that of most text- books, having been written in response to requests for an Index oj Diagnosis as a companion to the publishers' Index oj Treatment, issued in 1907. The book is an index in the sense that its articles on the various symptoms are arranged in al]jha- betical order ; at the same time it is a work upon differential diagnosis in that it discusses the methods of distinguishing between the various diseases in which each individual symptom may be observed. Whilst the body of the book thus deals with symptoms, the general index at the end gathers these together under the headings of the various diseases in which they occur. The Editor lays jiarticular stress upon the importance of using these two parts of the book together. Unless reference is made freely to the general index, the reader may miss a number of the places in which is discussed the diagnosis of the disease with which he has to deal : for while each symptom is considered but once, each disease is likely to come uj) for diseussioii inider the heading of each of its more important symptoms. The guiding princijile throughout has been to suppose that a particular syini)tom attracts special notice in a gi\en case, and that the diagnosis has to be established by tlifferentiating between the various diseases to which this symptom may be due. One of many difficulties arising during the construction of the work was that of deciding where to draw the line as regards symptoms themselves. The <-xcIusion of many borderline headings such as " Dullness at the base of one lung." ■ Inability to breathe through the nose."' and various signs such as Romberg's. Stcllwag's, Von Graefe's, and so forth, nuiy ])erhaps seem arbitrary ; but reference to the minor symptoms and physical signs which have not been thought sufficiently miportant to merit se|)arate articles will be found in the general index a I I lie end of the volume. Tre;itnieiit. patliology. uiid |)rognosis .uc uol dcall willi cxcci.l ui so far as tlii-y may bear upon (liff)1. Dead lingers, 162. DlaceturLa, 170. Diazo- reaction, 173. Dilatation of the stom.ach, 173. Discharge, naa.al. 178. Dysphagia, 194. Dyspncea. 199. Emphysema, surgical. 203. Enlargomont of the forehead. 203. Enlargement ol tho heart. 206, Eoslnophllla. 218. Ei-ylhoma, 222. Fa-'cos passed per urethram. 238. Fatty stools, 239. Fr.acture, spontaneous. 242 O.-ill bladder onlargomont, 262. Grinding of tho tooth during sleep, 65. Haima- tamosls. 2G6, Hoemogloblnurla, 284. Hajmoptysis, 286. -Heartburn, 296. Homiiinopsia, 300. Hemiplegia. 302.- -Hiccough, 307. Hyperacusls, 308. Hyperpyrexia, 309. — Hypothermia, 310. Impo tenoe, 3 2. IndlcanurLa, 314. Jaundice. 324. Leucocytosls, 359. I oucopenia, 361. Limping in children, 362. Lymphatic gland enlargement, 376. Mar.asmus, 384. Moryoism, 388 Meteorism, 388. Mucus in the urine, 399. Nightmares, 402. Noises in tho ho.ad, 405. Obesity. 408. (Edema, sym- metrical, 410. Opisthotonos, 417. Orthopna).a, 418. Ox,-iIurla, 423. P.-vln in tho breast, 429. P.aln in the eye, 445. P.aln In the lll.ac fossa (loft), 462. Pain In the lilac fossa (i-ightl, 454. Pain, inter- X tX)XTRIBUTORS AND THEIR SUBJPX'TS scapular, 461. Pain in the shoulder, 474. -Palpitation, 484. Paralysis, laryngeal, 494. Paraplegia, 510. -Parasites, intestinal, 519. Peristalsis, visible, 521. Phosphaturia, 522. Photophobia, S24. Pigmentation in the mouth, 526.- Pneumaturia, 52&. Pneumothorax. 530. Polycythaemia, 532. Polyuria, 534. Priapism, 537. Ptyalism, 542. Pulsation, undue abdominal aortic, 543. Pulses, unequal. 550. Purpui-a, 552. Pus in the stools, 657. Reaction of degeneration, 583. Reduplication of heart sound, 587. Regurgitation of food through the nose, 588. -Retraction of the gums, 589. -Retraction of the head, 589. Risus sardonicus, 598. Skodalc resonance, 611. Smell, abnormalities of, 611. Snoring, 613. Sore throat, 613. -Spleen, enlargement of the, 628. Sputum, 641. Stertor, 647. Strangury, 649. -Stridor, 650.- Succussion sounds, 651. Swelling, pulsatile, 693. Swelling of the tongue, 698. Tache cer^brale, 702.— Tachycardia, 702. Taste, abnormalities of, 705. Tenesmus, 716. Thirst, extreme, 719.- Trismus, 729. —Urate deposit in the urine, 740. Dric acid deposit in the urine, 741. Veins, varicose abdominal, 748. Veins, varicose thoracic, 750. Weight, loss of, 768. AiiCiiiBALD Edwu. Gaiikoij, C.M.G., .M.A., .M.i). Oxoii.. 1 .K.c.i>., 1 .U.S. : I'livsiciitii. St. BarthoIomcwV Hospital : Consulting Physician to the Hospital for Sick Children, (Jreat Ornioiid Street. Urine, abnormal coloration of, 742. (;i;ouGE Ernest Gask. i .k.c.s. : Sin-oeon with Charge of Out-iiatients, St. Bartholomc\\ "s Hospital : .Toint Lecturer in Siiroci\ . .St. Bartholomew'.s Hospital Medical School. Discharge from the nipple, 131. — CEdema, asynunetrical, 410. Pain in the jaw, 462. — Pain in the umbilical region, 483. Rectum, abnormalities felt per, 584. Rigidity of the abdomen, 592. Stiff neck. 647. Swelling, axillary, 666. Swelling on a bone, (67. — Swelling of the face, 673. — Swelling, femoral, 674. — Swelling in the iliac fossa, 676. Swelling of the jaw (lower), 683.- Swelling of the jaw (upper), 685. Swelling, popliteal, 691.-- Swelling of the salivary glands, 694. -Swelling, scrotal, 695. — Thyroid gland enlargement, 721. Ulceration of the leg, 736. Ulceration of the tongue, 738. Hastings CiiLFOBD, f.ii.c.s. ; Considting .Surgeon. Kiugvvood Saiiatoriuiii. Heading. Dwarfism, 186. .Artiiuk Fkedi;iuck Hihst, m.a.. .m.d. Oxon., f.r.c.p. : I'hysieian and I'hysician Tor Nervous Diseases and Lecturer on Therapeutics, Guy's Hospital. Constipation, 121. — Fullness, sense of, 243. Robert HiiTCHisoN, m.ij., cm. Kdin., i-.r.c.p. ; Physician to tlie London Hospital : Physician with Charge of Out-patients to the Hospital for Sick Children, Gicat Orniond Street. Appetite, abnormal, 42. Diarrhoaa, 170. Flatulence, 240. Indigestion, 315. Pain in ihe epigasti-ium, 436. Pain in the hypochondrium Heft), 450. Pain in the hypochondrlum (right), 450. Arthi K John Jex-Blake. m.a., m.b., b.ch. Oxon. m.r.c.p. : Senior Assistant Pliysician, St. GeoigcV Hosjjital : Assistant Physician. Brompton Hos])ital for Consumption. Contractions, 131. Contractures, 139. Convulsions, 143. Cramps, 150.- Epistaxis, 221. Gangrene, 255. Gangrene of the lung, 259. Insomnia, 320. Pain in the chest, 430. -Pain in the limbs, 463,- -Rigors, or chills, 694. Swelling, abdominal, 656. Tenderness in the chest, 706. - Tenderness in the scalp, 710. Tenderness in the spine, 712. -Tremor, 724. Sir i\L\lcolm Morris, Bart., K.c.v.o., i-.r.c.s. Edin. ; Consulting Surgeon. Skin Department. St. Mary's Ho.spital ; Surgeon, Skin Department, Seamen's Ho.spital. Baldness, 70. Sore finger, 239. Flushing, 241. Futigous affections of the skin, 246. Lips, affections of the red part of the, 365. Macules, 382. Nails, affections of the, 399. Napkin region eruptions, 400.- Nodules, 402. Papules, 487. Pigmentation of the skin, 527. Prm-itus, 540. Pustules, 557. Scabs, 599. Scaly eruptions, 601. Sweating, abnormalities of, t54. Tiunours of the skin, 731. Ulceration of the face, 735. Ulceration of the foot, 735. Vesicles, 753. Wheals, 771. HoBEin P, l{o\M.ANi)s. M.B., M.S. Loud., 1 .R.c.s. : Surgeon. Guv's Hospital : Lecturer on Anatomy. Guy's Hosjiitiil .^ledical School. Club foot, or talipes. 111. Curvature, spinal, 153. Swelling, inguinal, 678. Swelling, Inguinoscrotal, 682- .I.vMES K. H. S.\wvEH, .M.A.. M.D.. ii.cii. Oxon. : Assistant Physician, General Hospital. Birmingham. Bruits, cardiac, 89. Deformity of the chest, 167. Heart impulse, displaced, 297. Thrills, precordial, 720. Frkderick John Smith, m.a., .m.o. Oxon., f.r.c.p., f.r.c.s. : Physician and Senior Pathologist. London Ho.«pital : Consulting Physician to the City of London Dispensary and to the National Orthopjedic Hospital. Breath, shortness of, 87, Cough, 148. Delirium, 169.— Gait, abnormalities of, 261. Lineffi albicantes, 365. Pain in the back, 427. Pyrexia without obvious cause, 571. CONTRIBUTORS AND THEIR SUBJECTS xi 'I'lioMAS George Stevens, m.d., b.s. Lond., m.r.c.p., f.r.c.s. : Obstetric Surgeon, St. Mary's Hospital ; Gyna^eolooical Surgeon, Hospital for Women, Soho Square : Physician to In- patients, Queen Charlotte's Hospital. Amenorrhcea, 17. Discharge, vaginal, 185. Dysmenorrhcea, 192. Dyspareunia, 193. Dystocia, 199. Menorrhagia, 385. Metrorrhagia, 390. Metrostaxis, 392. Pain, bearing down, 427. Pain in the pelvis, 467. Prolapse of the uterus, 538. Sterility, 645. Swelling, mammary, 685. Swelling, vulval, 699. Id ■<-,i;i.!. H. .JocKi.vN S\v.\x. .m.is.. .-m.s. LoiuI., i .it.c'.s. : Suri;coii, t'aiiccr Ilosjiitai, Bioiiiptoii. Anuria, 39. Discharge, urethral, 181. Enuresis, 218. Hasmaturia, 276. Kidney, enlargement of, 352. Micturition, abnormalities of, 393. Pain in the Penis, 469.- Pain in the perineum, 474. Pain in the testicle, 477. Pyuria, 674. Sores, penile, 617. Sores, perineal, 619. Sores, scrotal, 621. Ki(KiJi;uitK T.ivi.oit, M.D. Lund., i.r.c.p. ; Coiisultiiiy Physician, Guy's Hospital, and Kvelina Hospital for .Sicl; C'liikhen : Physician, .Seamen's Hospital, Greenwich. Pyrexia, prolonged, 563. Philip Tlrner, b.sc, m.b., M.S. Lond., f.r.c.s. : .\ssistant Surgeon, Guy's Hospital : Drmoastrator of Operative Surgery, Guy's Hospital Medical School. Deafness, 163. Earache, 202. Otorrhoea, 421. Tinnitus, 723. Vertigo. 750- \Vii.i.iA.\i Half. Wuite, .m.d. Lond., m.d. Dub., f.r.c.p, : Senior Physician and Lecturer on Medicine, Guy's Hospital, Joints, affections of the, 337. Liver dullness, deficient, 366. Livei-, enlargements of the, 366. Mucus in the stools, 398. Pain, abdominal, 426. Sand, intestinal, 599. LIST OF COLOURED PLATES Platk I. — Renal tube casts __--_-.- A, Hyaline; B^ Waxy; C) Uynline cast containiug small ciystals of cnlcium oxalate; D, Blood; E, Leucocyte ; F. Epithelial ; G, Granular ; H, Fatty. Plate II.— Red and wliite blood corpuscles ,.--.- A, Xormal red ; B, Megalooytes and microcytes ; C, Normal red corpuscles made angular by imperfect' fixation; D, Crenated red coi-puscles ; F, Poikilocytes ; F, Nucleated red corpuscles — (1) Normoblasts, (2) Mefjaloblasts. (3) Gigantoblasts ; G, Punctate basophilia and polychromasia ; H, Small lymphocyte: I, Indeterminate lymphocyte ; j. Large hyaline lymphocyte ; K, Polymorphonuclear corpuscle ; L, Coarsely granular eosinophile coipuscle ; M, Myelocyte ; N. Eosinophiie myelocyte ; o, Easophile corpuscle. Plate III. —Blood film in pernicious antemia _.---. showing poikilocytes, microcytes, megalocytes, nucleated red cells, and punctate basophilia. Plate IV. — Blood film in spltnnincdiillary leuktemia _ . . . , Showing five neui in|.!iil.> tm .In, \ ti.-^, one eosuiophile myelocyte, three basophile cells, and one binucleated red cell, in addition to im.iui.W ."■mi pu>.'les. Plate V. — Blood film in lymphatic leukaemia ...... Sliowing a lai^e increa-se in the small lymphocytes. Plate VI. — Blood film in malaria ._..__, Showing three malarial panisites of the ring type. Plate VII. — Pigmentation of the skin due to arsenic . . . _ . Plate VIII.—Koplik's spots . . , . ... Plate IX.—Pellaora _....._.. Plate X. — The hand of u i)ellagrin -.-,_.. Plate XI. ^ — ^Acute inflammations of the eye -._,_. A, Acute conjunctivitis ; B, Acute iritis ; C, Glaucoma ; D, Phl^'ctenular conjunctivitis : e. FoIUcuUir conjunctivitis. Pl.\te XII. — Acute inflammations of the eye .--_-- F, Chi-onic blepharitis ; G) Interetitial keratitis ; H, Ti'aclioma ; |, Hypopyon and ulcer of cornea. Pi^\TK XIII. — ^Symmetrical gangrene of the fingers in Raynaud's disease Plate XIV. — Gangrene of the foot _ - . . . . Plate XV. — Bladder appearances seen thrtniiih the cystoscope ... - A, Blood-stained urine issuing fi-om the ureter ; 8» Pmnleut urine issmng from the ureter ; C, Conges- tion round a ureteric orifice in calculous pyehtis ; d, The reti-acted ureter common with descending renal tuberculosis ; E, Tuberculous ulceration around the ureteric orifice in descending tuberculosis. Plati: XVI. — Bladder appearances seen through the cystoscope - _ - - F, Pedunculated carcinoma of bladder; G-, Pedunculated bald carcinoma of bladder; h, L'ric acid calculus in bladder; |, Appearance at tlie urethral orifice in bilateral adenomatous enlargement of the jirostate ; K, Bilhaiv.ia hasmatohia. Plate XVII.— Multiple bleeding narvi of tlu- tongue, niuutii. and ehtek Plate XVIII. — Familial acholuric jaundice _-_.-. Plate XlX.—Ophthalmoscopic appearances _-,-.. a. Physiological cup ; &, Congenital crescent ; c. Pigmented crescent in disc mai^gin ; d, Colobomu of choroid ; e, /, Opaque nerve fibres ; y, Advanced syphilitic choroiditis ; A, t", The myopic crescent ; k, I, Eecent optic neuritis. Plate XX. — ^Ophthalmoscopic appearances - - . . _ 7«, 11, Primary optic atrophy ; o, Tln-ombosis of the central retinal vein ; p, q, i\ .Vlbuminnric retinitis ; .V. Embolism of the central retinal artery ; r, Detachnipnt of the retina : r, Glaucomatous discs ; ir. Tubercles in the choroid ; x. Hypermetropic astigmatism. i*LATE XXI.^Pigmentation of the tongue and nioutli in Addison's disease Plate XXII. Picnicntation of tlic mouth in j)ei'nicrous aniemia LIST OF I'OLOUREI) PLATES PL.vn; XXIII. — Intestinal sand -------- 1. True intestinal sand ; 2. False intestinal sami. PLiVTE XXIV. — Pityriasis rubra ------- Plate XXV. — Diagram showino tlie radicular sensory areas of the human body - Plate XXVI.— .Sore throats -_.,._-- I. Ordinary hypenemio sore throat ; II. Jlild follioular tonsillitis ; III. .Severe follicular tonsillitis ; IV. Left-sided quinsy ; \. Syphilitic sore throat. Plate XXVII. — Sore throats _--.---- VI. Mild diphtheria, simulating follicular tonsillitis ; VII. Diphtheritic sore throat, of medium severity ; VIII. Diphtheritic sore throat, severe, showing spread of membranous exudate to palate ; IX. Phlegmonous diphtheria ; X. Vincent's angina. PL.\rE XXVIII. — Bacteria and blood parasites _ . . - - - A, ilalaria, early ring form ; B, Malaria, ordinary ring form ; C, Malaria, m,ature tertian ; D, Malaria, tertain, ready to sporulate ; E, Malaria, crescentic ; F, Filaria embryo; G, Trypanosoma Gambiense ; H, Leishman-Donovan bodies obtained by splenic puncture; I, Spirochaeta Obermeieri of relapsing fever; J, Spirochaeta palhda of syphilis; K. Tubercle bacilli and pus cells; L, Diphtheria brcilli ; M, Vincent's angina. Spirilla and fusiform bacilli ; N, Meningococci within a leucocyte ; o. Pneumococci and pus cells ; p. Staphylococci and pus cells ; Q, Streptococci and pus cells ; R, Gonococci. in and outside of pus cells ; S, -A.ctinomyces ; T, Tetanus bacilli. Pl-vte XXIX. — Splenomegalic polycytliBcmia ------ Plati-: XXX. — Po])liteal aneurysm ..-.--- Plate XXXI. — Cirsoid aneurysm -------- Plate XXXII. — Cancer of the tongue : very early conditions . - - - P1.ATE XXXIII.- Ochronosis --------- Plate XXXIV. — Urine tests --------- 1,2,3. The three stages of the sodium nitroprusside test for acetone. 4, 5, 6. The same in a urine containing no obvious acetone. (I and 4, noi-mal urine ; 2 and 5, the appearance after adding caustic soda and sodium nitroprusside : 3 and 6, the appearance after adding acetic acid, 3 being positive, 6 negative, for acetone). 7, Kothera's test for acetone, p. Ferric chloride reaction of diacetic acid. 9, Indicanuria test. to, Melanuria- 1 1, Diabetic urine. 12, The fluorescent reaction of urobilin. Pi..\TE XXXV. — Urine tests and Gunsberg's test ----- 1 , Iodine test for bile pigment in urine. 2, Gmelin's reaction for bile pigment in urine. 3, Gunsberg's test for free HCI in gastric juice. Pl.vti: XXXVI. — TuJ)erculin reactions ------- Cutaneous reaction (von Pirquel) ; Dermal reaction {Woodcock). Pi..\iK XXXVII. — Tuberculin reactions ------- Dnroinl reaction (.Vor«) : Oplithalmo-test iCulmellf). ILLUSTRATIONS IN THE TEXT F7G. 1. — Accoucheurs luind 2. — Method of making a blood-film •i. — Miculicz's syndrome 4. — Temperature chart in leukiemia ■>■ — .. ,, relapsing fever <), 7. — .. „ malaria 'i- — .. ,, quotidian ma- laria - '■>■ — .. .. double tertian malaria 10. — ,. ,, complex ma laria - 11. — ,, ,. to illustrate ir- regular pyrexia in chronic ma- laria 12. — Pyrexia in cirrhosis _ _ , 13. — Pseudoleukaemia infantum 14. — Facies previous to myxa-dema 15. — Myxirdema facies - - Ifi. — Hands in iiiyxcrdcnia 17. — Maliyiiant kit supraclavicular glands 18.— Hydatid hookkts - m. — Infantile paralysis - 20. — Tooth's peroneal palsv (bov) 21.— „ ., ' (girl) 22. — Wrist-drop from diphtheria 23. — E.'itragenital chancre 24. — Cancrimi oris - - - - 25. — Ama?ba histolytica and A. coli 26. — Ova of bilharzia ha>matobia - 27. — Ankylostomum duodenale 28-9.— ■ „ ova 30. — Spectrum of oxyhjemoglobin - 31. — „ reduced hiemoglobin 32. — ,, carboxyha;moglobin - 33. — „ alkaline ha^matiii 34. — ,, acid haematin - 35. — ., methicmoglobin - 36. — .. urobilin 37—8. — Heart-block electrocardiogram 39. — Bruits of mitral stenosis - 40. — Flint's murmur - - - - 41. — Skiagram of phthisis 42. — „ sarcoma of lung - 43. — Cheyne-Stokes breathing 44. — Claw-foot ----- 45. — Syringomyelic claw-hand 46. — Clubbed fingers with pulmonary stenosis ----- 47. — Habitual constipation 48. — Dyschezia - . - . - 49. — Time relations of food in large bowel ■)0. — Post-dysenteric atony and paresis of colon ------ 51. — Constipation due to lead poisoning 52. — ,, with mucomembranous colitis - - - 53. — .Skiagram of carcinoma of splenic 4 flexure 54. — .. bismuth enema and carcinoma coli PAGE 3 21 60.— ( 61. 68.—' 69. 79 85 80 86 80 87 80 88 80 89 80 90 80 91 80 92 95 96 103 105 97 107 98 109 99 110 100 111 101 122 102 122 103 123 104 105 123 106- 124 108 109 124 110 in- 125 ns 114 126 115 PAGi: The colon in Hirschs])rung's disease 127 Visceroptosis - - - - - 127 Athetotic hand - - - 132 Volkmann's paralysis - - 141 Dupuytren's contracture - 142 Contracture after a burn - - 142 Skiagram of caseous bronchial gland 149 ,, carcinoma of bone - 152 — Osteitis deformans - - - 155 Deal-porter's bursa - 156 Myopathic lordosis - - - 156 Morbus coeruleus, pulmonary stenosis 157 Caseous gland seen with bronchoscope 158 -Vena cava superior obstructed by aneurysm - - - - -Skiagram of miner's phthisis - •Temperature chart of pneumonia and empyema - . - ■Cystin crystals ■Politzer's acoumeter ■Tuning-fork with foot-piece Galton's whistle -Rickety chest outline Normal adult chest outline Pigeon chest outline Fibroid lung, chest outline Knipliyscniatous chest outline Hoiniiiiynious double images Criissctl doidjie images - Effects of paralyses of ocular muscles Transillumination of the antrum Rickety dwarfism Achondroplasia Osteogenesis imperfecta •Cretinism - - . . Pituitary infantilism •Mongolism - - - - Anangioplastie infantilism Ateliosis - Progeria - - Tooth-plate im])actcd in larynx Bean in oesophagus Bismuth skiagram with epithelioma of a?sopliagus - - - - Stcuoscd cardiac end of tesophagus Ididpaihic ililatation of oesophagus Vena cava superior obstruction by aneinysm - . - - 208 Skiagram of aneurysm - - 209 Temperature chart in pellagra 225 Meningocele of face - - - 230 Cretin with frog-belly - - - 233 Jlyxffidema - - - 234 Face previous to myxoedcma - 234 — Congenital syphilis - - 234 Hutchinsonian notched teeth 234 .Myopathic facies - - - 235 Rirc en travers - - - 235 — Myastlicnic facies 235 F.xojilitliahnic goitre 236 I'aralvsis aaitans - - . 230 Tabetic facies - - - - 236 158 159 160 161 164 164 165 167 167 167 167 167 176 176 177 180 186 187 187 189 189 190 190 190 191 195 195 190 197 198 LIST OF ILLUSTRATIONS FIG. PAGE 116. —Acromegaly ----- 237 117.- —.Achondroplasia - . . - 237 118- 120.- 9. — Mongolian idiot - - - - — Facies of familial lenticular degenera- 237 tion _ . - - - 238 121. — Sarcina: ventriculi 241 122.- —Skiagram of normal stomach - 245 123.- — Favus _ . - - - 246 124.- — Cholcsterin crystals 254 125.- —Local asphyxia in Raynaud's disease 256 257 126. —Raynaud's disease, fingers 127. — Phenyl-glucosazonc crystals - 262 128. —Skiagram of hour-glass stomach 268 129.- — .. normal stomach 269 130. — .. carcinoma of stomach 269 131 . — .. .. ,. pyloric 270 132.- ., diffuse 270 133. - .. renal calculus - 279 134. — .. tuberculous kidney 280 13.3. vesical calculus - 282 136. — .. pneumonia 289 137.- —Hydatid cyst of lung 291 138. —Connections of optic ner\-es and tracts ----- 300 139.- —Bilateral temporal hemianopsia 300 140- 1. — „ homonymous hemianopsia 301 142.- -Temperature chart of hypothermia with mitral stenosis - 311 143.- —Hypothermia in malignant cachexia 312 144.- —Skiagram, bismuth shadow of a dropped and dilated stomach 318 14.5.- -Pyrexia with carcinoma of liver 326 146.- —Skiagram of gall-stones - 327 147. — Leucin crystals - - - - 333 148. -Tyrosin crystals - . - - 333 149. -Temperature chart showing effect of salicylates in acute rheuma- tism 338 150.- .. of gonococcal ar- thritis - 338 151. — ., ..in acute gout 339 152.- — ., .. in rhcumatoi'l arthritis 341 153. — .\cutc rluinnaloid arthritis 342 154.- —.Skiagram of hands in acute rheuma- toid arthritis - . - . 342 155. — HebcrdcM's nodes - - - - 343 156.- — Hhcuinaldid arthritis, transparency of bones in 344 157. —Henoch's purjmni 345 158.- —Gout 345 159. —Skiagram of chniiiic gciul 346 160- 1. — Pads (m fingers - 347 162. — Charcot's joint 349 163. —Skiagram of Charcot's hip 3.-.0 164- 5. — Pulmonary osteo-arthropattiy 3.-,1 166. — Pyelogra])liy 3.1C, 167. -Pvrexia in cirrhosis 371 168. -Ilodgkin's disease 377 169. Still's disease .•f77 170. Macular sypliili.lcs 383 171. - Hirschsprung's disease 3H9 172. Mucous 66 :>(M Ilodgkin's .lisease - sarcoma LIST OF ILLUSTRATIONS IIG. •249 250 2G0 201 262 2()3 266 267 268 . — Rectum oiKuing into virctlira - , — Malformations of rectum in male -2. — ,, ,, ,, female . — Temperature chart in cerebrospinal meningitis — .. .. rat-bite fever — Distribution of sensory nerves in the skin - - — Glove and stockini; ana>sthesia in peripheral neuritis , — Sensory effects of ulnar nerve division . . - . . — Sensory tracts in cord , — Ansesthesia from fracture of sacrum — .. myelitis — .. fracture of cervical spine — Sensory changes in syringomyelia — .. ,, tabes dorsalis - — Dissociative ana-sthesia from throm bosis of posterior inferior cere- bellar artery _ . _ . — Temperature chart in Kirkland"s disease - - — Speech centres — Splenic anemia - . . . — ^Temperature chart of typhus ending by lysis ----- — Temperature chart of typhus ending by crisis ----- — Enlarged liver and spleen in fun- gating endocarditis — Elastic fibres - - - — Temperature chart in lobar pneii- FIG. 273 274 598 278 279 605 280 281 606 282 283 606 284 607 288 608 608 289 608 290 609 291 609 292- 294 615 297 624 298 633 299 300 638 301 302 639 303 304 640 642 305 306. PAOE . — Calcareous concretions in sputum - 644 . — Spondylitis deformans - - - 648 . — Regions of the abdomen - - 659 . — Idiopathic dilatation of stomach - 664 .— „ „ bladder - 665 . — Skiagram of chronic periostitis - 668 . — ,. tuberculous dactylitis - 669 . — .. syphilitic radius - - 669 . — .. exostosis of femur - 670 . — .. cnchondroma of hand 671 . — .. sarcoma of tibia - 671 -7. — .. ., radius 672-;j . — Carcinoma of stomach simulating aneurysm ----- 694 . — Electrocardiogram in ■ paroxysmal tachycardia - - . - 703 . — Cutaneous nerve-supply of the scalp 710 . — Molluscum fibrosum - - - 711 -3. — Segmental areas of the scalp - 712 . — Areas of referred spinal pain and tenderness ----- 716 . — Movements in intention tremor - 728 . — - ., ataxy - - - 728 . — Perforating ulcer of foot - - 736 . — Diagram of a gummatous ulcer - 737 . — .. a tuberculous ulcer - 737 . — ., an ei)itheliomatous ulcer 737 , — ,, a rodent iilcer - - 737 , — Uric acid crystals - - - 741 , — Varicose abdominal veins - 749 — Renal growth extending into vena cava ------ 750 — Small-pox eruption - - - 757 — Ridging of nails after pneumonia - 769 ILLUSTRATIONS, ALPH.^BETICALLY ARRANGED Abdomen, the regions of - - - Abdominal varicose veins Accoucheur's liand - - . - Achondroplasia . - - - - ,. facies of - . - Acoumetcr, Politzer"s - - - - Acroiiicu:il\ . larirs of - - - - .\m(rli;i li\slol\ lira and coli Anaemia, iicrLiicious (tem])erature cliart) - ,, splenic - - - . - .\na?sthesia from fracture of cervical spine ,. injury to sacrum - myelitis syringomyelia thrombosis of post. inf. cerebellar artery Aivangioplastic infantilism Aiicinysm, large saccular (skiagram) obstructing the superior vena cava - - skiagram of - Angioneurotic oedema - - - . .Ankylostomiasis of the duodemun - .\nkylostomum duodenale ,, ova of (2 figs.) Antrum, transillumination of - Aortic aneurysm obstructing the vena cava .\reas of referred spinal pain - .\rsenic, pigmentation of skin from - I'AUK 659 749 3 187 237 164 237 569 633 008 608 608 609 610 190 209 180 208 716 .\scaris lumbricoidcs. ovum of - Ataxy, movements in - Atelciosis ------ Athetotic hand - . . - - .Atiiny and jjaresis of colon, post-dysenteric .Atrophy in hand from cervical rib - muscular - - - . Auricular fibrillation (electrocardiogram) Bean in opsophagus (skiagram) Bilateral facial palsy - - - - homonymous hemianopsia (2 figs. temporal hemianopsia Bilharzia lucmatobia, ova of - Bismuth l)loekcd by epithelioma in nso- phagus (skiagram) ,. in normal colon (skiagram) Bladilcr. idiopathic dilatation of Blood-film, method of making Botliridcephahis lalus. head of Brcincliial caMous f^ianil (skiagram) Brown-Si(|uar(l jiaialysis (2 diagrams) Bruits of mitral stenosis (6 diagrams) Csecimi. tuberculous - - - Calcareous concretions in phthisical sputum Calcium oxalate crystals Calcidus, renal (skiagram) ureteral (skiagram) - vesical (skiagram) t'ancrum oris - - . . . PAGE 520 728 190 132 123 508 59 486 195 493 ) 301 300 79 196 426 665 21 519 149 497 94 458 I 644 423 279 455 282 74 LIST OF ILLUSTRATIONS C'arboxylifeniofiloljiu, spectrum of - Carcinoma of bone (skiagram) coli with bismuth (skiauram) of liver, pyrexia in (chart) splenic Hexurc (skiagram) - 320 125 stomach simulating aneurysm 694 Caries of lumbar vertebra? (skiagram) - 460 Caseous gland seen witli Ijronchoscope - 158 Cerebrospinal meningitis (temperatme chart) ----- 591 Cervical rib in adult (skiagram) 443 „ child (skiaurain) - - 443 ,. spine, anasthcsia In mi injury to 608 C'ervicobrachial plexus (iliagrani) - 507 Chancre of lower lip - - - - 73 Charcofs hip-joint (skiagram) - 350 knee-joint . - - . 349 Chest outlines ------ 167 Cheyue-Stokes' l>reathing (diagram) - 107 Cholcsterin crystals _ _ . _ 254. Cirrhosis, pyrexia in (temperature charts) 35, 371 Claw-foot ------- 109 Claw-hand - - - - - - 110 Clubbed fingers in pulmonary stenosis - 111 Coli bacilluria (tem])erature chart) - 456 Colon, dropped (skiiigram) - - 426 ., in Hirschspiung's disease - - 127 ,, normal (skiagraiu) - - - 426 Complex malaria (temperature chart) - 31 Concretions in phthisical sputum - 644 Confluent small-pox . . - - .-jei Congenital svi>hilis, faeies in (2 figs.) 234 notched teeth (2 figs.) 234 Connections of optic nerves and tracts - 300 Constipation, habitual (diagram) - 122 from lead poisoning (diagram) 124 with miicomembranous colitis 124 Contracture after a burn Dupuytren's Cretin, showing a 'frog-belly" - Cretinism . . . . , Crystals, calcium oxalate cholcsterin cysfin - . . . leufin - . - - plicnylglueosazonc triple ])liosi)hatc ly rosin uric acid Cutaneous nerve supply of the scalp Cyrtometrie tracings of various forms chest - - Cyst (hydatid) of Imig (skiagram) Cystin crystals - - . Dactylitis, tu^crculous (skiagram) Deal-porter's bursa Diphtheria, wristdrop riilluwiiig Diplopia, crossed double iinngcs hotnouyninus doulilc images Discrete smail-poN Dissociative aiinsthesiii Ironi I liiciinbosis posterior iulcrior ccrcbeiliir ;irlery Distribution of sensory uerxis jr] liic si Dropped colon (skiagliun) Dupuytren's contracture Dwarfism, riekelv Dysclie/.ia Dvstrophia adiposogenilalis Keliinricoecal booklets l-;i:islii- tibr<'s from spuluru l';iectiocar from syphilis - 541 Faeies of achondroplasia - 237 acromegaly - . . . 237 congenital syphilis (2 figs.) 234 exophthalmic goitre - - 23*> familial lenticular degeneration 23H locomotor ataxy - - - 23(i a Mongolian idiot (2 figs.) - 23H myxu-iUrna (2 figs.) - 38 myasthenic (2 ligs.) - - 235 myopathic (2 figs.) - - - 235 paralysis agitans - - - 236 Familial lenticular degeneration, faeies of 238 Favus ------_ 246 Fibrosis of left lung, chest outline - 167 Fingers, pads on (2 figs.) - - - 347 Flint's murmur ----- 95 ' Frog-belly ' in a cretin - - - - 223 Gall-stones (skiagram) - - - . 327 Gallon's whi.stlc ----- 105 Glands, malignant, left supraclavicular - 49 ' Glove and stocking ' anaesthesia in peri- pheral neuritis ----- Gonococcal arthritis (temperature chart) Gout, acute (temperature chart) chronic - . . . . „ (skiagram) Gummatous ulcer (diagram) - HuMuatin, acid, spectrum of - in alkaline solution, spectrum of 80 Hirmoglobin, reosacral plexus (diaijram) - 500 iMacular syphilides - - _ - 383 Malaria, double tertian (temperature chart) 30 ,, chronic (temperature chart) - 31 ,, quartan (temperature chart) 29 „ (|UOtitlian (temperature chart) 30 „ tertian (temperature chart) . . 28 Malformations of rectimi (4 figs.) - - 586 Malignant endocardititis (temperature chart) 566 cachexia (tem])erature chart) - 312 ,, left supraclavicular glands - 49 Mediterranean fever (temperature chart) 565 Meige's disease (2 figs.) - - - 411, 414 Meningocele of face - - - . 230 Metha-mrglobin, spectrum of - 80 Miculicz's syndrome - - - 25 Milrov's dis'iMM- (•_> fios.) - - . 411, 414 Miners' i>h(lii-.is (ski:mram) - - - 159 iMitral stenosis, diagram of bruits of - - 94 ,, „ (temperature chart) - - 311 Molluscum fibrosimi, early - - 711 Mongolian idiot, facies of a (2 figs.) - 238 Mongolism (2 figs.) - - - - 190 :\Iorbus ctrriUeus, pulmonary stenosis 157 Movements in ataxy . - - - 728 „ intention tremor - 728 Mucous cast of intestine - - - 398 Muscular atrophy - - - 59 Myasthcni.' laciei (2 ligs.) - 235 Myelitis, ana-stlicsia from - 608 Myoi)atliic lacics (2 figs.) - - 235 lordosis _ _ - - 155 Myxci'dema, facies before and during (2 _^ M^-) - - - - 234 facies in (2 figs.) - - 38 hands in - - - - 38 Nails, ridged after pneumonia - - - 769 Nod\dar leprosy ----- 404 Notched teeth in congenital syphilis (2 figs.) 234 Ocular muscles, double images in paralysis of ------- 177 (Esophagus blocked by a bean (skiagram) 195 idio])atliic dilatation of (skia- gram) - - - - 198 ., stenosis of (skiagram) 197 OiJtic nerves and tracts, connections of - 300 Osteitis deformans (2 figs.) - - - 155 O.steo-arthropatliy. pulmonary (2 ligs.) - 351 Osteogenesis impcrlccta - - - - 187 Oxyhajmoglobin, spectrum of - - 80 Pad.? on fingers (2 figs.) - - - - 347 PAGi; Paralysis agitans, facies of - • - 236 facial (4 figs.) - - 491, 492 infantile - - - - 59 of internal rectus - - 541 of right serratus magnus - 506 Volkmann's - . . - 14] Pellagra (temperature chart) Perforating ulcer of foot Periostitis, chronic (skiagram) 66K Peripheral neuritis, 'glove and stocking' anaesthesia in - 60(i in leprosy - - ,50.") Pernicious ana'uiia (temperature chart) - 56i> Peroneal palsy. Tooth's (2 figs.) - - 60 PlicTivliiliiicsa/.onc crvstals - - - 262 Phthisis, mottling of the hmg in (skiagram) lO.T Pigeon-chest outline - . - . 167 Pigmentation from arsenic - - - 529 in exophthalmic goitre 527 Pituitary infantilism - . . - 189 Pnemnonia (skiagram) - - - - 289 with empyema (temperature chart) - - . . 160 ridging of nails after 769 Politzer's acoumeter - - - 164 Polygra])h tracing of heart-block - - 546 ..of incomplete heart- block - - - 54.-, ., of ventricular extra- systole - - 547 Progeria --.-.. 190 Pseudoleukamia infantum - - 37 Ptosis and healed gumma of lace - - .541 Pulmonary osteoarthropathy (2 figs.) - 351 Pulsus bisferiens - - - - . 550 Purpura in fungating endocarditis - 555 Pyelogra|)hy (skiagram) - - - - 356 Pyopneumothorax (skiagram) - - 531 Hat liiti- fcyer (temperature chart) - 598 Haynauds disease, fingers - - 257 ,, local asphyxia - - 256 Rectum, malformations of (4 figs.) - 586 Reflex centres in spinal cord - - - 518 Regions of the abdomen - - - - 659 Relapsing fever (temperature chart ) - 27 Renal calciUus (skiagram) - - 279 ,, growth into vena cava - - - 750 Rheumatoid arthritis, acute - - - 342 ,, hands in (skia- gram) - 342 (temperature chart) 341 transparency of bones (skiagram) Rickety chest outline - - - - ,, dwarfism - - - - Ridging of nails after pneumonia - Rigors and pyrexia from lateral sinus thrombosis (temperatiu'e chart) RodcTit ulcer, diagram of - - - Sacrum, anasthcsia from injury to - Salicylates in acute rheumatism, effects^of (temperatme chart) - - - - Sarcini ventriculi - - Sarcoma of lung (skiagram) - radius (skiagram (temperature chart) of til)ia (skiagram) Seal]), cutaneous nerve supply of segmental areas of - - - Sensory areas of face, head, and neck (4 diagrams) - - - - disturbances in tabes - 344 167 186 769 507 737 608 - 338 241 - 105 i figs. I 672, 673 - 570 - (>71 - 710 448 6(»il LIST OK ILLUSTRATIONS TACK Seii.'ory olTccts of ulnar luivc divisioii - (■,{)(; localization in spinal cortl - - 518 nerves in the skin, distribution of ()()5 traets in cord - - - _ 007 Septic dermatitis wrongly diaijnosed small- pox - - - - - - - -.f.2 Serratus niaKUUs paralysis - - . .-;()(; Skiagram of aneurysm - - . . (,3.-, Iiean in the u'sopliajius- - lo.'j bismntli blocked by epitheli- oma in (esophajius l!)f> in dropped colon - 420 in normal colon - -1.2(i eareinoma of bone - - ],'52 coli with bisnmth enema - - 12(1 of s])lenie llexiire- I2.j stomaeli - - 200 [)ylorie 270 cardiospasm - - - . 19^ caseous bronchial jrland - 149 cervical rib in adult - 4J.;{ child - - 443 Charcot's hip-joint - - 350 chronic frout - _ 345 periostitis - - 0O8 dropped and dilated stomach 318 enchondroma of hand - - 071 exostosis of femur - - - 070 ^'a 1 1 -stones - - - _ ;j27 hands in acute rheumatoid arthritis - - . . 342 hour-glass stomach - 2(>8 hydatid cyst of lung - - 29] large thynms gland - 41 9 leatlier-liottlc ston)aeli 27() lobar pneumonia lumbar caries lung in ])htliisis ,, sarcoma - - lo.^ miner's phthisis - l-,9 normal stomach 24.";. 20il perl.isteal sarcoma of tibia " 7i'\ pyelography - - . ;;.-,() pyopneumolhoraN ^ . r,:U renal calculus - . . 27!) saccular aneurysm - 2()!» sarcoma of radius (4 figs.) 072, (i7;i tibia - (171 ■ spine ' on os calcis stenosis of the lesophagu syphilitic radius - sliowing transpareiu-v of In Jn rheiUTiatoid arlhiilis Ihymcis gland crdarged tuberculous daelylilis ,. kidney ureteral calculus '• v<'sical c'aleulus Sinall-po\. corilluenl .liser.le eruption >pcelral absorption bands V'O'lrimi or aei.l lia-irialirj HO '■•"■'"'^^yl'''- tilobin 80 'licmalui in alkaline solution 80 niell,a-n,og|,,lMn - , 80 oxyha-moglobin - 80 reduced ha-moglobin - 80 ,'• . "r<-l)ilin - - 80 pceeli centres - - . . _ ,.., , pinal cord, rellex eenlres in - - . ,'Xh 28!t 4 „ malaria, chronic - 31 ,. ., complex - 31 .. double Icr- liau 30 (pi.artau 29 ipjolidiau - .'iO !. !, .. Iciliau - 28 >. ,. malignaid cudoear ilitis - 500 „ ,, .Mcdilerrauc.-m fever 50.5 " >, pellagra - 223 pernicious auaiuia 5(i9 ,, pneumonia willi empyema - - KiO ,. pneumonia, lobar - (i42 pya-mia - 507 rat-bile fever 598 rela|)siiig fever - 27 .. .. I'hcumatism, acute, eireel ofsalieylales 3.38 :. .. rheumatoid arllirilis 341 <-ase of sarcoma - .570 typhoid fever - 505 I \phus fever ending bv crisis (i39 LIST OF ILLUSTRATIONS TerajH-niturc i-liarr in typluis lever cixliiis by lysis - - - Tetany, tlie liaiiil in Thymus ■.land cnlaificd (skia<.n-am) Tiiiie relations iit food in lar^e (diaiirani) - - - - Tooth-plate iinpaetcd in larynx Tootirs |)eroneal palsy (2 figs.) Transillumination of the antrum Triehnccphalus dispar in the colon ., ovum of Triple (ihosphate crystals Tuliere\dons ea-eimi - kidney (skiagram) iilcer (diagram) Tuniny-fork with foot-jjicce Tyjihoid fever (temperature chart) - Typhus fever ending by crisis (temperalui 'chart) I'AGE 038 3 n9 1 23 19.5 458 280 of Typhus fever ending by lysis (tempcrati chart) ----"' Tvrosln crystals - lUcer of foot, perforating T 'leers, typical (diagrams) Ulnar nerve division, sensory elTcet Ureteral calculus (skiagram) - Uric acid crystals - Urobilin, spectrum of Varicose abdominal veins Vena cava obstructed by aortic aneurysm superior, obstructed by aneurysm Ve'iitrieu'lar extrasystole (polygraph tracing) Vesical calculus (skiagram) Visceroiitosis - - - Volkmann's paralysis Xon .Jaksch's disease Whip-worms in the colon Wrist-drop after di])htlieria 638 333 (iOO 45.5 208 1;58 547 282 AN INDEX OF DIFFERENTIAL DIAGNOSIS OF MAIN SYMPTOMS ACCENTUATION OF HEART SOUNDS.— It may be that, without cardiac bruit, me or other of tlie heart sounds is much louder tlian it ouglit to be. Such accentuation eneraily has important clinical significance. It is the first sound that is likely to be accen- uated or prolonged at the impulse ; whilst in the second right, or second and third left ntcrcostal spaces close to the sternum, it is the second sound that is likely to be accentuated athcr than the first. It is very unusual to find the first sound accentuated at the base ir the second sound at the impulse, unless there is at the same time still greater accen- uation of the first sound at the impulse, and of the second sound at the base respectively, lence the three conditions under which accentuation of a cardiac sound becomes clinically mportant are: (1) When the second sound is unduly loud in Ihc second right intercostal pace close to the sternum ; (2) When there is accentuation of the second sound ivith nadimum of inleuaiti/ in the second or third left intercostal space close to the sternum ; :j) When there /.v accentuationof the first sound icith maximum intensiti/ at or near the impulse. Accentuation of the second sound witli maximum intensity in the second right ntercostal space close to the sternum nearly always indicates that the systemic hlood- )ressurc is above the normal. The latter can only be determined with certainty by actual neasuremcnt of Ihe systemic blood-pressure instrumentally. The causes of the increase vill probably be one or other of the following : — -Irtf. — Even liealthy jjcrsons over fifty begin to show sliglit increase of Blood- RKSSuitK (p. 81) : and their aortic second sound begins to get louder than the first. Arteriosclerosis or granular kidney. — These can be discussed together, because it s extremely dillieult to tell where the one ends and the other begins. In both there is ardiae liyperlniphy, increase in the blood-i)ressiire, prolongation of the first soimd at he impulse, possibly a blowing systolic bruit there, a ringing or clanging aortic second ;oun(l, albuinimiria. a tendency to heart failure as time goes on, with all its concomitant lyniptoms, and albuminuric retinitis. It is sometimes stated that the accentuation of he aortic second sound is due to local atheroma ; but this is inaccurate, for atheroma )y itself, though it may easily produce an aortic systolic bruit, does not accentuate the iccond soun(^: and when in the second right intercostal space there is a soft systolic bruit •eplacing the lirst sound, and a clanging second somul, the former indictites atheroma of he aortic valves, and the latter arteriosclerosis. These two absolutely sis. In a typical case, the attitude of the fingers is almost pathognomonic. There is full extension of all tlie fingers and of the thumb at the interphalangeal joints, the four fino-ers are adducted firmly towards the middle finger, so as to form a cone, they are semi- flexed at the metacarpo-phalangeal joints, and the thumb is strongly adducted and opposed to the cone of which the middle finger forms the apex, or else into the palm of the hand. The spasmodic muscular contraction seldom ceases here, but generally affects the rest of the arm also, the wrist being flexed and abducted towards the ulnar side. The elbov/^ is flexed to a right angle, and the arm rotated inward and adducted so as to lie in contact with the trunk. The affection is symmetrical. The feet and ankles are apt to show similar spasmodic contractions, the ankle being fidly nlantar-flexed, the toes and the distal iialt of the feet rotated inward, the knees extended rigidly, and generally the thighs also. ACETONURIA 3 Tlie contractions may be limited to tlie liands and feet — the so-called carpo-pedal spasm — especially in the tetany of young children suffering from rickets or from gastro-intestinal disorder such as diarrhoea. AVhen adults are affected, the symptoms spread from the limbs to the trunk, the whole body being kept rigidly extended, the paroxysms lasting from a few minutes to many hours, and recurring for^ays. weeks, or even months. So far as the tetany itself is concerned recovery is invariable, though the patient may sometimes succumb to tlie associated malady, tetany itself being generally not a primary disease but a com- plication of gastric ulcer, gastrectasis, colitis, intestinal fermentation or putrefaction, thyroidec- tomy, or jircgnancy. The diagnosis is seldom dillicult. - One remarkable feature of the case is that in the intervals between the spasms, if the upper ami is grasped firmly between the observer's two hands, and the pressure maintained, the hand and wrist may be forthwith sent into the typical spasm, a sign described as Trousseau's. If the cheek close to the front of the ear is percussed gently but sharply from above downwards, the different groups of muscles supplied by the branches of the pes anserinus of the seventh nerve can be made to twitch successively — Chvostek"s sign. The muscles of the limbs often show altered electrical reactions in that, though still responding to faradism, with galvanism .\.C.C. is greater than K.C.C. — Erb's sign. Herbert Freiieli. ACETONURIA denotes the occurrence of acetone in the urine in amounts to be (lilcitcd by (iiiliiuiry clinical tests. In ])ractice the lalxiratory method of distilling a (|uantity of urine to get a concentrated solution of any acetone that may be present takes too long, and yet without distillation it is dillicult to apply the iodoform test for acetone. An easier and more useful plan is Legal's nitroprussidc test, or Rothera's modification of it. Legal's test consists in taking 5 c.c. of urine in a test-tube, adding a few drops of liquor sodic, then a few drops of fresh sodium nitroprussidc solution, and finally acidifying with strong acetic acid. The li(|Uor soda- causes no change of colour, or at most an opalescence from the prccii)itation of j)hosphates ; the sodium nitroprussidc produces a reddish-brown colour in almost all urines owing to the presence of creatinine : if the red colour is due to creatinine only it is discharged on adding acetic acid, whereas when acetone is present the red deepens into a rich burgundy that is unmistakable. Kothera's modification of this test consists in adding a few dro|)s of fresh nilroprusside solution to .5 c.c. r)f urine, li(|U()r anun(>ni;c till the tnixlure is decidedly alkaline, and llieii ainnioniuin sulphate cryslals in excess : as the solution bcc(jiiies saturated willi llie latter, a colour like that ol' polassiuni permanganate develops if acetone is present, the maximum being reached in about fifteen minutes. .\cetone is often ass{)ciatcd with diaeetic acid, oxybutyric acid, and ainido-oxybulyric acid ; the rietcction of these, 'however, affords no clinical inl'orinalion that is not alTorded by the acetone alone, so that it generally sullices to tesi for the latter, and jxissibly for diaeetic acid also. The tests for the butyric acids are clilliculf. When these subslances are being proilueed, the patient is said to be suffering from miilosis. the result of unnatural metabolism, .\cetonuria is indeed the chief i>ractical evitlenee of acidosis. It occurs in the most extreme degree in certain cases of diabetes mellilus ; from the point of view of prognosis all cases of glycosuria may be di\idcd broadly into two classes, namely, those with, and those without, acetomnia. 'I'lie same patient may. of course, l)e jiassing acetone in his urine at one time and not at another : the |)rognosis is always graver, howevir. when acetone is present, for it is tlic acidosis that causes the serious results of diahctis and glycosuria. .\ |)atient witimut acelonuria is in no immediate danger of enma. wliiiias. when acetone is present as well as sugar, coma may siiperx iiie at aii\ linic. Uroadly speaking, once glycosuria has been diagnosed, it is more iiiip(jrlarit to list the urine for acetone from time to time than it is for sugar, and thai t ic:it iiiriil wliieli ir(hiees the acetone to a miniinum is, ijciierally speaking, lining most g I, wliati\ir (|uaiililies of sugar may be passed. 4 ACETOXURIA Acetontiria may occur, however, without glycosuria ; even a healtliy person who is starved oi^ carbohydrate food is apt to pass acetone and diacetic acid in the urine. Tliis explains why it is that acetonuria occurs in such conditions as gastric ulcer : gastric carci- noma ; gastrectasis : oesophageal stenosis : intestinal obstruction : cachexia, whether tuberculous, malignant, syphilitic or malarial : in cases of persistent vomiting of pregnancy : ura>mia ; severe migraine ; infantile diarrhoea and vomiting : cyclical vomiting of children (p. 765) ; and probably in many other conditions in which there is either actual or virtual starvation. The same applies to surgical operations under ansestheties — the patient is often starved beforehand, and may then be persistently sick afterwards : almost all patients who have been under a general anicsthetic for any length of time have acetonuria. and in some the acidosis increases instead of being transient, this being to a large extent, perhaps, the pathology of so-called delayed chloroform poisoning. It may also result from gross intracranial lesions, especially those of an inflammatory nature ; thus, acetonuria may be pronounced even as early as the first two or three days in acute epidemic cerebro- spinal meningitis. The chief importance of acetonuria therefore from a diagnostic point of view lies, not so much in distinguishing one disease from another, as in detecting the existence of acidosis. The importance of this from the point of view of prophylaxis and treatment will be obvious when it is remembered that acidosis does not occur until the liver and tissues have lost their glycogen, and that glycogen storage depends largely upon the ingestion of carbohydrates either by the mouth, the rectum, or hj^DOdermically. Herbert Freiieli. ACIDOSIS.— (See Acetonuria, p. 3.) ACROPARiCSTHESIA.— (See Pain in the Extrejiitv, Upper, p. 442.) ALBUMINURIA. — This term is used to denote the passage in the urine of proteid that is coagulablc on boiling. More than one substance is included in this sense, and there are varying proportions of albumin and globulin in different cases. So variable may be the relative amounts of these, not only in different diseases, but also in different cases of the same disease, and in the same patient at different times, that little useful clinical infor- mation is to be obtained by dealing with them separately, at any rate so far as present knowledge goes. Nucleo-albumin (p. 424) comes in quite a different category. Although numbers of tests for albumin have been devised and advocated, for clinical purposes there is little need to trouble about more than the two common ones, namely the acetic acid and boiling, and the cold nitric acid tests. It is true that each of these has fallacies ; but the latter are not common to both, and therefore if there is doubt in the interpretation of one of the two tests, it can be confirmed or otherwise by the other. More delicate tests exist, but there is such a thing as too great delicacy in a clinical method. One does not want to find albumin in minute traces where it does not matter ; and it seldom matters until its amount is sufficient to give both the common tests. The Acetic Acid and Boiling Test. — A test-tube three parts full of urine — cleared by filtration if need be — is held by its lower end whilst its upper part is heated carefully to boiling point. It is best not to add any acetic acid before boiling unless the specimen is distinctly alkaline, in which case it may be just acidulated with a drop of acetic acid. After boiling, the tube should be held in a good surface-light against a dark background, such as the sleeve of one's coat : any opalescence will be obvious, and there may be a dense white cloud. Except in rare cases of Bence-Jones albumosuria (p. 16), this will be due to one or more of three things, namely, calcium and magnesium phosphate, calcium car- bonate, or coagulated albumin. One. two. or more drops of acetic acid solution (B.P.) arc now added : if the cloud disappears entirely, quickly, and at once, it was due to earthy phosphates, and no albumin is present : if it disappears entireh- but with brisk efferves- cence, the latter is due to calcium carbonates amongst the phosphates, and no albumin is present ; if, on the other hand, the cloud clears up but partially, or remains imaltered, or actually increases and becomes more flocculent, albumin is almost certainly present. There is only one serious fallacy remaining, and that is in regard to nucleo-proteid : this is preci- pitated by acetic acid, and it is possible for a cloud of phosphates to be cleared up by the latter and yet for a faint cloud of nucleo-proteid to come down in the place of the phosphates in such a way as to suggest that the original cloud was not wholly soluble in the acid, and ALBUMINURIA 5 therefore that albumin is present when it is not. There are three ways of obviating this soiirce of fallacy : the first is to add a single drop of dilute non-fuming nitric acid to the suspicious cloud that remains after adding the acetic acid ; if it is due to albumin it will persist or even increase, whilst if it is due to nucleo-proteid the nitric acid will disperse it ; the second is to perform the cold nitric acid test for albumin as described below — nucleo-proteid will not give a definite localized white ring with it ; and thirdly, a control test may be done, acetic acid being added to another specimen of the urine without boiling, and the cloud due to any nucleo-proteid present compared with the cloud in the acidulated and boiled specimen. Heller's Cold Nitric Acid Test. — About an inch and a half of urine is poured into a test-tube, the latter is held much inclined, and colourless nitric acid is allowed to flow gently down the side until about one-third as much as the urine has been added. The nitric acid is heavier than urine and goes to the bottom : if albumin is present a white ring lorms at the jimction of the two fluids. Some prefer to pour the nitric acid into the test-tube first, and then add the urine with a pipette. It is important not to shake the tube, or the nitric acid and urine will mix and there will be no definite junction line between them. Fuming nitric acid must be avoided because the nitrous oxide fumes decompose the urea and the resultant bubbles mix the fluids ; sometimes there is bubbling even when the nitric acid is colourless, in which case this is due tc CO.. set free from carbonates. The test is very delicate ; if any large quantity of albumin is present, the ring appears at once ; it there is only a trace, the white ring may not appear for a little, and the tube should be set aside and looked at again in a few minutes. Broadly speaking it takes three minutes for it to develop when the amount of albumin is 1 part in 30,000. This test is open to more fallacies, however, than the acetic acid and boiling test, so that it should not be trusted to alone unless it is negative. In concentrated urines it is common to get a dark- brown, reddish-brown, or violet brown ring of colour at the junction ; this is nothing to do witli albumin : it is generally most marked in eases of Indicanuria (p. 314). White rings, more or less like that due to albumin, may also be due to any of the following : — 1. Resin. — If the patient is taking copaiba or other similar drug, enough of the resin may be excreted in the urine to form a diffuse white cloud above the nitric acid. This fallacy is best avoided by bearing it in mind and checking the nitric acid test by the heat test ; this latter safeguard applies to all cases of suspected albuminuria. 2. Albumoses. — These generally occur in association with albumin ; should they occur alone the ring will disappear with warming, to reappear with cooling, and there will be no cloud with the heat test. 3. Tinici-.JoiHs'.i Albnntnse. — This occurs without albumin, gives a white ring with nitric acid that disappears on warming, to reapjiear on cooling ; with the heat test, a dense cloud appears about GO^ C, to disappear on further heating to boiling-point (p. l(i). t. Xiirlro-iilhiimiii. — The ring with this is not in contact with the nitric acid, but higluT up, and diffuse ; it may be a real difficulty in diagnosis from albumin, for it is also precipitated by acetic acid, and may therefore give a haze with the boiling test (see above). 5. I'raJcs. — These may form a cloud near the nitric acid if the urine is very concen- trated ; the cloud will disappear on gentle warming, to reappear on cooling, so that it mav also be mistaken for albumose ; the fallacy may be avoided by diluting the urine- with plain water before the nitric acid test is employed. 0. Urea Xilrale. — If the urine contains a large percentage of urea a crystalline deposit of urea nitrate may form at the junction ; as a rule the crystalline nature of the ring is obvious on inspcelioii ; but in case of doubt the urine should be dilulcd and Ihc (est repeated. It docs not niatler whicn lest is most relied upon when Ihc result is lugalivc ; bul before the positive deduction that a urine contains albumin is drawn, both the acetic acid and boiling, and ttie cold nitric acid tests, should be positive. In aiiiving al a diagnosis of the precise cause of .'dliuiniiiiiiia in an\- gi\(ii ease, it is rssciiliiil Ihul a mirroscnpiral ci'diiiiiHitioii of the iiiitrijiiildliud ilcjiiisit (i(i)n Ihc mine slioiilil hr made. Whatever else niay be ff)und, the first (piestioii to be answered is : Are renal tul)e-easts present as well as albiunin. or not r All cases of albumiimria may be divided into two iimin ^'voups, namely : (I) Crisis nilli loinl liihi-iasis : (II) Cases liilhijut rnuil liihe-(iis'\. 6 ALBUMINURIA Renal Tube-casts. — AVhen one speaks of renal tube-casts, however, one has to bear in mind tliat modern methods of centiifugahzing with electrically-driven machinery have reached such perfection that hardly anything that a specimen of urine contains escapes detection ; technique has become almost too perfect ; for when clinical methods become too delicate they begin to lose some of their clinical value. The result, in connection with casts, is that even in a great many normal urines an occasional renal tube-cast and an occasional red blood corpuscle are found ; therefore when one speaks of cases of "' albumin- uria witn tube-casts." one means "" witli enough renal tube-casts to be pathological." The observer learns from experience to know when the ' occasional ' tube-cast is inside or outside the normal limits. More than one examination may be rccjuired, and the urine should be as fresh as possible, for casts disintegrate on standing, especially in hot weather and in alkaline urines. Renal tube-casts are of various sorts (Plate I), and a certain amount of help can be derived from a knowledge of the particular kinds of casts present in a given case. Their matrix or foundation is a structureless material whose origin is obscure, thougli thought to be due to some kind of proteid coagulation. Sometimes the casts consist of this structureless matrix only, and according as they are then less or more highly retractile, they are spoken of as hyaline casts or ivaxy casts respectively. The hyaline is commoner than the waxy, but neither is characteristic of any particular disease. Embedded in the hyaline matrix there may be various substances or structures ; and according to the main features of the embedded substances the casts receive different descriptive names. If renal epithelial cells predominate, the cast is an epithelial cast : if leueocj-tes or pus corpuscles, a leucoci/tic cast ; if red blood corpuscles, a blood cast : if bacteria, bacterial casts ; if fat globules, probably derived from degenerated renal cells or leucocytes, fatit/ casts ; if non- fatty granular debris, granular casts. It is not at all imcommon to find a long cast which in one part is simply hyaline, at one end is granular, and at the other epithelial — a mixed cast. Upon the whole one may say that the hyaline cast occurs in all forms of nephritic conditions, whether acute or chronic ; that epithelial and leucoc\-tic easts indicate active catarrh ; that granular easts tend to occur along with epithelial casts, but that when they occur alone or in association with hyaline casts they are evidence of at least less acute mischief than are epithelial casts ; whilst fatty casts come between the two. Blood casts may occur in almost any variety of renal ha?morrhage. and by themselves they are not evidence of inflammation, though in association with other easts they indicate very acute inflammatory changes. I. -ALBUMINURIA WITH RENAL TUBE-CASTS. When it nas been decided that there are a jiathologieal lumiber of renal tube casts as well as albumin in the urine, it is almost certain that there is an inflammatory lesion of the kidney. The next step in the diagnosis is to decide by microscopical examination whether pus is present also ; in other words, the cases may be subdivided into two main sub-groups, namely : (A) Albuminuria -cvith renal tube-casts tcithout obiious ])us : and (li) Albuminuria with renal tube casts and obvious pus. There are border-line cases in which leucocytes are present in excess, and yet not in sufficient numbers to constitute pus ; other points about such a case will generally lead one to decide whether it come- in the apyurie or in the ])yuric group. The differential diagnosis of the latter is discussed under Pviria (p. 'i'i). so that it only remains lure tt) discuss : — (.1) The Differential Diagnosis of Albuminuria lvHIi Tube-easts without Obvious Pus. — The causes of tliis condition may be classilied as folk)ws : — 1. The Various Forms of Bright's Disease: — (a) .\ primary acute nephritis. (b) \n acute exacerbation upon an underlying chronic ne|)hritis. (c) Chronic nephritis of young ]K(iple : (i) Arising out of a known attack of acute nephritis : (ii) Arising without any known prexious attack of acute nephritis. ((/) Chronic nephritis of old ])CO])le : (i) cirrhosis of tlie kidneys ; (ii) Arterio- sclerosis. ((') Cystic disease of llie kidneys. •2. Nephritis of Pregnancy. PLATE I RENAL TUBE CASTS 4. /•- A. Il.vniiiiorasis; B, Wnxy casts: c Myaliiic MLst coritiiiuintr siniill crystals of raloiiim oxiihitc; D, Hloucl cints; E, A Icuc'or-ytc init ; F, Hpitlidiiil wists; G, . ALBUMINURIA 7 3. Chronic Ascending Nephritis, leadino; to scarred contracted kidneys, the result of {(!} ()l)structii)n to urine outflow by : — (i) Urethral stenosis, (ii) Enlarged prostate, (iii) Displacement of the womb. ■ (iv) Fibromyonia. ovarian cyst, or other |)elvic tiunour. (v) Pregnancies. (vi) Undue mobility of the kidney and kinkinw of the ureter, (vii) Rarities, such as abdominal aneurysm obstructing a ureter. (h) Irritation ascending from the pelvis of the kidney, the result especially of calculus, but also sometimes of chronic tuberculous lesions, 4, Lardaceous Disease of the Kidneys. '>. Infarction of the Kidneys, esi)ecially when the result of embolism in cases of fungatiiig endocarditis : Imt also due to thrombosis, as in some blood diseases, (i. Thrombosis i>f tlie inferior vena cava involving the renal veins. T. New Growth of the Kidney, some cases. In many cases the diagnosis soon becomes obvious, but in some there may be great dilliculty. The two following may serve to illustrate how such difficulties may arise : A patient of middle age, who had not been strong for a long time, began to suffer from tt'dema of the ankles, which increased rapidly and spread to her legs, thighs, genital organs, and back. Within a few days her abdomen began to swell, and she began to pass very little water, the colour of blood. Upon examination the urine had a sp. gr. of 1030. wa.s loaded with albumin and blood, and microscopically there was an abundance of red corpuscles, renal epithelial cells, leucocytes, and epithelial, fatty, granular, and blood casts, without ])us, crystals, or bacteria. It seemed almost obvious that she must be suffering frf)m acute Bright's disease : but there was no oedema of the eyelids, and there was delinite enlargement of the left supraclavicular lymphatic gland ; the discovery of the latter led to a very careful examination for malignant disease ; and a latent and <|uitc unsuspected carc'inoma of the rectum was foimd. 'I'lu- diagnosis was carcinoma recti, secondary dcjiosits in the retroperitoneal glands, obstruction and thrombosis of the inferior vena cava and of the renal veins, with consequent albumiimria, hematuria, and renal tube-casts from as])liyxial nephritis, sinnilating acute Bright's disease. Another case was that of a girl of !(!, suffering from increasing ana-mia, shortness of breath, (edema of her ankles and lac c, and slight pyrexia. The heart was a little enlarged, and there were soft systolic bruits that were regarded as secondary to the anaemia. The urine contained blood and albumin, willi renal e|)itlielial cells and tube-casts in abundance. Ascites developed, with increasing general (edema : there were also retinal ha'morrhages and neuro-retinitis. 'I'he diagnosis of acute nephritis, however, was only in small degree correct : for she was really suffering from maliiinani endocarditis of a subacute type, the nephritis being due to iidccted crTilioli of llie Uidney pnidueing intlammatory changes around nuiUipic renal itilarcts. 'I'hese cases will serve to show how it nia\ be impossible to arrive at a correct diagnosis excci)t by thorough examination of all the systems, by watching the case carefullw and by repeating the fidl systemic examination at intervals. We will now deal witli I lie headings in the abo\c table in their reversed order. If there is New Growth in a kidney the munber of renal lube-easts is likely to be small ; sooner or later a microscopic fragment of new growth may be detected in the ccntri- fugali/cd urinary deposit. .Mbuminuria will not be extreme unless the renal veins and the inferior vena cava become invohcd (/•'/;,'. ;iO f. p. 7.50). the same ap|)lying also to the nedema of the legs and trunk : h:iiiial uiia is liUclx to occur at iidervals, the attacks being separated by many weeks soniclinies. and liiing r(laliv<'l\ painless : there may be an in- creasing renal tumour: cystoscopic cxaminal ion may show blood-slaincd mine (see Philc .Vr. Fifi. .1, p. -jHti) coming from one ureter only ; and finally, when suspicion of new growth has been aroused, laparotomy may be indicated and the diagnosis conlirmed thereby. Thrombosis of the Renal Veins and Inferior Vena Cava has been rchrred to above as a conditioTi that may simulate acute nephritis. I'oinis lo lay stress on in nrri\ ing at the diagnosis are : (I) To make a Ncrv careful and svstcmatic examination, including 8 ALBUMINURIA that of rectum and vaiiina, in order not to miss anything, sueli as some latent growtli. wliose secondary deposits are obstructing the veins ; (2) To enquire carefully into the history — many cases of inferior vena caval thrombosis are due to extension vipwards i'rom iliac or saphenous clots, in which case there will nearly always have been swelling of one leg only to start with, followed later by extension to the back and to the other leg : (3) To note that although the oedema of the legs and back may be extreme, there is a delinite upper level to it and no swelling of the eyelids or scalp : and (4) To note that if there are any distended or varicose veins upon the abdominal wall (see Veins, Varicose Abdominal, Fig. 303, p. 749), the current in them has become reversed — to being from below upwards instead of from above downwards. Infarction of the Kidneys may be either embolic or thrombotic. The commonest cause of embolic renal infarction is fungating endocarditis. Each embolus gives rise to the sudden appearance of blood in the urine which may have contained none previously, or to increase in any existent hasmaturia ; there may or may not have been a sudden pain in the back at the same time. Around each infarct acute nephritis develops, so that in some cases all the characters of the latter malady may be superposed upon those of the fungating endocarditis. If the patient is already known to have heart disease the diagnosis is easy enough ; the difliculties arise in cases in which, notwithstanding the endocarditis there is no bruit. If fimgating endocarditis is suspected, the points that confirm the diagnosis arc those mentioned on p. 34. Thrombotic infarcts are less severe in their effects ; they may produce no haematuria at all, and the albuminuria may be slight, and unaccompanied by tube-casts. They generally arise in cachetic conditions, or in blood diseases such as leukaemia or pernicious anaemia, in whieli cases the diagnosis will be arrived at on other grounds, albuminuria not being the ]>nMiiineut feature of the ease. Lardaceous Disease of the Kidneys used to be common in the days of septic surgery, but it is uncommon now. It is a risky diagnosis to make, therefore, unless there is some obvious cause for it, such as long-standing suppuration in association with a .spinal, hip-joint, or empyema sinus, bronchiectasis, phthisis with cavitation, or the like ; or clear evidence of tertiary syphilis with cachexia. There is nothing characteristic about the urine. In the earlier stages there may be but a trace of albumin in an otherwise normal urine ; later, the albumin increases and it may reach very large amounts, such as 20 parts per 1000, casts being very few in proportion, the total amount of urine increased, its colour pale, and its sp. gr. low — 1005 to 1012 : later still, possibly as the result of superposed nephritis, the amount of urine falls until only a few ounces may be passed each day, of high colour and sp. gr. 1020 to 1035, loaded with albumin, and now containing hvaline, waxy, granular, fatty, and epithelial casts. Lardaceous easts may or may not occur, but they are not diagnostic, for they have also been found in cases of nephritis without lardaceous disease. Indeed, the diagnosis of lardaceous kidney resolves itself into one of guesswork in a case in which there has been prolonged suppuration or severe syphilis to give rise to it, and in which there may be smooth firm enlargement of the liver, moderate enlargement of tne spleen, and more or less severe diarrhoea, to indicate corresponding lardaceous change in the other organs that are generally affected at the same time as the kidnevs. Chronic Ascending Nephritis arises from precisely the same causes as acute ascending nephritis or surgical kidney, and probably results from recurrent focal inflammations which heal, with the result that, in the course of months or years, the kidneys are con- \erted into a mass of irregular fibrotic scars which together produce the same local and general changes and effects as are found in cases of ordinary red granular contracted kidney. It is important to bear in mind that any cause of prolonged obstruction to the urine outflow may cause granular kidney with albuminuria, without pus but with easts, in a pale abundant urine of low specific gravity. The diagnosis will generally be ob\ious when the obstruction is due to urethral stricture ; it is more apt to be overlooked in other cases, though if one bears in mind the causes mentioned in the list above, the methods of diagnosis will generally be clear. One would only mention in particular that uterine timiours or displacements are a very common cause for slight albimiinuria and a few renal tube-casts in women ; and that in men of sixty and over enlargement of the prostate causes a precisely similar condition long before Ihere is any delinite pyuria. Pregnancy Nephritis is sometimes spoken of as though it were an altogether different ALBUMINURIA 9 thing to nepluitis of the Brighfs disease type in general. I do not subscribe to this view, I hold that Bright's disease has many different causes and many different types. It may be due to scarlet fever, in which case it is very possibly streptococcal ; it may be due to pneumonia or empyema, in which cases it may be pneumococcal ; it may be due to various other micro-organisms ; it occurs in some cases of cholera, and in severe secondary syphilis ; it is frequent in malaria, especially the quartan type ; it may be due to chemical substances such as turpentine, cantharides, or oxalic acid ; it very often seems to come on from no known cause at all, though in such cases there must be a microbial or other cause that is not discovered : it may be due to pregnancy, in which case it is ascribed to unknown toxins. In all these cases the t>-pes of reaction on the part of the kidney are similar, and one can only regard pregnancy nephritis as a variety of non-suppurative ne])liritis in general. Very likely it is only a matter of degree whether it is non-suppurative or merges into the type in which there is pyuria as well as albuminuria — pyelitis of preg- nancy. Pregnancy may cause a primary acute nephritis, which may recover either com- pletely, or but partially and persist as chronic nephritis : or may seem to recover when in reality it is merely latent, or even slowly and insidiously progressive ; it may produce what seems to be a primary acute nephritis which is really but an exacerbation superposed upon a chronic nephritis that has been unsuspected ; and very possibly it may produce nejihritic changes which are not associated with definite symptoms at the time, but which ultimately result in what is spoken of as chronic interstitial nephritis. When, therefore, alliuminuria with renal tube-casts, but without pyuria, occurs during pregnancy, it matters little what name is given to the condition, provided it is realized that just the same difli- culties offer themselves here as in Bright's disease in general, in arriving at a conclusion as to wlietlier the renal lesion is acute, chronic, or acute on chronic. Various Forms of Bright's Disease. — Of all these, the hardest to diagnose with certainty is pih/iiiri/ acute iiephrilis in the adult. The majority of adult cases that are labelled acute J3right"s disease are really suffering, not from primary acute nephritis, but from an acute exacerbation upon the top of already existent but possibly latent chronic nephritis. The dilliculty is to arrive at the diagnosis between these two, particularly since many of the jxiints mentioned in text -books as occurring in acute nephritis are really due, not to thi' acute attack, but to the subacute or chronic i-enal lesion which has, until then, been unsuspected. The best exam|)l(s of |)rimary acute tiejiliritis are to be seen in eases that are already under observation for some other disease, notably scarlet fever or lobar pneumonia. Some- times the onset of the nephritis is indicated by general (cdema, especially of the eyelids and lace, ankles, genital organs, and loins ; but it cannot be insisted upon too sti'ongly thai irdema is not esseiilial. many cases of acute nephritis having no o-dema at all, especi- ally if the patient is already in bed when the kidney inllammation begins, as in scarlatina cases. If the urine were not examined the renal lesion would often escape recognition altogether : and there can be no df)ubl that many cases of primary acute nciihritis do escape rccognilion in this way, coming under observation later when they present symptoms of chronic Tvpliritis, or an acute exacerbation on chronic nephritis. The essential point in the diagnosis is urine examination. According to the severity of the nephritis there will be more or less diminution in the total daily (piantity : it is eoinnion for less than 20 oz. to be passed in the t W(iit\ -lour hours, and often the amount falls to 10 oz.. .> oz.. or even to none at all for a wliiU'. The spccilic gravity is raised to lO'J.j. KKiO, or even to lO:!"., but ranl\ to 10 10. The naction is generally acid at first, but it soon beconics alkaline on standing. The colour is extremely variable, according as little or much bloo |iiiniary renal or arterial, primary cardiac, or (o primary |)ulni()iiarv disease, and the only sure methods of deciding that there is a renal lesion are: tlie (liseover\- of more than an occasional granular anmia the result of syphililic. malarial, nialignanl, tuberculous, or hthisical cachexia, ankylostomiasis, or infection with otlici- parasites such as Itollirio- ephiilus latus or Trichina spiralis. There remain three other groujis of conditions in which albumimiria and its dilTercntial liagnosis are often important, and these are: (1) Febrile eonditions : (■>) Heart-failure onditions : and (:!) so-called ■ I'hi/siologicar albuminuria of adolescence. Febrile Conditions. — In nearly every fever there is some cloudy swelling of the larcnchyma Tif various viscera, especially the kidneys ; consetpiently most fevers may ometimcs be associated with albuminuria, and, broadly s[)eaking, the higher the patient's empcrature the greater is the liability to it. The amount of albumin present is generally lot great. We need not enumerate all the various fevers in this coimcxion. SulJice it o say that iilbumiiuiria is r(lati\ely conunon in scarlatina, diphtheria, variola, erysipelas, )yrexial i)hthisis. cholera, dysentery, Weil's disea.se. severe malaria, and yellow fever : lot so common in lobar pneumonia. bidncho[)neunionia. tvphoid fever, and empyema : ind relatively uncommon in other febrile conditions, such as acute rheumatism, inllucnza, neningitis, measles, German measles, follicular tonsillitis, and .so on. The albiMiiinuria nay, of course, be already present in a person who develops an inUrciirrciil \'r\ii- : Ihe liagnosis then depends upon considerations menlioncd above. If, on the other hand, the albuinimu-ia is known to have developed coincidently with he febrile illness, the chief point to decide will be whether it indicates actual nephritis )r not. .Many consider there is an essential difference between ■ febrile albumimiria " ind actual nephritis. This may or may not be so, but it is extremely dillieull to be sure if the distinction clinically. It may be urged that to take scarlet lexer as an example - he albuminuria of the lirst few days is ■ febrile.' whilst that of Ihe second or third week s ' nephritic' .Vs a niiitter of fact, in not a few cases in which death has occurred in the 14 ALBUMINURIA 1 liist week the ' febrile " albuminuria has been associated with larr mottled acute nephritic kidneys, even where there has been no oedema, no hiematuria, .id no very large numbers of renal tube-casts. Probably there are all degrees of acute nephritis, from very slight and transient, to very severe and possibly fatal ; and it is a mistake to try and make a distinction in kind. The great majority of cases of albimiinuria during fever recover completely ; some seem to recover but come under observation years later with pale granular contracted kidneys ; others die during the acute attack. The degree of albumin- uria is not a direct measure of the renal changes unless the amount of albumin is large ; a small amount of albumin does not necessarily indicate trivial nephritis. Absence of oedema is the rule. Microscopical examination of the centrifugalized urinary deposit is essential : the more the renal epithelial cells, red corpuscles. leucoc>-tes. and various renal tube-casts, the more conclusively can some degree of actual nephritis be diagnosed. When doubt lies between scarlatina and measles or German measles, or between diphtheria and other forms of sore throat, the existence of albuminuria sometimes assists in arriving at the diagnosis of scarlatina in the one case or of diphtheria in the other. In pneumonia, albuminuria has become much less frequent since blistering wutli cantharides has gone out of fashion in treating this disease. Heart-failure Conditions. — The right side of the heart may fail owing to many different causes, wliieh may be arranged under four main headings, as follows : (ri) Valvular disease : {b) Obstructive lung affections ; (c) Myocardial affections ; (rf) Granular kidneys and other liigh blood-pressure conditions. Each of these main headings has many sub- headings (see Orthopncea, p. 418). Any one of them may result in albuminuria, though the amount of the latter is extremely variable, some cases of severe heart failure exhibiting no albiuninuria at all, whilst others may have as much as 10 parts per 1000, or more. The first step in the differential diagnosis is to exclude primary renal conditions by negative microscopical examination of the centrifugalized urine deposit for casts, examin- ation of the retime, and exact determination of the blood-pressure. Curiously, even with feeble irregular pulses, such as are found in jjanting cases of mitral stenosis, the blood- ])ressure is considerably higher than normal, doubtless owing to partial asphj-xia ; so that merely finding a systolic blood-pressure of 150 or 160 mm. Hg is no proof of granular kidney or arteriosclerosis ; sometimes, however, the reading is as high as 200, 250, 300, or even :J20 mm. Hg, and then the diagnosis of one or other of the latter is almost certain. If renal and arteriosclerotic conditions can be excluded, the diagnosis lies between the other three main groups. The cardiac bruits, the history of growing pains, chorea, or acute rheiunatism, the youth of the jiatient, the family history of heart disease or rheumatic fever, the association of other rheumatic affections such as recurrent tonsillitis subcutaneous nodules, or erythema, will often serve to point to primary vahular disease ; in older patients, esiiecially in men between forty and fifty, there may be aortic disease and a history of syphilis and not of acute rheumatism. In severe heart failure in children imder puberty, the result of mechanical dillieulty with the circulation, an adherent peri- cardium is generally found, and clinically, t!ie heart is large out of jjroportion to the general physical signs. When there is a definite history of recurrent winter cough in an elderly person, with a hyper- resonant and over-expanded chest, the likelihood of emphysema and hronchilis will at once suggest itself. Similarly fibroid lung, or fibroid hmg and bronchiectas^is, as a cause of heart failure and albuminuria, only needs mentioning, the diagnosis generally being obvious from tlic physical signs, the clubbed fingers, and in the bronchiectatic cases, the abundant intermittent, and frequently foul, expectoration. Myocardial affections, such as fibroid, fatty, or primary alcoholic heart, are generally diagnosed by guessing at them when other causes of heart failure can be excluded. The jjatients are generally middle-aged, shortness of breath on exertion, precordial pain and even angina pectoris occupying a prominent position amongst their cardiac symptoms ; there may or may not be a high blood-pressure, the albuminuria is not associated with renal tube-easts, there is often no cardiac bruit, or at most a more or less localized blowing systolic bruit at the impulse ; at the same time the heart is clearly enlarged, and it may be beating rapidly and irregularly ; there may be a history of syphilis or of chronic alcoholism : the jjatient may be ver>- stout in the fatty, though generally not so in the fibroid, cases. There may be a history, either of an extremely sedentary life upon the ALBUMOSURIA 15 one hand, or of over-use of the lieart by strenuous hard physical work — as a blacksmith, an athlete, and so forth — on the other. Electro-eardiographic tracings may be required in determining the nature of the heart lesion. Needless to say, the exact nature of the cardiac lesion remains obscure or uncertain in many of tliese cases, many a patient who really has mitral stenosis being regarded during life as suffering from chronic bronchitis and emphysema, and so on. ' Physiological ' Albuminuria. — Finally, we come to the albuminuria of apiiarently healthy males and females lietween the ages of fifteen and thirty. The condition was little known until medical examinations at schools, or for life insurance, or for the services became common. It has received a number of names, of which the following are some : " accidental,' " essential,' " postural,' " cyclic,' " orthostatic,' ' intermittent,' ' physiological,' " functional," • orthotic,' albuminuria, Pavy's disease, albuminuria " of adolescence ' or "of puberty.' It derives its chief importance from the fact that young males who suffer from it may be rejected for life insurance or for the services, from the fear that they have some form of nephritis. A similar condition occurs in females of a similar age. but it is detected less often than in males because one has less occasion to examine the urines of healthy girls than is the case with boys and youths. Collier and others have tlirown much light upon the nature of the affection by their investigations upon the urines of rowing men. It is found that tlie urine passed just before a boat-race being free from albumin, that voided immediately after is generally loaded with it. A few hours later this albuminuria is gone again. Now university oarsmen are, u])on the whole, long lived, hence this recurrent albuminuria cannot matter in them ; and the same applies to the albuminuria of many adolescents. A prominent feature of such a case is that the urine first voided in the morning is quite normal, wliilst that passed later in the day may contain anything from a trace to five parts per thousand of albumin ; the more the youth has exerted himself physically by walking or otherwise, and the more he has exposed himself to cold, for instance during a train journey to the city on a winter's day, or in a cold ijath. the greater is the liaijility to this unimportant but possibly alarming albumimiria. Some youths may pass albumin for days together before an interval of freedom from it occurs. Sometimes they appear to be in robust health, sometimes they look a little pale, as though they had been overworking at an indoor occupation ; they may be nervous, but often they are not. A natural nocturnal emission is supposed to predispose to albuminuria next day ; so also is a diet which includes eggs, especially raw eggs. The point is that these individuals have to be differentiated from sufferers from Hright's disease. The method of diagnosis is as follows : a complete routine examination is carried out, and no obvious affection of the heart or other viscera is detected ; the blood- pressure is normal : the albumin having been discovered, the patient is directed to sui)ply a scries of samples, at intervals of a few days, and ])referably passed inmiediately after rising in the morning. If all samples contain albumin it will be very didicult to exrludc organic disease ; if some contain albumin in aliundancc, however, and others none at all, llie ])resu»iiptioii will be that it is • functional " : before l)eing finally satisfied, however, it is important that a careful microscopical examination of the centrifugalized dc)iosit from a specimen containing albumin should be made, no casts or other abnormal consti- tuents being found. The administration of calcium chloride or calcium lactate greatly .< diminishes the lendincy to this form of albuminuria. In an adolescent male who has no sym|)toms. albumimiria discovered accidentally, present after exertion or after exposure to cold, but absent alter rest in bed. and when |)resent not associated with renal lube- casts or with signs of arterial, cardiac, or other disease that should be delicled by physical examination, is almost certainly " phvsiological." needing no treat mcTit and not judical i\c of any lindcrlyiiii; disease. Ilrrlurl Fiiixh ALBUMOSURIA may be iliseussed under I wo main hca.liugs. naincly : (1) Onliiiiinj .llhiiiniisiiria. which is not uncommon but is of little clinical importance: and fJ) Hiiicc- ■ loiits .llhiimnsiiriti. which is rare hut is clinically im|)ortant. Ordinary Albumosuria is seldom recognized because the albumose generally occurs along with albumin, and is not detected imlil this has been removed by acidulating with accli<- acid, boiling t iKiroii^lilv. and |j||( ring. Albumose mav be rceogiii/.cd in the lillrate by the facl tliMt with llillci--, nilrir aciil lest it uives a while cloud which disappears on 16 ALBUMOSURIA warming, to reappear on cooling ; and its presence may be confirmed by the violet -red colour ft gives with the biuret test, which consists in adding excess of caustic soda to a drop of dUute copper sulpliate solution, adding this mixture in drops to the urine, from which all albumin has been removed, and warming. Another test for albumose is Hofmeister's, which consists in acidulating the urine with acetic acid and then adding phosphotungstic acid ; albumoses give a milky cloud with the latter. The deutero- albumose that gives these tests occurs in the urine under a great variety of circumstances : apparently the one essential factor is cell destruction within the body. It will suffice to mention some of the many diseases in which it has been found : — (a) ' Febrile ' Albumosuria : in severe infective fevers, such as tyijhoid. scarlet, small-pox, measles, acute rheumatism, lobar pneumonia. (fo) • Pyogenic ' Albutnosuriii : in empyema, phthisis with cavitation, bronchiectasis, appendicular subdiaphragmatic or hepatic abscess, suppurating gall-bladder, pyosalpinx, suppurative periostitis, arthritis or osteomyelitis, gangrene of the lung, gangrene of the leg, breaking-down cancer, acute peritonitis. (c) • Hepatogenous ' Albumosuria : in cancer of the liver, cirrhosis, catarrhal jaundice, phosphorus poisoning, acute yellow atrophy, infective cholangitis, suppurative jn lci)hlehitis. {(I) ' Alimentary' Albumosuria : in cases of gastric or duodenal ulcer, carcinoma of the colon or stomach, ulcerative colitis, tuberculous ulceration of the bowel, acute and chronic dysentery. (e) • Hcvmatogenous ' Albumosuria : in leuka-mia, scurvy, purpuric conditions, and with internal hcematomata, such as pelvic hsematocele. (/) ■ Albuminuric ' Albumosuria : many cases of acute nephritis, syphilitic, cardiac and other forms of albuminuria, are associated with albumosuria. There is some doubt, however, as to whether the reagents employed in the qualitative analysis do not themselves convert some of the albumin into albumose. (g) Albumosuria due to unclassified causes : such as pregnancy, especially if the fcetus has died, though sometimes even without this. The amount of albumose present in any of the above conditions is seldom large, and diagnostically it has little if any significance except when it occurs apart from albumin. Even then its main importance lies in the necessity of not mistaking it for albumin. This error would only arise with the nitric acid test, for albumose does not form a cloud on boiling with acetic acid. It is urged by some that albimiosuria in appendicitis points to abscess rather than to simple inflammation ; that in a pleuritic case it points to empyema rather than to serous effusion : that in a mcningitic case it points to the suppurative or epidemic cerebrosjjinal forms rather than the tuberculous ; and so on ; but it is very doubtful if the symptom can carry so much weight as this. In a given case the presence of ordinary albumosuria points to a graver prognosis upon the whole than if no albumose were present, but it is not particularly helpful in differential diagnosis. Bence-Jones Albumosuria, on the other hand, though rare, is clinically important. The nature of the jiroteid present is still undecided : it certainly is not ordinary albumose. Its most striking characteristic appears when the urine is warmed after aeidulation with acetic acid to prevent precipitation of phosphates : long before the urine boils a dense milky precipitate appears, suggesting at first sight either phosphates or coagulated albumin ; it attracts attention at once from the fact that on further warming it begins to clear up again, and after boiling it almost or completely goes. It will be reaUzed that the precipitat'e cannot be albumin or phosphates, for not only would neither of these clear up at boiling-point in this way, but also the aeidulation of the urine has been sufficient to prevent phosphates from coming down, whilst the temperature at which the dense sticky precipitate appears (about 60° C.) is far lower than that at which albumin coagulates. If any albumin is present at the same time the clearing at boiling-point will be but partial ; the albumin should then be removed by boiling and filtration, when nitric acid added to the filtrate will gi\'e a white ring which redissolves on warming, to reappear on cooling, like that of albumose. This Bence-Jones proteid, when present, generally occurs in much larger amounts than ordinary albumose ever does, so that it is seldom overlooked unless it is mistaken for albumin. It may amount to anything between 1 and 20 parts per thousand, or more. It may be present on some days and not on others. It indicates, almost with certainty, that there is some affection of the bone-marrow ; it might be due, AME\()RHH(EA 17 for instance, to secondary deijosits of nialignant disease in bones, or to leukieniia : but in the great majority of cases it has occurred in connection witli multiple myelomata — Tvahler"s disease or myelopathic albumosuria of Bradshaw. Unless there is other evidence ro the contrary, abundance of Bcnce-Jones i)roteid in the urine indicates multiple tumours in%olving the bone-marrow, Herbert Freiieh ALKAPTONURIA. — (.Sec Urine, Abxormai. Coloratiox of. p. 74C.) ALLOCHEIRIA — Literally means ' other handness.' It sometimes happens that when a patient is touched upon, say, the back of his right foot, and is then asked where he has been touched, he says, " Upon the back of my left foot." This reference of sensa- tions to exactly corresponding parts of the limbs or body on the wrong side is known as allocheiria. ]-:xperiments have shown that complete allocheiria results from transverse hemisection of the spinal cord. It seems that sensory impulses travel much the more readily up their own side of the cord, but can also pass by the opposite side if necessary : when they arc compelled to do .so, the brain interprets them as coming from that side of the body which usually sends impulses up tliis particular side of the cord. AMien a patient exhibits allocheiria. therefore, it generally indicates that there is a lesion affecting one side of the spinal cord, or the upward extensions of the tracts which convey sensory impulses from the cord to the brain, more than the other. It is necessarily a rare symptom. It might result from a stab or a bullet wound damaging the cord unilaterally ; or from a gununa or neoplasm of the spinal meninges ; it may be functional ; rarely it may result from the cord becoming comjjressed more on one side than on the other by spinal caries, a new growth, callus, or a fracture-dislocation : and occasionally it may be noticed when there is a cord disease which, though usually bilateral, happens to have advanced more rapidly on one side than upon the other, as in exceptional cases of disseminated sclerosis, locomotor ataxy, or softening from syjjhilitic endarteritis and thrombosis. Except in functional eases, allocheiria will seldom be the only, or even the chief, feature in the case : paresis, pain, or some other symptom i)resenl will afford greater assistance in the diagnosis than will the allocheiria itself. Herbert FrencI,. ALOPECIA.— I See Hai.dm-.ss. p. 70.) AMAUROSIS.- (See N'isio.n. Uia-ixrs ok. p. ?.-,«.) AlVlBLYOPIA.^(Sec Vlsion. Dki-hcts oi-. p. T.>!t.) AMENORRHOHA.- 'I'lie lime al which menstruation lirsl appears is very variable wilhiii (crhiiii Imiits, being itilluciieed largely by climatic and racial |)eculiarilies : in this ■ounlry alioul roiirleeu may be taken as the average. When the meiislrual Mow has not X'ciime cslablislicd it is usual to speak of primary amenorrluea. whilst cessation of the How alter II has once been regularly established is known as secondary amenorrluva. From the lahlc of the causes of amenorrha-a below, it will be seen that .some of them must f necessity give rise to primary anienorrlKea. whilst others more coirunonly produce the icoiulary variety. In investigating a ease, therefore, it is imijortant to ascertain first whelher the condition is primary or secondary, and next whether it is real or only apparent. The latter cotidilion. known as cryptometiorrlKra. implies that the menstrual How takes place but is imable to escape exiernallv because there is some closure of a pari ot Ihe genital an.il. The congenital I'oriTi of ( iyploMienorrhf Ihe vagina is irnperfor-ali'. Ihe liynicn iisrrally bcirrg visible on llie outer side of Ihe ■Cdudiirg rrrernhrane. The eoir.|,lrt,- , xainniiilion irr sncli ;i case uill i-e\eal a llnel iral ini; 18 AMENORRHa^]A .swcllinji- reaching from the \iilva to tlio ])clvic brim, above which the uterus can oftii be palpated and moved about. It is further of considerable importance to make oni wliether the uterus and Fallopian tubes are distended with menstrual products alonu- witi llie distended vagina, for in the presence of ha-matosalpinges the treatment is considerablx modified. Abdominal section is required in such a case to avoid rupture of the tubes wlici tlie vajiina collapses after incision of the occluding membrane. Distention of the vagin; (jr hicmatocolpos is complete in this case, but may be partial where the lower part of tli( vagina is absent, and then is likely to be accompanied by distention of the uterus (ha-matometra) and ha-matosalpinx. Complete absence of the vagina can only be inferrei from ]3hysical examination, when the distended organ appears to be only the uterus. Although a secondary phenomenon, acquired cryptomenorrhoea produces the saim symptoms and requires the same kind of investigation as the congenital ca.ses. It niu^ not be forgotten that ae<|uired closure of tlie vagina following the vaginitis of specific fe\ ( i may t)ccur in infancy, and will then, of course, produce ])rimary amenorrhoea. CAUSES OF APPARENT AMENOHRHCEA. Cniigeiiilal : Iiiipeiibrate vagiiui Iniporforatc hymen AljseiK'c of the vagiiui Acijuireil : Closure of the vagina : Due to specific fevers Due to injury I'lii/sidlogicdl : IJeforc puberty After the menopause During ])reanancy During lactaticm I'alliohgiail : (Jenerative System : Ah.sence of essential organs Infantile uterus Small adult t\pe of uterus Deficient ovarian activity Destruction of both ovaries : By double ovarian growths I?y )ielvi<' iMll;iinniatiiin Supcriiuohitiiui oi' the uterus Note. — Real atnenorrlicpa Ini])erf'oratc ecr\ix Double uterus with retention Hivmatocolpos Ilaniatometra Iheinatosalpinx Closure of the cervix : Due to injury Following operations CAUSES OF REAL AMENOI?RHCE Circulatory System : Chlorosis Anfemia Leueocvtha'uiia II(i(lgkiM"s disease Wastiiii; iliseases : Ahili^iiant growths Tubercle Prolonged siippiu'ation Diabetes Late stages of nephritis Late stage of some forms of heart disease Late stage of cirrhosis of the liver Nervous system : Tnihceilifv L' Cretiiiisni \'arimia. that is to say from innution in the percentage of ha-moglobin. and probably from a diminution in the red Is dso. the next step in the diagnosis is to ,l..ter„,ine what is its nature. Attempts Ire nct'-cs ma,le to ht all cases of ana-mia into one or other of two main grou s itnJd m,,,,,-!, and .«ro,,r/«ny respectively; but this is noi reallv very helphif clinical In n||ny e..es the nature of the ana-mia is obvious at once-^t may be ™ a v o po^^ .ar uu han,or,l,age or other blood loss, or the later stages of phthisis, svphil s ca icer IK arKd cachexia, and so„n. Sometimes, however, even though ana.mii is n. Iv h^ . a use which ,„ some patients is obvious, it is not obvious in (he pali..,,, with whom one .nc ""„''""'"«• ""•' '""> "-• ^'-«""-« '- to be arrived a, bv a pro<.ess of ex.^l .13 Lis r^ '"";'"' '".™'"""'-- l-'-|.s. the diineulties that arise sometimes agnosinn l,,|wee„ lungaling en.loearditis. gastric eareinoina. and pernicious anxmi- he ween a„:..„.,a dii.- to blood-loss and bloo.l-,..ss due to anemia.' In arii^a 1; ' . . . ) . un,n.,s n , , „. n„Hrnnn..„r or nrgaNvc WW pirl.n: is probablv more i n < 7,; Lr ;'''";:'■'■ '■'":'^"''-"""- ''-'-■ ""•>• — -- m which tn.: biood ;::.;.-;i.tiu";:;:';,;;;:;;;;;;^:;r;;;;;--^ "r;,;:::;:"'""-" "'" ' ' "" '■'' -""■ — - — -1;,';::::::;;:: Blood Changes common to all .Severe Ana-mias. I,, mmv s.x.n a„.,M,ia Ih.n ar.. .22 AN.EMIA certain blood changes wliich are almost always to be found, which are not characteristic of any one variety of anaemia, but which, seeing that pernicious anaemia in its later stages is |)robably the profoundest of all the ana?mias, are perhaps better seen in it than in any other disease. These are : — (a). A very great diminution in the iiiiiiibcr of red corpuscles, down even to so low a figure as 600,000 per c.mm. (6). Great variation in the slnqyes of the red cells — poikilocytosis ; poikilocytes (Plate II. Fig. E) always retain a smooth, curved outline, but instead of being flat circular discs, like normal corpuscles, they may be oval or pear- or hour-glass-shaped, and so on. It is important not to mistake crenated corpuscles [Plate II. Fig. D), or red cells that have become polygonal by reason of mutual moulding when fixed in too close apposition with one another (Plate II, Fig. C). for poikilocytes. ((•). Alterations in the sizes of the corpuscles. In normal blood the red cells are almost all of the same diameter, about 7/i : in any severe an;emia they may vary considerably in size, many being much smaller than iwrmnl—niicioeyfes (Plate II. Fig. li) : some larger than normal — macrocytes or megalocytes (Plate II, Fig. B). (d). The presence of nucleated red corpuscles. Normally none are present in the blood even in infancy ; in any severe anaemia they may appear in varying numbers, and according to their sizes they are termed microblasls. normoblasts, megaloblasts. or gigaritoblasts (Plate II, Fja, P) the latter containing more than one nucleus, the others only one. It has some- times been stated that the greater the number of nucleated corpuscles the less favourable tlie prognosis, but this is not necessarily the case, except in so far that it is unusual for nucleated forms to appear until a severe stage of the anaemia is reached. None of the above changes, one must repeat, are diagnostic of any particular variety of severe ana-mia, though they are perhaps most marked in the later stages of pernicious aniemia. Normal Varieties of White Corpuscles. — It often happens that variations in the relative proportions of the different leucocytes in the blood afford means of differential diagnosis. Before changes from the normal can be understood, it is necessary to say a word or two about the normal varieties of white cells : these number anything from 5.000 to 10,000 ])er c.mm., the total changing considerably at different times of the day. \V\\en lilms are made it is found that four easily distinguishable varieties are to be seen. These have received different names at the hands of different observers, but they are so distinct tliat names hardly matter, and they might be termed quite well types A, B, C, and D respectively. If. however, one has to choose between the different names that have been g.\en to them, the following may jjerhaps be selected as the most frequently employed :— (\) Small lymphocytes : (2) Large- lymphocytes ; (3) Polymorphonuclear cells ; (4) Coarsely granular ciisinophilc cdr/iiiscles. 1. The stiKill IjinipliiHyles (Plate II, Fig. H) stain blue with Jenner's stain, both as to nucleus and proto|jlasm. The nucleus is round, and the i)rotoplasm is relatively small in amoimt and free from granides. 2. The large lymphocytes, or Injaline corpuscles (Plate II. Fig. J), stain blue, both as to nucleus and protoplasm. The nucleus is more or less kidney-shaped, and the proto-, plasm relatively large in amount and free from granules. 3. The polymorphonuclear cells (Plate II, Fig. K) stain blue as to the multilobed, nucleus, red as to the relatively abundant protoplasm, which imder the high power isl seen to be speckled with very fine red granules. 4. The coarsely granular eosinophile corpuscles (Plate II. Fig. L) stain blue as to thi multilobed nuclei, red as to the protoplasm, the amount of which is approximately tlK same as in the polymorphonuclear cells, but differs from the latter in that it is studdet with very striking large eosinophile granules. The Only dilliculty that arises in making a differential leucocyte count in normal bloof is that whereas tlie small lymphocytes usually become fixed in such a way as to covei relatively small areas, so that the cells seem to consist mainly of nucleus, at other time: tliey spread out flatter over larger areas, and then the rounded nucleus seems to bi surrounded by much protoplasm (Plate II. Fig. I). A small lymphocyte flattened out ii this way is apt to be called either a large lymphocyte by those who do not insist upon \\v reniform micleus of the latter, or a transitional lymphocyte by others. There is no deductioi PLATE .II RED XND WHITE BLOOD CORPUSCLES As seen umler the ',th inrh .ijl-hiiiiifrsion lens. o ♦ofJ^ ^i:K;.^ ^^Hp »^' IP CoiiyriijhI. "" V^ 7. /^ Ford, lid. A. Normal red corpuwU's; B. Mc?,'alocytes and microcytfs ; C. Ni)rniJil red corpuscles made aiiiiulnr by imperfect ILvntlon ; D C'reimted red <(H'pUik.*Ie»; E, I'oikilocylori ; F. Xucleuled rod corpuscles; {!) Xormobkisis, (2) Megaloblnsts; (.1) <;ii;antobla«l.s; G. I'liiictuto biisophillu niid polychromnsia; H. Small lymphocyte; I. Imleterminatc lymphocyte; J. I.Hree hyaline lymjilioc-yic; K, I'olymorplioniiclcar corpuscle; L, Coarsely granular eoaiiiophile corpuscle; M, Myelocyte; N. Kosinophtk-'inyelocytc ; *0. Hsiwdphilc corpuwle, SliKX 01' iu,\r;N(»s(s— 7V. /air /t. '2'J AN.^iMJA 23 of particular clinical value to be obtained by distinguishing these cells from small lympho- cytes : it is better that they should be grouped with the small lymphocytes for clinical purposes at any rate, only undoubted large hyaline cells with reniform nuclei being included in the group of large lymphocytes or hyaline corpuscles. The relative proportions of these cells differ according as the individual is a child a grown-up person : for an adult one may say that, roughly speaking, out of 100 leucocytes Alioiit 2.") will III- siiiiill lymphocytes S will be lai>;e hyaline lymphocytes 65 will be polymorphonuclear cells, and 2 will be coarsely granular cosinophile corpuscles 100 In children the tendency is for the small lymphocytes to be relatively more numerous in health, and still more so in any illness — up to 40 per cent or even more — whilst the poly- morphonuclear cells are correspondingly diminished. Some observers prefer to represent the different varieties of white corpuscles not as percentages but as total numbers per c.mm. of blood. Abnormal Varieties of Wliite Corpuscles. — \Vhereas the above are the only kinds of white cells in healthy blood, in certain diseases the following abnormal forms are met with :— Myelocytes. — These are large cor]niscles (Plate II, Fig. M), comparable in size to the polymorphonuclear cells, but differing from the latter in having either a perfectly round, an oval, or possibly a slightly kidney-shaped nucleus, rather than a multilobed one. There are all gradations of them, and at the two extremes it is difficult to differentiate some from large lymphocytes and others from polymor])honiiclear cells. They arc to be distinguished from the latter by the roundness of the nucleus, and from large lymphocytes bv the granularity of the protoplasm. The granules in fpiestion are sometimes stained brightly with eosin — cosinophile myehrytcs (Plate II, Fig. iV), distinguishable at once from the -)rdinary eosinophile corpuscles by their nuclei being nearly spherical : more often, how- -'ver. the granules stain blue, or some colour between blue and red — ordinary or neiitrophile 'Hyeloeytes. No uselul clinical information can, so far as is at present known, be oi)taincd )y laying stress upon these differences in the staining reactions of different mycloc-ytes, io that they are usually coimted together simply as myelocytes. There is only one condition n which they are very numerous, and that is spleno-medullary leukicmia : but the\- may )CCur in small numbers in various other affections also, particul.nly in lymphaih iioiiia, Hodgkin's disease, i)ernicious ana'inia, and aplastic ana>mia. Iiasoj)liile Coijiiisctcs (Plote II. Fig. ()). — These are nuich smaller Ihan myelocytes, :heir size being comparable to thai of small lymphocytes: they differ from the latter in hat the prolopliism. instead of being homogeneous, contains from 2 or .'J to jicrhaps 20 or norc very large gramdes which stain deep blue with Jenncr's stain. They are unniistakc- ible. No deliiiite clinical deductions can be drawn from their presence beyond the fact that, r there are more than 1 or 2 per 1,000, the blood is abnormal. They may be present in nany different varieties of anatnia, but they are not characteristic of any: they seldom iniount to more than 2 or :i per eciil, and oflcn to no more lliaii ()•.". per ecnl, even n disease. Plinctale ISiisDjihiliii. 'I'Ikic mic ccrlairi coiKlil ions, pailieiilarl,v pririieioiis aiiainia in ts later stages, leukaniia, and lead poisoning, in which the red cells, instead of staining liuforrnly pink with the eosin of .lenner's stain, ])resent large munhers of small blue specks ir granules in Iheir protopl.ism (Plate II. Fig. (1). a condition known as pinietate haso/iliilia. [n a case of doulil. when pcriiicioiis anainia has been cxeludel pictures. 24 AN.EMIA (.1).— AN/EMIAS WITH POSITIVE BLOOD PICTURES. Pernicious Anaemia is a distase (jf insidious onset in adults, the main syni|)toins heino; progressive loss of muscle-power and increasing pallor, with loss of weight, but with relatively less loss of body volmnc. Various other symptoms may be associated with these, or no others may be present. The diagnosis is seldom made until a relatively late stage of the malady has been reached, by which time there is a great diminution in the hipmoglobin, down ])erhaps to 30 per cent of normal or less, and a still greater diminution of the red cells, down perhaps to 25 per cent, 20 per cent, or even 10 per cent of normal ; consequently the colour index is high, and this is the pathognomonic sign of the disease. Tiiere is no leucocytosis, but rather leucopenia (p. 3S1) : the differential leucocyte count shows a relative increase in the small lymphocytes, a corresponding diminution in the poly- niorphonuelear cells, normal numbers of eosinophilc corpuscles and large lymphocytes, occasional bas()i)liili' corpuscles, and one or two myelocytes. Blood films also show all the changes described above (p. 22) as conmion to any severe anaemia, but with particularlj- large relative mniibers of megalocytes. When these blood changes are all present there can be no doubt about the diagnosis, and we need not enter here into all the other symptoms that may be presented by the patient. It is important to remember, however, that there is one group of the cases in which ner\e symi)toms predominate before the anaemia is pionounced. The diagnosis of ])crnicious antemia cannot be made without a blood-count, anil it can be made absolutely with one : one word of warning is required, and that is that the colour index is not continuously high in every ease of jjernicious anaemia, so that perhaps several blood-counts may be required at intervals. It should also be noted that the power of temporary recuperation is considerable, and wlien the patient's condition improves the Ijlood may return partly or wholly to normal ; during such remission the colour index, instead of remaining greater than 1. becomes 1 or less than 1. There are certain cases of very severe ana;mia which some would include under the heading of pernicious anaemia, although the colour index is persistently less than 1. It is more useful, however, from a clinical point of view to leave these cases unlabelled, or at any rate not to call them pernicious anaemia, which has so characteristic a tjlood picture. One variety has recently become separated from the rest under the title of aplastic (nurmia. the cliief characters of which are a profound, [jrogressive, and ultimately fatal anicmia for which no cause can be foinid. which seems in many respects to simulate pernicious an;emia, but which is persistently associated with a low instead of a high colour index. It is, moreover, imaccompanied by a positive Prussian blue reaction in the liver — Perrs test with jjotassiimi ferrocyanide and hydrochloric acid — post mortem : this, when positive, is strongly confirmatory of pernicious anaemia, for very few other conditions give it, and they are rare sprue, for example, is one such, and bronzed diabetes another. Spleno-meduUary Leukaemia. — In the earlier stages of this disease there is no antemia at all, though later diminution both in the ha-moglobin and in the red cells may be profound. The essential ])oint in the diagnosis is the occurrence of a very great increase of the total number of leucocytes, not at all uncommonly up to such a figure as 200,000, and sometimes up to 600.000 or even 1.000,000 per c.mm. There is only one other condition which can l)roduce so extreme an increase in the total number of leucocytes, and that is It/mphalic Icidiccmia. The two are immediately distinguishable from one another by the differential leucocyte count, the characteristic point about which, in spleno-medullary leukaemia, is the large number of myelocytes present. These may amount to £0, to even 50 per cent, or more, of all the leucocytes present, with the consequence that there is a relative but not an absolute diminution in the other varieties of white cells. Occasional basophile cells are seen : but whate^•er may be the proportion of these or other leucocytes, the main jioint in the diagnosis is the large relative number of myelocytes in association with an enormous increase in the total leucocyte count. When an. H AN.EMIA 25 wortliy tliat in jiatients treated with the .i-rays the spleen very often becomes greatly reduced in size, and the blood picture may return nearly to normal, though it seldom if ever happens, even when the number of leucocytes ]3er e.mni. has reached the normal, that there is an absence of myelocytes in the differential leucocyte count. Notwithstanding this apparent improvement in the blood and in the spleen, the length of time the patient survives does not seem to be increased. The splenic enlargement is not associated with enlargement of the lymphatic glands. Lymphatic Leukaemia. — There is no age at which any form of leuktemia may not occur : but uijon the whole the spIeno-meduUary form affects adults rather than children, whereas the lymphatic affects children rather than adults. Its course is usually rapid and invariably fatal, death resulting, as a rule, within three or four months from the first definite sym])tonis. Ana?mia is much more rajiid in its development in the lymphatic than in the spleno-medull- ary form. The first symptoms may be either anaemia, or lymphatic glandular enlargement in the neck, axilhr, and groins, or the occurrence of purpura, epis- taxis or other forms of luemorrhage, or in certain cases a complete change in the ehihrs temperament in the direction par- ticularly of excessive irritability of temper, with loss of appetite and obvious and pro- gressive illness. There are cases in which no glands are enlarged, the diagnosis not being at all obvious without a blood-count. More often there is general enlargement ol he lymphatic glands, visceral and peri- )heral, sometimes a.ssociated with similar ucreasc in the size of other glands, par- icularly the salivary and lachrymal — 'III ulic/.'s syndrome — and the spleen is I' il\ always palpable and sometimes n-'. though seldom so big as it is in spleiio-incdulJary Icuka-mia. Serous iiillammations " Miinnon. and there is apt to be pyrexia, as in other severe aiuemias. especially h) |||' no-inedullary leuk;emia {Fia. 4). Ilodgkin's disease (Fig. 247. p, ,570), and pernicious iiriiiiM iFi'S- "JKi, J). .">(><)). The diagnosis is afforded at once bv the blood-count in the FiV- 3.— A i laclirvma iipliutic leuka- of chronitT enlargement of the saliv.iry case of tKindlii lent hii llr. I'nchTid: Tiuili.r.) i,i'>nl\- of cas There a \iirving degree of in llic leucocytes, sometimes ■0 L-liiirt (niortunt' anil evnninj,') in a t who improved very inurlicclly under . hdlar.- lonka-niia it wliile in liosiiital. •aching no higher than 2<),()(H) or .•iO.OOO, more ollen SO.dOO lo KHl.oiMt. and soiucliiiK s. Ut more rarely, lo rnueli higher figures, siicli as -JOO.OOO. (idO.OdO. ,S(M(.(!IH> or iven 500,0(1(1 per e.iiiTii. Whalever the lolal leucocytes coiml. linwev.r. Ilie striking fealme the I ii.iriiioiis rclalixc increase in the small lyinphocylcs in tin- ililierenl iai leucocyte Hint. Out ol every hundred leucocytes it is not uifeommou to (itid thai <((>. or even AN.EMIA 95 or 98 are lymphocytes : so that there is an enormous relative and sometimes absohiU reduction in the other white corpuscles. Amongst them will be found an occasional mvelocvtc and one or two basophile corpuscles. The red cells and the lia-moglobin become diminished progressively, and the former may exhibit all the other changes described above (p. -22) as characteristic of any very severe anemia. Whereas m most cases the colour index becomes less than 1 as the disease progresses, in a few mstances, especially some time before the end, the colour index has been found to be greater than 1, as it is in pernicious ana-mia. There is no likelihood of mistaking one condition lor the other on account of the changes in the white cells. Some authorities describe two t\Tes of lymphatic leuksemia according as the lympho- cytes seen in the films are of relatively large or small size : as has been explained above, however there is always difficulty in deciding whether differences in apparent size of the lymphoc'ytes constitute differences in kiiul. and there is no very great climeal purpose served in drawing the distinction here, unless perhaps that upon the whole the larger the lymphocytes present the greater the number of months the patient is likely to survive. The' chief difficulties that arise in the diagnosis occur in two ways : first, there are a few instances in which lymphatic leuka-mia has run its course without any actual increase in the number of leucocytes per c.mm. of blood, the diagnosis being afforded only by the enormous relative increase in the small lymphocytes; and secondly, children normally have a relatively high leucocyte count, from which it happens that lymphatic leukaenna may sometimes be suspected in them when it is not really present. Suppose, for instance a eiiild suffers from an obscure illness associated with ana-mia of the chlorotic type with an increase in the leucocytes up to 25,000 per c.mm. and a relative increase of the small lymphocytes up to 55 per cent, would one be justified in diagnosing lymphatic leukaemia ! One micriit be if there was general enlargement of the lymphatic glands and enlargement of the spleen ■ but otherwise both the leucocytosis and the relative increase in the lympho- cytes mio-ht be due to some other complaint, and the only means of arriving at the diagnosis mi w n;;;; t| ;;H;; \^ :; --- ;; 5; " 'I »'' \ », / :i \.'. / 1 v" i ■101 :ioo 99 ~q ■J . ?6 '. ' 1 . : ' , ] '•.<-' ^' .... ; r-^^i / ^» ., '■•' " ' ' ' j ' i ' '^.-•'.j /' " ^;- I - • '■/ " •' t ' i ' il ! ,. ■ ; j , r " .i-i--l-:|::! /■■"J. irly tPiniiomturn chart i pliipsiMi; toy r> some tni|ii(;il country where the disease in fpicstion is likely lo occiu', will suggest the |iagnosis. and the examination of Ihc blood, cillicr fresh or. in lilms. will be coiilirmalive. Hclfi/tsiiiii fiTcr iisi'd lo be prcMilcnl in (ircal Hiilain. and it still occurs in cpiilcmic jf>rm in times of famine in association with Mnclciiiiniss. II is commoner iibroail. It is Its best known It ■28 ANtEMIA PLATE V LYMPHATIC LEUK/EMIA A. # oo o o W m C: G O « Oo #i o '■"" of ^ I' 1 liln, fnmi u . ,i,p „( lv„il.l,:.li,- Wnk.vmv.K sliowini; :. hir-c rc:.>c in llu. small lympliocyte IXIIKV l)F I.IAi:NC)>is -7V) /,„v ;,. SS AX.TIMIA 29 irt-orthy of note tliat one variety of severe an;eniia occurring in Assam, associated with nTexia and enlargement of the spleen, and formerly thought to be a variety of malaria, is lue to a variety of trypanosomiasis in which only immature forms of the parasite (Leishman- Donovan bodies) have been found (Plate XX\ III. Fig. H. ji. (>14) : and here not in the general blood stream, but in the fluid obtained by splenic puncture. The disease is emied Kula-azar. Mdhiiia is not essentially associated with anicmia ; but in jiatients who have had ■ecurrent attacks blood destruction by the parasites leads to considerable reduction both II the red cells and in the ha;moglobin, the colour index generally being of the chlorotic ype. The changes in the white corpuscles are described on p. ;J61. Tlie diagnosis can iften be surmised when a patient who is, or has been, resident in a malarial district suffers rem ])eriodic rigors with pyrexia. Theoretically there are two main types of the disease, Fi(j. 7. — Case of quartan malarial fpver, the attacks recurring every fourdi day. • (Chart supptwd by llic London School of Tropical Mcilicin, .} the terliiin. in which the paroxysms come on everv alternalc das uilh complete jery intermediate day (Fi«. (i) ; and the qunrUin. in which llicr.'are two-day int |al the paroxysms occur every fourth day {Fi<>. 7). What happens in a malaria ^•wever, is that alter a patient has Imcii infccte.l by one set of mos,|uit(. bite tlian or ((uarlaii ague, he becomes infected subsctitiently upon differeni days *>si|iiit<>(s ujil, „t|,er tertian or (|iiartan parasites, so that there is a minglin<. •the cllcls (>r different sets of luematozoa. For instance, if a patient'' had •ifected by two tertian parasites, the one producing rigors upon .Monday \\\ Jiday, and Sunday, and Ih,. other attacks u|.on Tuesdav. 'I'lmrsdav. Satiin -mday, tins patient woulrl have a paroxvsm everv day. the Ivpe Ixiii..' tli.n spo ■edom ds. so strict, ilh a other etlK'r 'Come sday, and (.r as ,,Q AX.EMIA ,,„nMian {Fis 8). If l.o were infected by two quartan parasites, the one produeing attacks uln Monda;. Thursday, and Sunday, and the other upon Tuesday. Fnday and Monday, e oec'n-renee of the paroxysms beeon,es less regular, for the patient would haye a r.gor r^,n Monday, another on Tuesday, none on Wednesday, a rigor upon Thursday and Friday, t n.Mu. ouSatunlay. and so on. Eaeh infection by a fresh brood of malanal parasites 1 ipli.ates the elinieal picture, until finally in those who haye been long in nialanal districts attacks of pyrexia may be quite irregular or even almost continuous. Kach paroxysm as three charac eristic stages, any one of which may last from half an hour to two or three (Cliarl riijtiilial hij Ihe London School of Trop hours.' or eyen more. During the first or cold stage, the patient shiyers w th a e^ere r.go, eels ;old, looks blue and pinched, but neyertheless has a rise of tempera ure to 102 K o loV F. The teeth chatter and the patient wraps himself up to try and keep -am Th, s followed by t.,e ho, staae. which begins with flushing of the face, seyere headache, pa us he back further rise of the temperature to 104= F. to 106^ F.. and a sensation of such he^ at 1 e patient throws off the clothes and calls for cooling drinks. This ends in the thi ,,„ ., -, ■;.. of malarial fever Ulustrating severe tertian attacks alternating with mild tertian attack, due to double iniection. (.Chart supplied i,j Ihc London School ol Tropical Media,,-.) or srccnting singc. during which the skin, previously dry, breaks out into perspiration so scv. t ha alKthe bedclothes may be .vringing wet. The temperature now falls, and the pa . more or'less exhausted, sleeps, and on waking feels comparatively well except for a sens Takness ; he may be able to do his ordinary work until the next paroxysm comes on O. Ta few cases do'^nruch severer symptoms supervene if proper treatment be adopted, the absence of treatment, however, malaria may lead to hypeinnTcxaa (10, F-11- J o coma • or to a condition of algidity and collapse ; any one of which may end in dea The diagnosis may be confirmed to some extent bv findino that tlic inrcxial outbursts inninish or cease altogether under the administration of quinine, but tlic only real proof f the nature of the complaint is the discovery in tlie blood of the malarial parasites Plate XXVIII. Figs. A. B. C. D. and E. p. 614). It is important to note that the idnnnistration of ,|uinine renders it dillicult or impossible to (hid these in blood films and Fir: 10.— Case o! m»larml lever befoming complex from multinle malari:il ii.feL-tion. (Chavl supplird lij llie London Sc/mol of '/'ro/iiml .Valichie.) len the behaviour of the leucocytes (p. 8(il) mav bo verv heli)hil. .Vllnnninuria is .mmon. and the urine generally contains urobilin .luring aetixc malaria, ceasino- to do so hen the latter becomes latent : microscopically, golden brown piun.ent granules\re often be lound ui the centrifugali/.ed deposit : these and the urobilin together may point to e diagnosis when no parasites can be loun.l in the hlo.,,1. For a detailed account .,f all ■...y, .l".'?;?'^'! \y....'J\ .1 .... 3 1 — » — 1 — r~~] — i — I — li Fiij. 11.— CImrt to illustrnte irrewilnr pyrexiii in chronic ni'ilnria. (Chart mijiplied bij the I^mton .fclmol of Tropical Medicine.) • Stages and apju-aranccs of various malarial parasil.s. leM-l„M,lri naiasil.s alii.ir 32 ANAEMIA thouoh the two types are distinct from one another, are sufheiently similar not to be distinouishable in films except by experts. If blood is examined at the begmnmg of the ri..or the stage most commonly seen is that of Plalc XXV III. Fig. B. p. 614. The two chief points of morphological distinction between tertian and riuartan parasites are, fnsi, that the pi.nnent granules are much blacker and fewer in number with the quartan than the tertian" and secondly, that in the rosette stage the quartan seg.nents are fewer than the tertian One remarkable feature about malaria is that it may remam latent for many years and yet recur in those who have long since returned to Great Britam from the tropics. What has happened to the parasites in the interval is not known, but their re-appearance is brought about by such conditions as general depression of health from overwork or worry, or as the result of some intercurrent malady. (B).— ANEMIAS WITH AN INDETERMINATE OR NEGATIVE BLOOD-PICTURE. The diaonosis of the fact of anfcmia is made by means of a blood-count, but in the oreat maiorit'v of cases the cause of the anaemia itself is not indicated by the blood con.l.tion. The differential diagnosis has to be made on other grounds. One may subdivide 6Yo»;j B into four sub-groups, namely. (1) Those cases in which the ana-mia is slight and in itself not a very prominent symptom ; e.g., in an indoor worker or a convalescent : (2) Those cases in which though the ansmia mav be severe, the routine examination of the patient d'iscovers some more or less obvious and not absolutely uncommon cause for it ; e.g., chronic tubal nephritis : (3) Those cases in which, though the anemia may be severe, no obvious lesion c-.m be discovered, but in which there is nothing about the case to suggest that the condition is a rare or unusual one : e.g.. chlorosis : (4) Those cases in which the ■inxmia may be more or less severe, in which there may or may not be obvious lesions to Leconnt for "it, but in which the circumstances of the case suggest that the disease is unusual or rare ; e.g., chloionia. . Cases in which the Ansemia is slight and in itself not a very promineni symptom —It is clear that before any an-xmia that is not due to acute blood loss Iron intern il or external hemorrhage reaches a severe stage, it must pass tlirough a phase ii which' it mav be regarded as slight or mild. This group therefore really includes all the other crroups at some stage of their development, and the diagnostician will often label 1 1 case to'start with comparatively mild or unimportant, when the course of events nltunateh shows that this was wrong. For instance, a case of pernicious ana-mia may exhibit wha seems to be unimportant svmptoms for months or years before the ana-m.a reaches s. definite and severe a stage as to be diagnosed correctly. The group now under discussioi is meint to include onlv such slight degrees of anemia as are themselves not important i the niatter of diagnosis ; for instance, in people who live too much indoors, in those wh. •ire convalescent from some illness, in those who suffer from chronic indigestion, constips tion obesitv some forms of chronic intoxication by microbial products, due to such thing as infective synovitis or arthritis, pyorrhoea alveolaris and oral sepsis, uterine or ovar.a , disease the earlier stages of phthisis, empyema, latent or deep-seated caseous glands < tuberculous affection of joints, vertebrae or peritoneum in children, the milder cases , olumbism and so on : in all these cases there may be a sufficient degree of anaemia to attrae some attention, but the diagnosis will rest upon other symptoms and signs than thoS'j connected with the blood, and in most cases the anemia will not be extreme. Cases in which, though the Anamia may be severe, a routine examination ( the patient discovers some more or less obvious and not absolutely uncommo *'''"*//«"L!rk«2e.-Some of the most striking cases of anemia in this group are those i which there has been recurrent or severe loss of blood. When the latter has been la bv euistaxis hemoptysis, hematemesis, hematuria, menorrhagia. metrorrhagia, metrostaxi nurDura or by the escape of blood per rectum, the nature of the anemia will generally 1 '.bvious'and the differential diagnosis will depend upon the cause of the particular lienio rha^e in question (see Epist.vxis, etc.). One should insist upon a complete blood-count ■ill these cases however, in order to exclude pernicious anemia, leukemia, and the otU , conditions in which the blood-picture is positive, lest the bleeding be due to the blood sta and not the blood state to the bleeding. The possibility of melena should also be borne I'jirl of a. blood tihn from ii l- we of iiiuliui i, !?howiriij three in;il:iriil iKinisites of tlie ring ty\ INDKX <>K |pi\.;\()sis -To face p. .".li AN.BMIA 33 mind, for without examination of the faeces the extreme pallor resulting from loss of blood from such a lesion as a duodenal ulcer maj^ not be diagnosed correctly. Hcemophilia should not be forgotten : the way the patient bleeds excessively from slight scratches or cuts will generally point to the diagnosis, especially if there is a family history of a similar condition, males being affected more than females. The blood-i)icture in haemophilia is entirely negative, the ana-mia that results from the bleeding being of the chlorotic type. It is •sometimes stated that the result of blood-loss is to jjroduce an antemia in which the red corpuscles and the hicmoglobin are equally reduced, so that the colour index remains more or less normal. This may be true of an acute bleeding such as venesection or post-partum haemorrhage, but the effect of recurrent blood-loss is to produce the chlorotic type of ana-mia, in which the red corpuscles are less diminished than is the hicnioglobin. Cachexia. — A similar blood picture, namely an anemia of the chlorotic type more or less severe, but without anything which may be called pathognomonic, either as to the red cells or the leucocj'tes, is to be found in almost all forms of cachexia, whether due to syphilis, tuberculous or malignant disease, malaria, beri-beri and other tropical illnesses, oesophageal stenosis, or starvation. .\ careful physical examination of the patient and enquiry into his symptoms may point to the correct diagnosis ; but it is to be borne in mind how dillieult it sometimes is to detect phthisis, or some cases of carcinoma or sarcoma, even when far advanced. Sputum analysis should not be omitted ; rectal examination should not be forgotten ; the a;-rays may serve to detect lesions within the thorax, and Wassermann's serum reaction may be employed when sj-jjliilis is suspected. It is remarkable how little anaemia may result from some varieties of cancer, particularly carcinoma of the breast ; whilst other varieties, especially carcinoma of the stomach, produce progressive ana-mia eom|)arativeIy early. It is noteworthy that, whereas in former times the absence of free hydrochloric acid from the gastric juice at the ])roper interval after a test meal was regarded as good evidence in favour of a carcinoma ventriculi, it has now been established firmly that the hydrochloric acid may be very deficient or entirely absent in a great many other conditions also ; it is absent in almost all cases of advanced carcinoma, whether of the stomach or not : and in many chronic maladies associated with ill-health all the .secretions of the body suffer, and amongst them the liydrochlorie acid of the gastric juice. It follows, therefore, that it is only when the diagnosis has been narrowed down to there being some lesion of the stomach, that the discovery that the hydrochloric acid is very deficient or absent affords evidence that the lesion is a carcinoma. Parasitic affcclions sometimes escape recognition, even when they have led to siilHcient an;emia to attract attention (see Parasites, Intkstin.vi., p. 519). The two varieties most a|)t to lie associated with ana?mia arc Ayihi/lnslnnnini diindcnalc and Rotliriocephaliis latas. liilliarziri lifotialohiti may also lead to severe anicmia. but generally does so on account of the II.KM ATI HI A (p. -IH-J.) that it produces. I'.osinophilia (p. 218.) may suggest a parasitic infection. Certain drufix are apl lo produce annniia ol' I he simple ciiloi-olic tyjie if llicir adniiiiisi ra- tion is continued over a long period ; pai'licuiarly niciciiij/. ai\ciiif. lead and srdiciilrdcs. .Veute mereurialism is commonly assoeialed wilh stomatitis and salivation, l)ut in cliniiiic cases, in addition lo aiia-mia, there is apt to l)e a motor ty()e of peripheral neuritis all'ccting the limbs and associated with a remarkable tremor (p. 72(>), ))artieularly of the hands. The diagnosis is generally arrived at from the fact that the patient has been receiving mercury nicdit'inally, or is employed in some work in which mercury is used, for instance, the making of thermometers or mirrors, or the curing of rabbit skins for the manufacture of hats. Arsenical paisoiiiii!' seldom gives rise to ana-mia as its sole symi)tom : but it is noteworthy that although liipior arscnicalis is an admirable remedy for the relief of pernicious aiia-mia, arsenic it>(ir is also a cause of ana-mia amongst those who work in it. .\s a ruli;. in addition to a?i:emia there is iiiarUcd pigmentation of the skin (I'late I'JJ), and Addisorrs disease may be siimilated. In the latter, howexcr. the pigmentation occurs on the nuicous membranes, particularly of the lips and cheeks, as well as upon the skin, and this - though in very exceptional cases a similar |)igmentation within the mouth has been obser\-ed ill |)eriiicious ana-mia (see Plate \.\H. p. :V2H). and perhaiis after taking arsenic lor long periods — is ;dways very suggestive of Addison's dis(-asc, and the diagnosis may be eoiifiriiK-d by finding a slight di-grec of cosinophilia, a remarkably low blood-pressure, down (-\(-M to N(» mm. Ilgor less, attacks of \-omitiiig, syiK-ope, ami n-miirkahli- asl lu-nia. 1) " ;5 34 AN.EMIA If there is active tuberculosis of the suprarenal capsules, Calmette's or von Pirquet's reactions with tuberculin {Plate XXXl'II. p. 770), may be positive, but these two tests are now less relied on than formerly. In arsenical cases there may also be evidence of peripheral neuritis and of hyperkeratosis of the soles and palms. Analysis of the hair will discover an abnormally hiirli percentage of arsenic. The chlorotic type of anaemia in lead poisoning may be extreme, but the diagnosis will depend upon other symptoms, of which any or all of the following may occur : — a blue line upon the gums ; constipation ; nausea ; vomiting ; epigastric pains ; abdominal colic ; a tendency to repeated abortion in women ; peripheral neuritis, particularly of the wrist-drop type ; various cerebral symptoms of any degree, from mere headache or insomnia to epileptic convulsions or acute mania, or other serious mental signs summarised by the term saturnine encephalo])atliy : impairment of sight ; optic neuritis : ophthalmoplegia, chiefly affecting the sixth cranial nerve : a tendency to gout, albimiinuria and granular kidney, and the secondary effects of the latter. The absence of a blue line on the gums does not exclude lead poisoning in those whose teeth are clean ; nor does its presence ])ro\'e lead poisoning, for most workers in lead exhibit a blue line whether they have other symptoms or not. In cases of doubt, it may be necessary to collect an abimdance of urine, evajjorate it, and apply the ordinary tests for inorganic lead. The occu])ation of the ]iatient will often suggest the diagnosis. Salicylates are said to produce an;emia if their administration is continued for a long period ; but it is also possible that the anaemia may be due to the condition for which the salicylates are being given, namely acute rheumatism. The diagnosis is generally obvious. In addition to the aniemia that may result from acute rheumatism itself, there is apt to be pronoimced an;emia in some forms of vahiilar heart disease, particularly affections of the aortic valves, whether rheumatic or syphilitic. Mitral disease, particularly mitral stenosis, is more likely to cause polycj-thasmia (p. 533), unless there is fungating or infective endocarditis. The occurrence of a progressive anaemia in chronic heart cases always arouses suspicion of the latter ; most cases of fungating endocarditis present synijjtonis of failing compensation which are often very difficult to distinguish from those due to the mechanical effects of chronic vahnlar disease, so that it is often difficult to distinguish a heart case without fungating endocarditis from one in which fungating endocarditis has supervened. In addition to aniemia the following points would be in favour of the latter : sudden and radical changes in the character of the heart bruits, for instance from musical to blowing, and vice versa ; enlargement of the spleen ; the occiuTcnce of haemorrhages, particularly subcutaneous or retinal ; optic neuritis : pyrexia {Fig. 243, p. 566), whatever its type, provided it cannot be explained by any intercurrent affection such as tonsillitis or jileurisy — though the absence of pyrexia does not exclude the disease : rigors, though these are often absent ; and symptoms of infarction or embolism in the spleen, kidney, brain, intestine, retinal or peripheral vessels resulting in convulsions or paralysis ; cessation of pulse in one or other of the accessible arteries such as the radial, posterior tibial or dorsalis pedis ; acute gangrene of some part whose circulation has thus been cut off suddenly — a toe, or the tip of the nose for example ; the develojiment of a spontaneous peripheral aneurysm ; sudden hsematuria : sudden acute pain over the spleen, associated jjerhaps with a peritonitic rub. It is noteworthy that there is but little leucocytosis- in infective endocarditis. Cultivations from the blood obtained by aseptic venesection may serve to clinch the diagnosis, and also to indicate what seriuii or vaccine treatment should be employed ; though it is remarkable how often blood cultures are negative in these cases, even when the blood is obtained during a period of high pyrexia. , It is in some cases easy, but in others relatively difficult, to be sure of the diagnosis of subacute nephritis. Anaemia is a prominent symptom in the chronic nephritis of yoimg peojjle, though the reverse is generally the case in the red granular kidney of later life ; for the differential diagnosis, see Albuminuria (p. 9). The old aphorism of "■ the large white person with the large white kidney " may sometimes suggest the malady. Many subacute or chronic maladies associated with continued absorption of microbial toxins have anaemia as a prominent sj-mptom. One may mention, for instance, chronic colitis, whether muco-membranous, ' simple ' ulcerative, or tropical dysenteric (see Diarrhcea, ]). 17"2) ; deep-seated suppuration acts in the same way, and one is familiar with the pallor of patients suffering from empyema : the development of this aiuemia after the crisis of lobar pneumonia, or in connection with broncho-[3neumonia, in children, not AN.ilMIA 35 infrequently suggests that an empyema lias" developed ; the diagnosis may be confirmed by the physical signs, but it will be clinched by finding pus when the chest is needled. Leucocytosis or a relative increase in the polymorphonuclear cells does not help in determining the presence of empyema so much as in other cases of suppuration, because empyema is nearly always secondary to lobar or lobular pneumonia, and in each of these there is also a polymorphonuclear leucocytosis. Other examples of chronic sepsis which may produce severe ana-mia are chronic appendicular abscess ; pyosalpinx ; hepatic abscess ; the breaking down of ovarian or uterine timiours ; chronic endometritis ; pyorrha?a alveolaris : infection of sinuses connected with bones or joints, particularly unclean tuberculous hi]) or knee joints ; psoas abscess ; suppurative periostitis or osteo- myelitis, with necrosis of bone ; secondary coccal infections in phthisis with cavitation, or in bronchiectasis. Chronic sepsis may produce Jardaccnus disease, which itself is also a cause of profound anaemia, with a peculiar pale yellowish or transjjarent appearance of the skin, though its diagnosis is exceedingly ditlieult in any but advanced cases. It is guessed at, as a rule, on account of there being a chronic purulent discharge from lung, joint or limb, or else severe tertiary syphilis. There may be enlargement of the liver and spleen, albuminuria, and a tendency to diarrhoea ; but even when all these symptoms are present, it not infrequently hap|)ens that the post-mortem examination shows that there was no lardaceous disease at all. Rheumatoid arthritis is an indefinite group of joint diseases which differ essentially from osteo-arthritis (]). S48), in that with the former there are more or less severe constitutional symptoms, including slight pyrexia, loss of appetite and weight, pigmentation of the skin, and ana-niia. The nearest lymphatic glands, e.g., the eijitrochlear when the hands are affected, are often enlarged and tender. The diagnosis seldom depends upon the anicmia, however. Probably there are many varieties of rheinnatoid arthritis which will some day be classified upon a bacteriological basis into those due to gonococci, streptococci, staphy- lococci, ])neumoeocei, JiaciUus coli communis, Spirochceta pallida, and so on. There are two types that are ])artieularly prone to anaemia, and these are, first, the form in which there is marked spindle-shaped enlargement of all the first intcrphalangeal joints in adults, whatever otiicr joints may be affected at the same time (p. IH'I) : and secondly, a general destructive affection of the joints in children, associated with emaciation, an;emia, enlarge- ment of the spleen and of the lymphatic glands, and known as Still's disease {Fig. l(ii), p. 377). (See .Joints, AtTiicxiONS of, p. 3;:17.) .11^ »_< »_' - I > c > I " ■(" .«. M I - c 1" 6 M C 1" I > c > I > [ 5-t, 5_t M El> t « 1 101 lOO E = = I - z z i z = - E r E E E [r E E = z I E E = - Z = I E E \ I E = = = i E E E E. E E £ jz ^ En E E E E E, ^ P ~A Z = E^ z ^ E E E E E f I:- / =1 z L^ ^ f\ ^ / ■~, )i- M- / •sJ V^ 1^ ^ ^ ^ Jz r ^ h V z z Z z v^^ I- k _. ~ - - - _ — - — — ^ - — - - - — - - _ _ z ? f z k \ E z E z = "= E = i E E z ' E r E = z - E E • |88 76 80 88 96 76 8* 76 84 84 84 76 80 ' 80 80 88 84 88 72 84 104 96 96 80 84 92 80 e4| .[a* 84 90 86 84- 88 80 68 86 88 84 80,68 80 20^20 J2^0 .24-'20[26 90 92 24-J20, 96'92 88 68 100 84 88 84 76 72 90 96 " 24.|24- 24-,24.:24.j20 20 20 ,20:24, 20,24- 24 20,20 20,24|24^4 ■ 2* 124-126 j24-|24-'|22 ,2* 22 20|24.|22|20 22 [26 22[24.|24-]20[24j24r26 26l20|20|20'24|26'20| Thosis of till' In Cirrhosis of the liver sooner or later leads to ana"mia of the chlorotic type, although' in the earlier stages the alcoholic jiatient may have a rubicund complexion ; by the time the ana-mia is pronounced there will almost certainly have been other .syni])toms of the complaint, particularly II.kmatkmksis ([). 'ifi.T), Jalnuicf. (p. :!21-), or Ascitks (p. i'.i). Patients with cirrhosis of the liver often have some evening pyrexia {Fig. I'J), and they tend to undue pigmentation of the skin. Ilil/icrlailalion is a pniininent cjiuse of anu-mia and general ill-health, especially in women in towns. The cause for prolongation of the period of lactation is often an idea that pregnancy will not recur whilst the last infant is being suckled. The diagnosis is generally obvious if its j)o.ssibility is borne in mind. 36 AN.milA Gastric ulcer, or rather the symptoms which are often stated to be those of gastric ulcer, is frequently associated with anaemia ; the latter in a few cases is the result of direct loss of blood by H^matemesis (p. 268), or, in the case of duodenal ulcer, Mel^na (p. 75). A duodenal ulcer may sometimes simulate gastric ulcer, but more often it produces symptoms which are apt to be mistaken for gall-stones, the pain being referred to a spot about an inch below the tip of the ninth right rib. As a rule the pain in cases of duodenal ulcer bears a definite relationship to food, being greatest when the patient is beginning to be hungry, and relieved by the taking of food. Gastric ulcer, on the other hand, is much more difficult to diagnose, for even when the patients have suffered from epigastric pain coming on inmiediately after food, from vomiting whicli relieves the pain, and from one or more attacks of hoematemesis, it is possible for the latter to be due to generalized oozing froin the gastric mucosa — '■ gastrostaxis '" — rather than a definite measuraljle ulcer. AVlien there has been no hiematemesis the diagnosis is still more dilficult, though it is noteworthy that in nearly half the cases in which the presence of an ulcer has been proved by operation there has been no history of hsematemesis. It was formerly stated that gastric ulcers are common in the female sex between the ages of fifteen and thirty, especially in the unmarried and the anaemic : notably amongst the servant class ; operative demonstrations of gastric ulcers, however, seem to show that they are really commoner in later life, and affect men as often as women, so that there is a very decided possibility that the gastric symptoms of ana?mic women are not in fact due to idcer. One meets with patients who have pain the moment they take food, in whom vomiting after meals is persistent, in whom the diagnosis of gastric ulcer would certainly have been made in former years, but in whom that diagnosis is made now only with considerable caution. It has become increasingly recognized that the vomiting and the gastric signs arc often due to the anaemia itself, and result from anaemic lli( ,ril,rspl. 38 AN.^MIA Myxcedema is a condition which may be mistaken for simple anremia, and consequently it is apt to be overlooked, particularly at that stage which merits the term ' hypothyroidism ' rather than myxocdema. It is an affection of women ratlier tlian of men ; it conies on \'ery slowly, and sometimes it can be diagnosed only by watching the beneficial effects of thyroid treatment. There is generally excess of gelatinous subcutaneous tissue, which Fig. 15. — My-xcedema : the character- istic facies, illustratitiff tlie broadeniiis of the features ami the niahir flush. (Com- pare Fi'j. It.) gives the patient a puffy or a?(lematous appearance, especially in the face [Fig. 15), hands (Fig. 10), and lower limbs, so that not a few cases are mistaken for nephritis. The urine is copious and of low specific gravity, but usually does not contain albumin : thovigh in some cases there is sullicient albimiiniiria to make the case still more like one of Brights disease. The ajiiiarent a'deiua docs not i)it on pressure, or pits far less easily than it would if it were ordinary oedema ; the skin becomes thickened, and the hair decreases in quantity and becomes brittle. Physical move- ments are lethargic, and the in- tellect dull, so thiit there is slow- ness of action bt)th of body and (if mind, symptoms that disappear in a remarkable way under thyroid treatment. In some cases the mental symjjtoms predominate to such a degree that some form of flelusional insanity or dementia may be diagnosed, or even a cerebral tumour. The chlorotic type of amemia which accom- |i;inics myxocdema may be masked liy a local flush over the malar bones, not unlike that of mitral stenosis. Scurvy is a rare disease which may lead to the most ])rofoimd anaemia, though it seldom does so without also producing extensive haMnorrhage into the skin, beneath the periosteum of the tibia- or other bones, from mucous membranes, and especially from the spongy and ftrtid gums. It is not common now-a-days, except in a mild form in children, — scm~vii- rickctfs or Burloiv's disease — in which tenderness of the bones associated with antemia, often mistaken for rickets is the main sym])tom. The tenderness in question is due to ANURIA 39 local sub-periosteal hiemorrhage, and the vfiCy in which the complaint rapidly gets better under suitable treatment with fresh vegetable diet helps in clinching the diagnosis. Tlie severer forms of scurvj' are due to prolonged de])rivation of fresh food, such as is rare in modern practice, though it used to be common on board ships. Chloroma is a very rare affection, related to lymphatic leukaemia on the one hand and to lympho-sarcoma on the other. It is associated with the formation of multiple tumours, especially in connection with bones, and a progressive and severe ana?mia of indeterminate tyi)e. The condition is fatal, and the diagnosis is at once suggested by the green colour of the nei)])lastic dcpi'sits. Ilerberl French. ANjCSTHESIA. -(See Sensatiox, AnNoitMAi.niKs ok. \). fiOt.) ANALGESIA. — (See Sens.vtiox, ABNomiAi.iTiES ov, p. COl.) ANASARCA. (See CEdema. p. 411.) ANKLE-CLONUS is best elicited when, the patient lying on his back, witli his knees slightly Hexed, the ob.server quickly, but not violently, dorsiflexes the foot, the liand being api)l)ed along its outer border in such a way as to keep it well outwardly rotated. The result, when ankle-clonus is present, is a scries of rliythmical jerks at tlie ankle-joint. a[ the rate of al)out 7 per second — fite contractiniis coiiliiiiiiHii "x /"",2 <"'■' the pressure is iiiiiiiilaiiiril. The last proviso is inii)ortant. because it often ha|)pcns that a few ankle-jerks are olHained. varying in number from two or three to as many as twenty or thirty, but gradually tailing off and ceasing, although the pressure on the sole is maintained. This is sometimes spoken of as a ■• tendency to ankle-clonus,"" but for clinical purposes it is not ankle-clonus at all, and indicates nothing more tlian hypersensitiveness of the nervous system, and not organic revious disease, the ureter of the remaining organ then becoming obstructed by a stone. Exceptionally, the blockage of one ureter may cause reflex suppres- sion of urine in the other kidney, especially if the function of the latter is impaired already by disease : but in these cases the anuria is usually temporary. Calculous anuria may occur suddenly, and in patients who are apparently in good health, for it is no imcommon thing for a patient to go on in good health when he jsossesses only one functionally active kidney, the other ha^'ing been destroyed by slow disease, or being absent : or there may be a history of ]}re\ious linnbar pain, ha?maturia, pyuria, or the passage of calculi. At the onset of anuria there is usually pain in the lumbar region along the course of the ureter of the side most recently affected ; it commonly lasts a day or so and then subsides, or it may last throughout the period of anuria. In addition, there is frequently a constant desire to mic- turate, although no urine is passed, or if the anuria is intermittent, urine of pale colour and low specific gravity, sometimes blood-stained, may be passed. If the anuria remains complete, no other symptoms may occur for several days, a feature which is common to the obstructive forms of anuria, but is in marked contrast to the non-obstructive variety. After a period of anuria lasting from seven to ten days, the patient becomes drowsy, the tongue is dry, there is disinclination for food, and the general symptoms of uraemia may come on ; but in many cases the patient may die before any symptoms of iirremia occur. Thus, it is usual to speak of a tolerant and a urcemic period in obstructive anuria. The tolerant stage of obstructive anuria may be even further prolonged if the fimctional kidney be already hydronephrotic from previous intermittent obstruction, even to twenty days. The sudden ANURIA 41 obstruction to the urinary flow in a comparatively normal kidney causes complete suppres- sion, whilst a partial or intermittent obstruction causes dilatation of the kidney. It such a kidnej' be the fimctionating organ, and become completely obstructed, the dilatation will increase ; and a lumbar tumour may be palpable. If there is pain on pressiu'c over the kidney, or aloni; the coiu-se of the ureter, the diagnosis is strengthened, or it may be decided to settle the diagnosis by immediate operation. In some cases in which one kidney has been destroyed gradually without pain, and anuria occurs, there may be great dilliculty in determining which of the two kidneys is the functional organ which has recently become obstructed ; in these cases it is a good rule to operate ujion the side on which the pain has occurred most recently. If the patient is not too stout, palpation may detect a distinct area of pain over a calculus impacted in the course of the ureter : or on careful rectal or vaginal examination a calculus impacted in the vesical end of the ureter may be felt. If the case is seen early, evidence of ureteric calculus may be obtained by the cystoscope, wlien the ureteric orifice of the obstructed side may be seen to be congested or ecchymosed ; or a ureteric bougie impermeable to the Rontgen rays may be passed into the ureter and a skiagram obtained, though it is only exceptionally that this can be carried out. Operation upon the side of the recent pain may be urged strongly, when the kidney can be opened and drained, and opportunity taken to explore as much of the m-eter as can be felt by the parietal incision and bj' catheterization from above. Anuria from Vesical Carcinoma implies that either both ureteric orifices are involved in the disease, or tliat the ureteric orifice of the only functional kidney is implicated. The condition is uncommon as a pine oljstructive anuria, for in most cases the kidneys ai'e already the seat of changes due in part to the back pressure and in part to sepsis, so that when anuria terminates a case of vesical carcinoma, it is more often due to renal disease than to ureteric obstruction. If the bladder has remained uninfected by septic organisms, the gradually increasing ureteric obstruction may first cause hydronephrosis, so that when the obstruction becomes com])lete the renal distention may increase quickly, and the sym- ptoms of ura?mia be delayed. In cases arising from vesical carcinoma, it is very rare for the anuria to occur before symptoms of vesical growth arc a|)])arent, such as hirniaturia. pyuria, increased frequency and ])ain on micturition; but in the infiltrating tyj)e of carciiionia, hicmaturia and frequency of micturition may be absent for a long time. In all cases, careful vaginal or rectal examination will detect infiltration and thickening of the base of the bladder, and the growth can be seen through the cystoscope (Plate A'l'/, Fig. F. p. "284). Uterine Carcinoma. — .Anuria is fre(|uent in the tenniiial stage of uterine carcinoma, when tlic growlli lias extended into the cellular tissues of the l)road ligament and involved the terminal portions of the ureters, or when the orifices of the latter are implicated in the direct infiltration of the growth into the bladder base. In the majority of cases dying from uterine cancer in the inoperable wards of the I-ondon Cancer Hospital, the kidneys are found to be hydronephrotie. the renal pelvis dilated, or the renal .secreting tissue sclerosed. a])art from the fre(|uent infeetion with septic micro-organisms. In all cases the growth has rcacheil an adxanccd stage, and (he disease has been apparent, but it has been recorded that anuria has occurred before the paliciil lias coinplaiiud of any symptom pointing to the uterine condition. 'I'liese eases iniglil simulate olhei- I'onus i>[ ohslruclive anuria. l)ul the diagnosis woulil be apparent iipoti \agirial examination. Pelvic or Abdominal Tumours, such as iilerinr lihroinx cimal ala. may cause anuria from direct pressure on I he imcIcis. cs|iccI;iII' is iiupacted in the pcKic ca\ity. 'I'lie cause ol the anuiia will be a of the abdomen and of the peKic organs. /<.— NON-OBSTRUCTIVE ANURIA. MarUcd iliiiiiiiiil icm in Ihc aiiKiuiil nl urine or ciini|ilclc anuria may occur williiiMt obstrucli\c Icsiiiii cil llir iirin.ny a|i|i:MMl lis. due in many inslanccs lo disease of llie iciial secreting tissues. In iniiiiy (il llicsc ciiscs the symptoms dilfer reinarkalil\' from lliose seen in o))slrueti\c iiiiiiiia. in llial llic anuria is aci ompaiiied by symptoms of uriemia in a sliorl time, and not alter an inlcr\al of days as in the obslrueli\-e eases. Anuria may occur under eerlain loxic conditions, as in acute fe\'ers. or in acute poisoning by mercury, lead, phosphorus, or I iirpciil inc ; the liislorv and accom|)anying syniploms of such cases arc usiiiilly siiHicienl lo |iiiinl lo llie naliirc of the urinary siq)pression. o\ i iirian carciiinm- pai •1 (it IIh' tumour ■nt on r\aiiiiniiliiin 42 ANURIA Anuria in Renal Disease. — In acute nepliritis. anuria may occur early or after the disease is well established, and is usually accompanied by marked disturbance of the nervous system. The sudden onset of the disease after exposure to cold, or in the course of an acute specific fever such as scarlet fever, enteric, or pneimionia, or in hicmatogenous renal infec- tions, associated with pallor, backache, pulliness of the face and ankles, and slight pjTcxia, together with the small anioimt of urine jiassed before the suppression becomes complete, are points all suggesting acute nephritis. If the urine has been tested before the onset of anuria, it is often of reddisli-brown coloiu- from the presence of blood, and contains abundant albumin, together with renal, epithelial, and blood casts. In chronic nephritis, anuria may iKcur as a late symptom in the disease, and is occasionally jjreceded by a period in which polvuria is marked. Anuria in chronic nephritis is accompanied by prominent symptoms of unvmia. such as headache, giddiness, convulsions, stertor, and coma, and unless the flow of urine is re-established quickly, death ensues. The previous history of the case, high arterial tension, cardiac hypertrophy, retinal changes, and signs of baek-])ressure, with or without ascites and anasarca, will point to the nature of the anuria. In other diseases of the kidney, such as lardaccous cUsease, suppurative pyelonephritis, or bilateral tuberculosis, anuria may be preceded by general failing health, with loss of apiietite. subnormal tem- (lerature. a dry brown tongue, headache, increasing pulse-rate, hiccough, and attacks of dyspna-a : frequently there may be polyuria before suppression occurs. In these cases the anuria is terminal, the condition of the kidneys having been known |)reviously. With the occurrence of anuria there may be great restlessness, with muscular twitching, loss of sphincteric control, convulsions, and a gradual la])se into coma. Poli/ci/slic disease of the kidneys frequently terminates in anuria and ursemia. but the diagnosis of the disease has ])robably been arrived at ])reviously. The symptoms resemble in a great measure those of chronic nephritis, with the exception that ascites and a?dema of the extremities are imcommon. Headache, flatulence, and digestive troubles, sickness, anrl general lassitude are symptoms of renal inefHciency, whilst arteriosclerosis, a bilateral renal tumour, and a low-speeilic-gravity urine in increased quantity, would suggest ])olycystic disease. ILvmaturia is the lirst symi)tom in not a few of these cases. Anuria following Operations or Trauma. — .Anuria may occur in patients who have underuone an (iperiiticm and who are the subjects of renal disease, or may occur occasionally even when no renal disease is jjrescnt. .\ny extensive operation which involves a good deal of shock in a patient with renal disease, or in whom the kidneys have been subjected to back-pressure, as in uterine myomata, may succumb to anuria unless apjiropriatc measures are imdcrtaken : even an apparently trivial operation on the urinary organs may cause acute suppression of urine. This must be difl'erentiated carefully fniin the retention of urine in the bladder often seen after operations such as for ha-morrhoids or for hernia. Acute svippression of urine may follow operations upon the lower urinary tracts, such as the passage of instruments, or the performance of internal urethrotomy. Anuria is particularly liable to occur when a catheter is passed to relieve an over-distended bladder in a ease of prostatic enlargement or urethral stricture, the kidneys being already distenrled from back-pressure or infected with septic processes, and it must be laid down as a golden rule, that if a catheter is passed in these cases, the urine must be withdrawn very gradually. .Anuria following operations upon the lower urinary tract is diagnosed by the direct relationshi]) between the operation and the onset of symptoms : by the rigors, pyiexia, and the profound jirostration, rapidly followed by convulsive movements and coma. .Anuria may also occur in the severe collapse following an injinv, in the late stages of cholera or i/cllinv fever, and occasionallj- as a manifestation of hysteria. It may be simulated by a iiuiliiigfrer. li. II. Jocelyn Swan. APHASIA. — (See Spekch, .Abnormalitihs of, p. (i\Li.) APHONIA. — (See Speech. Abnormalities or. jj. (i2S.) APPETITE, ABNORMAL.— .Vppetite may be: (1) Increased: (2) Diminished; (3) I'rrverlcd. Increase of Appetite sometimes occurs in cases of hyperchlorliydria. The general condition is then well maintained, there is usually pain or discomfort in the later period of ASCITES 43 digestion, relieved (temporarily) by the takinsi; of more food. A test meal shows excess of hydrochloric acid. In (lifihetes. especially in its earlier stages, there is often an abnormal craving for food : but in si)ite of large meals the patient wastes. Kxamination of the urine will establish the diagnosis. Itilcslinal parasilcs (round-worms and tape-worms) are believed to be a cause of excessive ii])pctite in some cases. This is doubtful : but in any ease the point can always be cleared up l)y giving an anthelmintic. In some cases of Injsieria an excessive ap]jetitc is ])rescnt (bulimia). The patient is usually a young woman, and other stigmata of hysteria are present. Diminution of Appetite occurs in many forms of dyspepsia, especially when associated with a lessened gastric secretion. Thus it is almost constantly present in gastritis. exce])t, ]3erha]}s. in the acid form. If renal disease, advanced mitral disease, or cirrhosis of the liver be present, secondary gastritis may be diagnosed. If there be a history of the abuse of alcohol or tobacco, or of indiscretions in diet, or if there be a marked defect of the chewing- apparatus, there is probably primary gastritis. The tongue Avill probably be furred, and a test meal shows diminished acidity and probably an excess of mucus, but the examination of the stomach is otherwise negative. (See also Indigestion, p. 317.) Loss of ajjpetite is also an early symptom in eases of gastric carcinoyna, and should lead. cs])ecially in elderly subjects, to careful examination for other signs of that disease. There is fre(|uently a special distaste for meat in such cases. (See Indigestion, p. 31(>.) In children a jirofonnd anorexia is sometimes an early symptom of tiibercidosis. In hysterical young women complete disinclination for food {a)wre.ria nervosa) is some- times met with. The diagnosis is based upon the absence of other causes of the symptom, the presence of other signs of hysteria, and the history of mental or emotional shock. The loss of appetite in such cases may amount to a complete refusal of all food, and the jiatient may emaciate to a dangerous degree. Obstinate constiiiation is usually present as well. .Mlicfl to these cases is the loss of appetite which occurs in mel;'.ncln)!ic forms of insaiiiti/. In such a case delusions may be present. Perverted Appetite may occur in the course of prcgiiaiicji. and is of no special signili- oanee. It is met with. too. in nervous, anaruic children, in whom it often takes the form of pearanee of the ahdotuen depends a good dc.il on the position of the |)alient. If lying on one side, the most dependent part is the most prominent, owing to the lluid gravitating to that side of the abdomen. If the jiatient stands or sits upright, the hypogastric and iliac regions will be most bulged. The umbilicus becomes stretched transversely and Hush with the surface, or even protruded ; it retains its position in the median abdominal line, and remains nearer to the pubes than to the ensiform cartilage. In tiH)ereulous peritonitis the skin in its inunediate neinlibourliood may be reddened and (edematous, or there may be a fa'cal lislula lure. In cirrhosis of the li\-er the veins around the mnliilieus are said to be dilated, liul llir s(i. .■ailed ■ eapiil inc-dusa' " is rare. The siiperliciid \(ins :dl over I lie iilMlorncn and 44 ASCITES lower part of the cliest may be dilated, the blood flowing in an upward direetion, this reversal of the stream occurring mainly when the inferior vena cava is oljstructed. either by the tension of the ascites or by something related to its cause. (See Vkins. Varicose Abdom- inal, p. 748.) The abdominal respiratory movements may be absent or much diminished. The cardiac impulse may be displaced upwards and outwards. The legs, thighs, and scrotum may be cedematous, and so may the loins. Palpation. — The abdomen may be anything between quite flaccid and very tense. A fluid thrill may be obtained by placing the hand flat against one iUink and gently flicking the other with the fingers of the other hand ; the possibility of a thrill being transmitted in the abdominal wall should be eliminated by getting the patient or an assistant to place the side of his hand on the front of the abdomen, so as to stop the mural thrill at the point of contact with the abdominal wall. If the above precaution is taken, anri a thrill is obtainable, it denotes the presence of fluid. If the liver or s|)leen has enlarged it sinks backwards, so that between these organs and tlic abdoiiiiniil wall a layer of fluid is present ; if the hand placed on the abdomen, in the right or kit hypochondriac region as the case may be, is suddenly dejircssed, this lluid is displaced, and the surface of the enlarged organ can then be felt. This phenomenon of ■ dipping ' is almost pathognomonic of ascites. Percussion. — When the patient lies Hat on his back the fluid gravitates to the posterior part of the abdomen, and the air-containing viscera float to the anterior part, so that the percussion note is resonant in front and dull in the flanks. As the fluid increases in quantity, the line of dullness creeps forward from the flanks and upwards from the pubes, and keeps a concave upper border ; in extreme cases the abdomen may be dull all over, particularly in children. One of the most prominent jihysical signs of ascites is the efl'ect jiroduced on the per- cussion note by a change in the posture of the patient. If. after examining him lying on the back and finding dullness in the flanks and resonance in the front, he be turned on one side, the uppermost flank becomes resonant and the line of dullness on the other side rises nearer to the median abdominal line, owing to the fluid gravitating to the most dependent part. If only a very small (|uantity of fluid is present, the abdomen may be resonant all over when the patient lies on his back ; but if he is ))ercussed in the knee-elbow position, the umbilical region may be found to be dull. In some cases, especially of tuberculous peritonitis, shortening of the mesentery is apt to be associated with the ascites ; the intestines cannot then rise, and the result is didlness all over the abdomen, or in very exceptional cases dullness in front with resonance in the flanks. Chronic peritonitis may cause the fluid to be loculated, through matting together of the intestines. The abdominal distention may then not be uniform, and change of ])0sture may not alter the character of the ])crcussion note. Mensuration. — Tlie abdonun should be measured, fixed points being taken in front and behind, e.g., the umbilicus in front and the tip of the third lumbar spine behind. This is important in order to watch the effect of treatment. The distance of the umbilicus from the ensiform cartilage, pubes, and anterior superior iliac spines should also be noted, yin ascites, the navel is nearly always nearer the pubes than the ensiform cartilage, and -equi- distant from the two anterior superior iliac spines when the patient lies flat on his back. It is always important to examine the abdomen carefully after paracentesis ; the cause of the ascites can often be discovered in this way, in the shape of tumours, or enlarge- ments of organs, which were previously obscured by the tenseness of the abdominal wall. 2. DIAGNOSIS. — Ascites has to be distinguished from other conditions which may give rise to geiieral abdominal distention, especially from : — Tympanites : Ovarian and parovarian ci/fils : Gravid uterus ivitk hi/drops amnii ; Distended bladder ; Distention associated 7>.illi obesiti/ : Plianluni tumour ; Large abdominal eysts and solid tumours. Tympanites is distinguished from ascites by the following signs : — The outline of distended coils of intestine may be visible, and peristaltic movements may be noticed. There is no fluid thrill if precautions are taken to prevent a thrill being transmitted by the abdominal wall. The abdomen is resonant all over, both in front and in the flanks. Ovarian Cyst. — There may be a history of the enlargement of the abdomen having been noticed at an early date to be more on one side than the other, and to ha\e arisen from the pelvis. The umbilicus may be nearer to the ensiform cartilage than the pubes, and ASCITES 45 nearer to one anterior superior iliac spine than tlie otlier. A fluid thrill may not be obtained far back in the flanks, but only in front of the mid-axillary lines. There is usually dullness in front, with resonance in the flanks. The outline of the cyst may jiossibly be noticed during the respirator^' movements. On measuring the abdomen the greatest circumference is usually below the umbilicus ; whereas in ascites it is generally at the umbilicus. A vaginal examination may reveal that the uterus is drawn upwards and that its mobility is impaired : whereas in ascites it is low down and movable. If ])aracentesis has been per- formed, the nature of the ovarian fluid is characteristic, being usually thick, tenacious, viscid, and of a brownish or greenish colour ; whereas ascitic fluid is yellowish, limpid, and clear. Much dilficulty arises when ovarian cyst and ascites are both present, owing to infection of the jjeritoneum by secondary deposits from the ovary. Even without this, however, it is by no means alw.ays easy to distinguish between ovarian cyst and ascites when the abdominal disteutiiin lias become extreme. Gravid Uterus with H.ydrops Amnii. — In this condition it may be possible to make out the outline of the enlarged uterus ; the tumour may vary in consistency as the uterine wall contracts and relaxes ; on vaginal examination the cervix is soft and patulous and the uterus enlarged. There will be other signs of ])regnancy, the characteristic condition of the breasts, foetal movements and heart sounds, and the history of amenorrhoea. There will be dullness in the front of the abdomen, resonance in the flanks. Distended Bladder. — This may reach well above the lunbilicus, most frequently in women as tlic residt of a retroverted gravid uterus, or in men over sixty from enlarge- ment of the prostate. The most important symptoms are : incontinence of urine from over-distention and overflow, and abdominal distention. There is generally a globular mass to be palpated in the middle line above the ]>ubes and reaching up to the umbilicus or higher : it is dull to jiercussion in front, with resonance in the flanks. The passage of a catheter should clear up all doubt. General Obesity may cause much abdominal distention. The mesentery, omentum, and abdominal wall may be so loaded with fat that it is difficult to make a satisfactory examination, and it may be almost impossililc to determine with certainty the presence of even a moderate amount of fluid. Phantom Tumour, The abdomen may occasionally be so distended in women, espe- cially at the time of the climacteric, that ascites, ovarian tumour, or j>regnancy may be sinnilated when there is merely a phantom timiour. If an ana-sthetic is administered it often disap|)eais, the rigid abdominal wall becomes flaccid, and it can be determined whether fluid in the peritoneal cavity or any abdominal tumour is present or not. Large Abdominal Cysts may occasionally sinndate ascites, e.g., hy(lrone|ihrosis, pan- creatic cvsl, and hydatid <\sl : th(\- do not, however, cause unihirm distrutiou ot the abdomen as a rule. They arc most likely to be mislaken for simple chronic ))eritonitis in which local collections of fluid have arisen from matting together of the intestines. Hydro- nephrosis may be distinguished by its position and by the fact that it may vary in si/.e, a decrease being associated with an increase in the amount f)f urine passed. Pancreatic cyst may be dilTerenliated by its jxisition in the U)(per part of the abdomen and by its more or less circular oulline. If paracentesis abdominis has been peH'ormcd. the character of the llni. CAUSES. — Having made uj) one's mind that the general alHldininal disttiition is due to lluiri in the peritoneal cavit>, on<- must ni \l liiircrcnl iate Ihe canse ol the ascites. The following is a classilied list : — i. Diseases of the Peritoneum : Xon-snppinali\c aenle perilimilis ■.Simple" chronic peritonitis Tul)erenlons peritonitis Malignant ])erjtonilis, generally secondary to a priniaiy growth elsewhere Hydatid cysts in the peiiloncal ca\ity. ii. Obstruction to the main Portal Vein by : — Non-snppnral i\c thrombosis Ivilargcd portal lymphatic glands : — Maliijnanl I 'I'uIk lenluns l.ymphadincinialons | l.yrriphal ic lenka-mic ASCITES Tumours of adjacent organs, such as : — Liver I Duodenum Pancreas Colon Kidney Suprarenal capsule Stomach Rarities such as aneurysm of the hepatic artery iii. Diseases of the Liver : — Cirrhosis IVrihepatitis, really part of chronic simple j)eritonitis Carcinoma j Doubtful causes if the lesions are confined to the liver ; i.e.. Sarcoma I it there is ascites, it is probably not due to the carcinoma, Sypliilis j etc.. in the liver, but to simultaneous affection either of Hydatid disease ) tlie peritoneum or of the portal lymphatic glands iv. Obstruction of the Inferior Vena Cava above the Hepatic Veins by : — Tliriinil)()sis Mediastinal growth Clu'onic niediastinilis V. Chronic Failure of the right Heart (' backward pressure ') the result of : — Valvular disease : — Adherent pericardiimi Mitral stenosis Clironic lung affections, especially : Mitral regurgitation Emphysema Aortic stenosis or regurgitation with ' Recurrent bron- Generally as- sociated secondary mitral regurgitation i^- chitis Rheumatic or syphilitic Fibroid lung- Congenital pulmonary stenosis (rarely) Chronic high blood pressure : — Red gramdar contracted kidneys Pale granular contracted kidneys Arteriosclerosis Chronic myocardial affections : — Fatty degeneration I Fibroid heart Fatty infiltration | Primary alcoho- Fatty s\iperposition | lie heart vi. Bright's Disease. In Bright's disease ascites may be caused in at least four different ways. — namely, as the result of : — Part of a general dropsy I Secondary to hypertrophy and dilatation Acute peritonitis i of the heart, followed by failure of Clnonic ])eritonitis < compensation vii. Severe Anaeiqias, in wliich the ascites is usually the result of acute, subacute, or chronic intercurrent j)eritonitis, as in : — Splenomedullary leukaemia I Splenic ana-mia Lymphatic leukaemia j Pernicious ana-mia Hodgkin"s disease Aplastic ana-mia Pseudo-leukicmia infantinii [ Malaria f. DIFFERENTIAL DIAGNOSIS. — If a.scites is the only fluid accumulation present in the [latient: il'. althougli there is also swelling and oedema of the legs, the ascites is known to have apjjeared first : or if the ascites is out of proportion to dropsy elsewhere : it is most probably due either to some form of peritonitis, to portal obstruction from thrombosis of or pressure on the portal vein, or to cirrhosis of the liver. If it is associated with general anasarca, that is to say, with cedema of the legs, body, and face, perhaps even of the scalp, and possibly with other serous effusions, the probable cause is acute, or acute on chronic, Brighfs disease. If swelling and oedema of the legs were noticed first and the ascites followed, heart failure from one of the causes in Group V, or obstruction of the inferior vena cava abo\e the hepatic veins, would be the most likely cause ; it is important to remember, however, that in the slighter cases, or in those of long standing, the patient is often uncertain which swelled first, his legs or his abdomen, and his statements on the point may be misleading. If jaundice is associated with the ascites, it points to some form of portal obstruction as the cause, either cirrhosis of the liver, or, if the jaundice is intense, to some actual pressure on the portal vein and common bile ducts, generally due to malignant disease. If enlargement of the liver is associated with the ascites this may be due to carcinoma, ASCITES 47 sarcoma, cirrhosis, perihepatitis, s\'pliilis of tlie hver, or to nutmeg change the result of backward pressure from ctironic heart or lung disease. If the ascites is assf)ciated with multiple abdominal tumours it suggests tulierculous or malignant ])crit(initis. or in rarer cases hydatid disease. i. Diseases of the Peritoneum. Acute yon-suppurativePgjiiloiiilis is an acute inflammation of the peritoneum analogous to acute ■ simple " ])jeuris^^^ith serous eflusion. One seldom speaks of ascites, however, in connection with ac^te nifective peritonitis such as w^^ti ||j^l D6 pus formation if laparo- tomy were not resorted to : and it is dillicult to draw a decW^l^fte between acute peritonitis in which the fluid should be called ascites, and other conditions of acute generalized peritonitis to which the term would not be applied. There are, however, cases in which acute serous effusion due to non-suppurative peritonitis occurs in acute and chronic Bright"s disease: or acute tuberculous peritonitis almost simulating general suppurative peritonitis; c whilst pneumococcal and gonococcal peritonitis may be acute in onset, and yet take the form of an ascitic effusion, recovery occurring without the necessity for laparotomy. It is probably a question of the dose of the micro-organism that affects the ])eritoneum, and it is by no means impossible that, whereas the perforation of a gastric ulcer, duodenal ulcer, dysenteric, typhoid, or tuberculous ulcer of the intestines, or leakage from a pyosalpinx, an ai)pendicular abscess, stercoral ulcer of the colon, or a perirectal or prostatic abscess, generally gives rise to acute general [jeritonitis which would prove suppurative if it were not operated on, the same conditions may in some eases lead to a slighter affection with a severe but non-suppurative ascitic effusion ending in s|3ontaneous recovery. AVhether laparotomy is indicated or not in any given instance must depend upon the individual circumstances of tlie case ; but it is much safer for the jiatient to be operated upon for acute non-suppui>tive peritonitis of the type of wliich we are now speaking than for general suppurative j)eritonitis to escape operation. Sini])le Climm'c Perildiiilis is a chronic inflanunation tliat is not tuberculous or malig- n;uit. It may follow siniple acute peritonitis, but its two commonest causes arc : a former tuberculous ])critonitis from whieli the tubercles have disajjpeared ; and the chronic inllam- mation which results from repeated paracentesis abdominis for any other variety of ascites. The latter is important ; it sometimes happens, in a heart case for instance, that both trdema of the legs and ascites have been prominent symptoms, paracentesis abdominis being indi- cated on account of the cardiac distress ; the tapping of the abdomen may have had to be repeated scviTal times, and yet ultimately the cardiac compensation has been restored. the patient's general conrlition Incoming (juitc good and the (cdema of the legs disappearing : yet in spite of this general improvement, ascites may still persist and re(|uire further tapping at intervals. In such a case, whereas at first the ascites was due to backward pressiu'e from the failing heart, it ultimately becomes due to chronic ])eritonitis. the result of the repeated tappings. It is Tisually associated with perihepatitis, which indeed is only one of the local manifestations of <'hr(inie peritonitis. l^Aen when all inllamination has {•cased, the great thickening of the peritoneum over the diaphragm, liver, and spleen may liave blocked up those pores through which the peritoneal secretions naturally drain away, .so that the Ihiid keeps on re-accumulaf iiig, and necessitates re|)eatcd tapping, which in some cases has been performed over three hundred times. The peritoneum becomes thickened generally, aiul the intestines bfamd down and matted together. There may be local or general ahtlominal distention, depending on whether loculi are formed or not liv the adhe- sions. On iK'count of the short ciiiTig of the niesentcry and malting together of the inlesliiies there may he dullness all over the ahdoruen. so that this form of ascites is particularly liable to be mistaken for ovarian cyst or luinour. .Mbuniinuria is fre(|Ucnt on account of interfer- ence with the renal circulation, and IIkic may even be a few tube casts : there may or may not be actual renal disease, but this should not be diagnosed from the albuminuria unless there is also high hlood-prc'ssurc, retinitis, or other eonllrmalory sign. Ahdoniiiial pain is generally slight, and although there may be \-omiting or coiislipation. there is usually neither. Tiibcrciiloii.s Pcrilonilis.— This is the most eonunon cause of ascites In eliildrcn. There are several varieties, of which the following may be distinguished : — 1. The acute a.scltie form, whieli may siimilate acute general peritonitis due to perfora- tion of a viscus (see above). 2. The peritoneum may be studded all over with miliary tubercles without any caseous- 48 ASCITES masses. The ]ihysical signs are those of ascites without any abcloniinal tumour, and it is not diflicult to mistake it wlien it occurs in an adult for cirrliosis of the li\er or for malignant peritonitis, especially that form wliich is secondary to ovarian tumour. In a child, the occurrence of ascites witliout u'dema of the legs at once suggests tuberculous peritonitis ; in an older person tuberculous peritonitis is much less common. 3. The omentum may be contracted and thickened from infiltration with caseous or fibro-caseoiis material, and a hard abdominal tumour simulating an enlarged liver may be felt. It may be distinguished, liowever. by the resonant percussion note between it and the costal margin, and the liver edge may be palpable above and distinct from the omental mass which simulates it. Ascites in cases of this kind is generally less in amount than in the miliary tuberculous form. ■i. The intestines may be matted together and the adhesions thickened and infiltrated with tuberculous deposits, so that the peritoneal cavity may be divided into several loculi of fluid, tfie abdominal distention being not uniform, and paracentesis only removing part of the ascites. 5. The mesentery may be thickened and contracted, and tlie intestines bound down to the posterior parts of the abdominal cavity, so that if there is ascites there will either be dullness all over the abdomen, or dullness in front with resonance in the flanks, suggesting ovarian cyst rather than tubercidous peritonitis. After paracentesis, a more or less defined irregular deeply situated tumour may often be felt. 6. \Vhen the caseation affects the mesenteric glands in particular, multiple irregular tumours are felt, sometimes but not always associated with ascites. 7. Occasionally local thickenings in the abdominal wall are to be felt as the result of subperitoneal inflammatory deposits, a condition which may often be mistaken for rigid contraction of the recti muscles or for disease of the parietcs rather than of the peritoneum ; if. however, there is ascites at the same time, tuberculous peritonitis would be very proljable, particularly in a child. It will naturally depend upon the acuteness of the tuberculous process whether there will be pyrexia or not, and whether there will be abdominal pain and tenderness. In the caseous varieties, whether of the glands, omentum, mesentery, or abdominal wall, pain and tenderness are the rule, and the temperature generally rises to 101° F. to 104° V. each evening. It is not at all unconunon in such cases for redness and oedema to develop roimd the umbilicus, and for a purulent discharge to occur from the latter, or for a fiecal fistula to develop. The commonest cause for spontaneous fsecal fistula of the umbilicus is tuberculous ]jeritonitis. When the active tuberculous process has become quiescent there may still be ascites, though the temiierature is subnormal. AVhen paracentesis is performed, it is advisable to inject some of the fluid into a guinea-pig, to see if the latter develops general tuberculosis. The nature of the case may sometimes be suggested by the presence of tuber- culous lesions elsewhere in the patient's body ; for instance, in the spine, kidney, a joint such as the hip or knee, glands in the neck, or lupus, though very often tuberculous peritonitis is the only objective lesion. Ascilic Fluids. — It lias liocn stated tliat chemical analyses of ascitic lluid often afford material assistance in arri\ ini; at a diaL;iii'--is oT its eau>e : lait in |ji'actice only the broadest conclusions can be drawn. The liiulni I lie sihiiIh- ijiasily, llir laii^er the jicrcentage of albumin, and the greater the tendency to spuMlaiu mis c cpai;iilali"ii. tin- nimi- dilinitely can one conclude that the condition is an inflammatory exudate — e.g., specilic gravity l,0'j."i. luiiity ])aits per thousand of albumin, with a spontaneous coagulation. The lower the spn illc i;iavity, the smaller the percentage of albumin and the more definite the absence of spontaiu oiis ((laiiulatioii tlic more likely is the condi- tion to be a non-innamniatory transudate — e.g., speeilic gravity 1,005, five parts per thousand of albumin, and no coagulaf inn. There are, however, many intermediate cases in which chemical investigation of tlie lliiid leaves one in doubt as to wliether the condition is inflammatory or not. It lias also been stated that diflenntial analyses of the proteids are lieljjful, notably as to wliether there is more globulin or more alliiiiuiii lucsent : but it is doubtful whetlier this really is so. iMiei'oscopical examinations are ninre \ahialjle than chemical ; the centrifugalized deposit sliould be examined under the lii;;li pci«(r ; it may exliibit many leucoc\^es in intlaminatory con- ditions, polymorphonuclear cells inrdoiniiiating in acute conditions, small lymphocytes in siiljaiiite or chronic affections such as tulierciildus ]ieritonitis ; peritoneal cells in cases of inllanuiiation ; and ncra'.idnally the diagnosis is elinelicd by finding actual fragments of new growtli or hydatid liouUli Is ( /■(!'. IS). 'I'lic (li |M)sits may also be stained for bacteria, and sometimes tubeicle bacilli, strc]itci(iH I 1, sl:i|.h\ l.jcdcci, ^diincncci, or pneumoeocci may he found. When investigating ascitic fluid liacUiiulciijiealiy, lui\ve\er, it is jjrobalily better to resort to cultural or inoculation methods than to rely solely ujion liliiis prepared from the deposit. ASCITES 49 Cancerous Peritonitis usually occurs in patients over forty, and the growth is practically always secontiary. Primary carcinoma of the peritoneum is very rare, and it is usually colloid aufl not associated with ascites. In secondary cases the omentum may be thickened and infiltrated, the umbilicus fixed, the urachus palpably infiltrated, and nodules and masses may develo)) all over the peritoneiun. Rapid emaciation and cachexia are the rule. .\ large quantity of fluid may be present, and if it is blood-stained at the first tapijing tjiis is very suggestive of malignant disease. .Ascites may be the first and only evidence of growth, and it may be mistaken for that of tuberculous peritonitis or cirrhosis of the liver, especially when the abdominal disten- tion is so marked that no nodules can be felt. Evidence of a primary growi^h should always be looked for with care, especially in connection with the stomach, pancreas, colon, rectum, or ovaries. Rectal examina- tion should never be omitted, and if need be the sigmoidoscope may be used. It should not be forgotten that usefid indica- tion of intra-abdominal malignant disease is sometimes afforded by enlargement of the left supra-cla\icular lymphatic glands by secondary deposits {Fig. 17). There is one variety of secondary malignant peritonitis which merits special mention — namely, that which may result from a proliferating papillomatous ovarian cyst. The malignancy of the latter is sometimes relative, so that although there may be thousands of ])a))illoma deposits on the peritoneum, causing ascites that may need tapping scores of times at short in- tervals, there may be no other secondary deijosits aiiyv>lurc. The diagnosis may be made as I lie nsult ol careful vaginal examination, nanl ])apillomata in the ascitic fluid, or ])erliaps I ■ simple ' peritonitis until the abdomen is opened. Ili/iliitiil ( 'lists in the peritoneal cavity may Ix- primarx, hut more often they are seeondarx lo lix.iatid disease of the liver. The malady is rare in this country, though comiuoTK T ill Australasia and elsewhere. The patient is generally an adult and th<' diagnosis is often obvious, though sometimes it may be very obscure. There may be a large globular tumour in the lixer. rarely giving the typical hydatid thrill : lliere ma\ he I^osinoimtu.i.v (p. 219). and an investigation ol I he lilooil scniiii in special laboratories may show the specilie hydatid scniiii reaclioii. In some eases in whieii there are hydatid cysts associated with ascites it is possible to make the diagnosis by rectal examination ; one has felt globular bodies about tlie size of grapes in front of the anterior rectal wall, and when these have been pressed upon to investigate them more fully, they have slipped away frotn imder one's linger through being pushed up into the ascitic fluid ; after waiting a moment the back into Douglas's pouch. .Similar mobility of spherical masses Fiff. 17.— Knlarsremeiit of the left supraclavicular glands ill a ca.se of abdominal malignant disease (carcinoma of the si!,'inoid colon). ir bv findin fragments of the iiialig- l)e regarded as ehrciiiic I'iij. IS.— Eel 1 (P^ linger has icil thin in the asej|l<' fluid iii:iy ix diagnosis depends U|ioii I he centesis or by la|)aidlomy. of liooklcis dors nol rxellldc ease nol |ndduciiii; hooklrls Cliilloiis .i.scilis is nol ill noted where lor iristan<-e. in an iliac fossa. The ultimate ileleelion of hooklels (/•'/i,'. IS) in I he lliiid obtained l)y paia- II is iiii|iorhiiil to hear In iiiiiid. h hxdalid (lisr;isc, llie cysts sometimes ilscir specilie iiialaily. tor lln we\-er. that the absence icing si erile . and in llial ire Ihaii one eonililion in 1- 50 ASCITES which the ascitic fluid may ajjjjear hke milk. Tliis may result from obstruction to the main abdominal lymphatics, particularly the receptaculum chyli and thoracic duct ; or from their rupture after injury to tlie abdomen ; more often the condition is associated in this coimtry, in some way which is not fully understood, with the ]5eritonitis of chronic T}ri«lil'.s- Discaxc, or of leiihceniia. The best known tropical cause for chylous ascites is Filfirid saiigiiiiiis hotninis with cle])hantiasis. In rare cases the secondary deposits of nuilioiiant disease may be such as to obstruct the thoracic duct, and so produce' the chylous condition of the ascitic fluid. Chyluria may or may not occur at the same time. There are two types of chylous ascites, one in which actual chyle accumulates in the peritoneal cavity as the result of direct leakage from the thoracic duct or receptaculum — true chylous ascites ; the other in which the condition is in the main one of ascites, but the fluid becomes milky-looking from little-understood chemical changes taking place in it, particularly in the proteids. This is termed chyliform ascites, or pseudochylous ascites. There is much more real fat in the former condition than in the latter : but chyliform ascites is commoner than true chylous ascites. The diagnosis between the two is afforded by chemical and microscopical analyses of the fluid obtained by tapping, the chief points of distinction being as follows : — Chylous Ascites. 1 . The fluid tends to accumulate very rapidly, and in consei|Ucnec larjic vohuucs arc rcinoved at ])araccntesis. 2. (icneraily ycUowish-wliite in colour and less perfectly emulsified. 3. IJegree of o])alescenoe nifnc or less con- stant at successive tappings. 4. Possesses an odour corresponding to the odour of the food ingested. a. Microscopically the fluid contains fine tat "lobules, but vcrv few celhdar elements. 6. General n standin". distinct creaniv layer 7. S])erilic i;ravity i;inirally exceeds 1012. S. Drpivssiim i.t irc-i/.in;; piiint about 0-51° C. and approximating that lroximate to the values found for ehvle obtained from the thoracic duct. Cliijtiform Ascites. 1. Collects more slowly, the volume of the fluid varying with the exciting pathological condition. 2. In colour a pine milky-white solution in the form of an almost perfect enudsion. 3. The opalescence generally increases or diminishes at successive tappings. 4. Odourless. 5. Microscopically the qiumtity of free fat is variable ; often numerous Hue, highly refrac- tile granules are present, and these do not give the reactions for fat. Cellular elements may be numerous and often contain fat ; sometimes very scanty. (). \ cream may or may not form, but does not affect the o])aIeseenee ; a sediment fre- quently settles out. v. Specific gravity less than 1012. 8. Dei)ression of freezing point ranges from 0'36° to 0'61°, and thus corresponds to the tifiures for blood scrum. )l. Tcital solids rarely exceed 2 per cent. 10. The ])rotein constituents vary between 1 and 3 grams per cent, and of these the serum-globulin occurs in ap|)reeiable quantities. 11. .Mueiiioid substances present. 12. The fat content is generally low, and it may be present in traces only : in its melting and chemical composition it jjrovcs to be patho- logical fat. 13. The most characteristic lipin is lecithin, though cholesterol is occasionally present. 14. The lecithin is mainly combined with the iilobiilin, and when present is the cause of the opalescence of the fluid. Such fluids resist putrefaction. !.■). The salts and organic materials correspond closely to those of lymph and serous fluids. ii. Obstruction to the Main Portal Vein. — This is most commonly due to enlargcmctii I J llic jKirtiil lyniphiilic Shiiiils by secondary deposits of malignant disease ; it is common for the main bile-ducts to be ob.structed at the same time, so that an increasing depth of jaundice accompanies the ascites. When there are masses of secondarv' growth in the liver associated with jaiuidicc, or ascites, or both, it is seldom that the hepatic masses are themselves respon- ASCITES 51 sible for tlie syniptonis, these being more often due to tlie associated deposits in the i)ort:il lymphatic glands. The diagnosis is made on discovering a primary growth, more often a carcinoma tlian a sarcoma. It is much rarer for tlie lympliatic glandular enlargement to be lymphadenomatous. tuberculous, or due to lymphatic leukaemia. If ascites were a promi- nent symptom in any of these conditions, it would be regarded as consequent on affection of the peritoneum rather than on obstruction to the portal vein, unless there were deepen- ing jaundice at the same time. In the latter ease malignant disease would be simulated. General enlargement of the lymphatic glands in tlie axilla", groins, and neck, with or without evidence of enlargement of those in the thorax or abdomen, together with enlargement of the spleen, would suggest either lymphadenoma or lymj)hatic leuk;emia ; the absence of positive blood changes would render the former more likely, for in lymphatic leukEemia there is more or less considerable leucocj-tosis with a great relative increase in the small lympho- cytes up to 90 per cent or more (p. 25). Only in very rare cases do tuberculous portal glands cause ascites, and when they do the diagnosis must be one of guess-work only, unless in association with definite tuberculous jieritonitis there were jaundice suggesting obstruction to the common bile-duct and to the portal vein at the same time. Thrombosis of the porlti! rein may be su])purative. in which case there is no ascites, but a pjTexial condition with rigors and possibly jaundice, diagnosed as a rule only when there has been sonic delinite inflammatory focus in the portal area, such as appendicitis, which miglit lead to infection of the portal vein. Primary thrombosis of the portal vein is rare, and its diagnosis can seldom be more than guessed at. It leads to marked ascites, possibly with simultaneous increase in any tendency there may be to piles, and without evidence of tuberculous or malignant disease of the ijcritoncuni or cirrhosis of the liver. It is by a process of exclusion that the diagnosis of portal vein thrombosis might be arrived at. especially if the ascitic fluid withdrawn by paracentesis, when examined chemically, were found to contain a relatively very high proportion of coagulable jsroteids without any par- ticular tendency to spontaneous coagirlation. and without those polymorphonuclear cells or lymphocytes that would be found if the high i)ercentage of proteid were due to the ascites being iiiHaiumatory. 'riinioiiis (if iitljdci'rit orgaii.s seldom obstruct the portal vein enough to cause ascites willioul presenting other symptoms which suggest the diagnosis. Sometimes, however, unless the tumour can be felt, great dilliculty may be experienced in determining the nature ol the ease, t arcinoma of the pancreas may be accompanied by glycosiu'ia and the passage of fatly stools, io/etlier with deepening jauTidice, progressive enlargement of the gall-l)ladder, and a positive ('a\i.\iii)(;!-.'s I' \n( lii-.ATic Hi'.ac IION (p, 100). On account of the relation of the tumour to the aorta, marked transmitted pulsation may be felt in it, and by inflating the stomach it may be demonstrated tliat the tumour lies posterior to the latter. Kenal tumours may be dilliciilt to distinguish from enlargement of the liver when they are big ; but they are generally a.ssoeiated with Albtminuiua (p. 1). II.KMArrniA (p. "275), or l'^ I ui.v (p. 57 1). Carcinoma of the stomach, duodemun. colon, or suprarenal capsule would be suggested by tlie ])osition of the mass, or by the gastric or inteslinal symptoms ; if there were ascites aeeomjjanving them, it would generally be due not to the primary tumour, b\it to secondary deposits cither in the peritoneum or in the portal lymphatic glands, .Inriirysm of the liepiilic iirliri/ is a pathological curiosity, though in recorded cases it has produced ascites and jaundice. The conunonest cause of aneurysm of the hepatic artery is fungatiiiir endocarditis with embolism. iii. Diseases of the Liver, Cirrhosin of llif l.ivrr. Wlicn asciirs is ihic lo ihis the or under, in a way which is characteristic. It is only if this eurlcd-under or turned-up edge can be detected that the diagnosis of perihepatitis can be made with certainty. Syphilis is possibly the cause of the malady in some cases. Ascites associated with carcinoma or sarcoma of the liver is usually accomjianied by intense jaimdice. and there is always doubt as to whether these symptoms are not due rather to coincident affection of the portal lymphatic glands than to the deposits in the liver itself. The latter becomes much enlarged, \ ery hard, the edge often coming well below the uml)ilicus. Probably the largest livers that occur are due to secondaiy carcinoma or sar- coma. They may reach a weight of 22 lb. or more. Besides being very hard, the liver may be tender, and umbilicated nodules may be felt on its surface. Primary growth of the liver is exceedingly rare, and though it leads to progressive and deejjening jaimdice, it does not often produce ascites. Secondary growth is so much more common, that it is important to look for the primary growth elsewhere with great care before primary growth in the liver is diagnosed. Retinal and rectal examination should not be omitted ; and Cammidge's pan- creatic reaction (p. 100) should be tested, in case the primary growth be in the pancreas. Syphilis may produce local peritonitis over a gimima ; it may also lead to general chronic peritonitis and thus to ascites. The diagnosis is made upon the history, upon the signs of syphilis elsewhere, and upon Wassermann's serum reaction. Hydatid disease of the lix'cr seldom of itself causes ascites, though it may be associated with coincident affection of the peritoneum with ascites (p. 49). We may now pass on to consider those cases in whicli. if the history is correct, there has been swelling of the legs l)ef'ore. or at any rate not later than, swelling of the abdomen : and if one Icillows the classilication as given on pages f.") and +(i. one CDnies next to : — iv. Obstruction of the Inferior Vena Cava above the Hepatic Veins. — This is rare, and will seldom be diagnosed imless there is either (1) clear evidence of extension of throm- bosis to the inferior vena cava from a previous thrombus in one leg, associated with exten- sion of oedema up the back, followed by albuminuria and perhaps ha-maturia when the renal veins are involved, and then by ascites, together with varicose distentif)n of the abdominal veins and re\ersal of the blood-stream in them • or (2) a history or the physical signs of chronic mediaslinitis. which generally results from recurrent attacks of pleurisy and pericarditis, esijeeially rheumatic, or of iiitratiioracic neiv groicth. which is distinguished from chronic mediastinitis by the shorter history and by the .r-ray appearances. {Fig. 42, p. 105.) (See Veins. Varicose TnoR.\cic, p. 750; and Veins. Varicose Abdominal, p. 748.) V. Chronic Failure of the Right Side of the Heart (Backward Pressure). — Ascites as the result of backward pressure in chronic heart and lung disease is nearly always preceded by swelling and (edema of the legs. Careful examination ol' the heart and lungs, a history of acute rheumatism, or of recurrent winter cough, or an abundant and oftensi\e periodic expectoration, may suggest valvular disease of the heart, chronic bronchitis and emphysema, or fibroid lung with or without bronchiectasis, to account for the ascites. Nutmeg liver also results in these cases, the enlargement varying with the degree of heart failure, the surface of the organ being smooth, sometimes pulsating synchronously with the heart. ASCITES 53 tender, with a well-defined edge which may reach below the level of the innbilicus in the right nipple line. The urine is apt to contain albumin, and when the heart failure has reached an advanced degree it may be exceedingly difficult to say whether it is due to primary valvular disease, primary lung disease, jirimary kidney disease, primary arterial disease, oi to primary affection of the muscle of the heart. The importance of casts in the urine in the differential diagnosis has been referred to under Albiminuria (p. 6), where the significance of the blood-pressure, of retinal changes, and so forth, are also discussed. The valvular heart lesion most ajit to be mis-diagnosed in connection with ascites is mili/il stenosis ; for by the time the heart failure has reached a sufficient degree to cause ascites, characteristic bruits, especially the presystolic, become no longer audible in many cases. The heart beats very rapidly and irregularly, no bruits may be audible at all. Mitral stenosis may still be suggested by the characteristic appearance of the face, with its yellowisli |)Mlior of the forehead, and around the nose and mouth, with bright or dark red coloration of the lips and over the malar bones and upper portions of the cheeks ; or by the history of acute rheumatism or chorea, though absence of such a history by no means excludes valvular heart disease. It may, however, be im]M)ssible to say whether there is mitral stenosis or not mitil the patient has been kept in bed, given digitalis, and watched for a week or more, until there is some degree of recovery of the cardiac compensation ; by whieli time the characteristic bruits of mitral stenosis very often return with the increasing force of the lieart"s beat. Some of tlie luirdest ol luart-laiiure cases to diagnose with certainty are those due to cliioiiic iijjvctioiis of the iiijpciiiiUnm or to adhiicnt pericaidiiiiti. In each case the diagnosis is arrived at mainly by a process of exclusion. Chronic myocardial degeneration seldom occurs in young people, or at any rate it is much commoner in middle life and later. The symptoms are those which are connnon in all varieties of chronic heart failure (p. 418), what- e\er the cause of the latter. There may or may not be the systolic bruit of mitral regurgita- tion, or a7i aortic systolic bruit due to atheroma of the aortic valves, but upon the whole the physical signs do not suggest vahular disiase : the urinary ihanges and the absence of casts do not suggest nephritis or granular kidney : the blood-pressure may not suggest arteriosclerosis : the lung signs do not suggest bronchitis and emphysema, or fibroid lung : so that some myocardial affection is all that is left to diagnose. If there is a history of tlie drinking of much alcohol, particularly beer. iiriiiKiiii (ilcniiiilir heart may be susiiected, though this is less eonuuon in Kuglaud than in (iermany. Fall// superpiisition would he suggested if there was general ot)esity with shortness of breath on orditiarv exertion ; whilst overload- ing of the surlaee of the heart seldom occurs without some />(//)/ iiililtriilioii at the same time. Fatlij (leoeiiernlioii is more likely after a long febrile illness, or chronic (joisoning by phos- phorus, arsenic, or lead, or by the hy])olhctical toxins of severe anu-mias, such as pernicious or aplastic ana-mia. Fibroid lie/irl is very dillieidt to distinguish from fatty heart, but it is the more likely in a syphilitic patient, particularly if tlic palieiil is not obese and if there Is syphilitic aortic reyuruilatioii or angina pectoris. -lilliereiil perirardiinii is not in itself an explicit term, for tin re are three dill'ereiit <(indi- lions which come under the one heading : there luiiy be (1) .\dhesions between the parietal ami visceral layers of the perieardimn ; (2) Adhesions between the iiarietal |)erieardium and tlie structures around it, particularly the i)leura', diaphragm, and chest wall ; or (3) .Vdhesions bolli of the parietal to the visceral layer of |)ericardiiun and of the parietal layer to the structures outside it really a form of chronic niediastinitis. It is clear that the physical signs will difler aeeonliui; to which of these three things has hap|)eMed. That whic'li ought to be implied strictly 1>\ llie term adherent pericardium is adhesion of the |)arlctal to the \ise( lal layer, without aii\ oIIkt aclhcsioiis whatever, and of this condition there are no positive physical signs at all. \u\r need lliei<' be any symptoms. The diagnosis is generally made by "iiess-work. the palieiil being known to ha\c had pericarditis, or being suspected of having had it because of having sulfered from aeule rlieunialism willi severe complications, and the heart now being round iinieli larger than it ought to he in proportion li' the apparent valvular disease as indiealeil li\ I lie bruits. It is common, however, for the parietal and visceral layers of |)ericardiuMi lo he universally adherent without the hear! being big. iiiul without there being any ill erieets at all. the condition being met with posl- niorteni in patients who die of something cpiite dilTcrent. It is otdy when the parietal layer has become .•KlhcrenI lo the xisecral la\cr when the heart was alreads' dilated at the lime nf 54 ASCITES the |)eiiciirditis that symptoms subsefjuently accrue, the result riither of the inability of the already big heart to maintain siillicient hypertrophy than of any intrinsic interference with its action by the adJierent pericardium itself. It quite often hap])ens. indeed, that when there has been rheumatic myocardial affection without ])cricarditis. the big heart that results is out of all proportion to the valvular disease, and yet in the post-mortem room no abnormality of the pericardiinn is found. The following points in connection with heart disease in children are as true as most aphorisms : mitral stenosis is almost unknown before puberty, whatever the bruits that suggest it ; heart disease never proves fatal before puberty unless as the result either of the severity of the acute inflammation of valves, muscle, or pericardium, or else from adherent pericardium. Fatal mechanical failure of the heart before jjuberty in a patient who presents no symptoms of rheumatic reinfection points to adherent pericardiimi. Adhesions between the parietal pericardium and the structures outside it, without any adhesion between the parietal and visceral layers within the pericardium, are exceedingly common, generally resulting from former ])leurisy. The former inflammation must have extended outside both the pericardium and the pleune. so that it was really a mediastinitis ; but clinically the condition is seldom spoken of as mediastinitis. because it is of very little importance, and in itself produces no symptoms ; the physical sign which might suggest it is deficiency in the movement of the position of the cardiac impulse to the left or to the right as the patient rolls from one side to the other. The third variety of adherent pericardium, namely that in which there are adhesions between the parietal and visceral layers and between the jiarietal layer and the chest wall, pleurse, and other structures outside it, is really a combined condition of adherent pericar- dium and mediastinal adhesions which, when an extreme degree is reached, becomes what is known as chronic mediastinitis. Here again, it is possible for neither symptoms nor physical signs to present themselves, the condition being found unexpectedly in the post- mortem room. It is this condition which is generally diagnosed under the name of adherent pericardimn. There will be a history of former pericarditis, pleurisy, or both, probably rheumatic. The heart will be large out of all proportion to any valvular disease that is present, without there being other ob\ious cause for its hypertrophy and dilatation, such as nephritis, arteriosclerosis, hard work, alcoholism, fatty or fibroid heart, or chronic lung disease. If the ])arietal |)ericar(liiuu is adherent both to the pleura" and to the diaphragm — particularly the latter — there will very likely be retraction of the lower left ribs posteriorly, synchronous with the heart-beat ; it is this physical sign — systolic retraction of the lower left ribs — which is generally regarded as pathognomonic of adherent pericardium ; it is really evidence, of course, of adhesions outside rather than within the pericardimn. The sign needs to be looked for with some care ; the observer watching the posterior profile of the left chest from the patienfs left side, small movements obviously due to cardiac and not 7-esi)iratory action are to be seen in the ninth or tenth intercostal space in the line of the angle of the scapula, or just outside this : irregularity in the heart's action often render- ing these visible only now and then — perhaps only when a strong heart-beat happens to coincide with the most favourable phase of respiration. The sign, however, is far from uncommon. Another physical sign which is regarded by some as indicative of general pericardial adhesions, is an ingoing imi)ulsc in the third or fourth intercostal .space half-way between the left nipple and the left liordcr of the sternum, synchronous with an outgoing impulse nearer the apex, giving an oscillating or see-saw appearance to the precordial region — some of the intercostal spaces moving inwards at the same time as others move out with the heart-beat. As a matter of fact, the probable explanation of the ingoing mo\ement nearer the stern.mi when the part of the heart which is nearer the apex causes the ordinary outgoing impulse, is the visible withdrawal of the hypertropliied right ventricle as it contracts. This see-saw appearance in the precordial region is indicative therefore of great hypertrophy of the right ventricle ; it does not indicate what is the cause of this hypei-trophy, though amongst its causes would be adherent pericardium. A similar appearance is often seen in cases of extreme mitral stenosis of long standing, even when there is no adherent ])ericardium. Bright's Disease may produce ascites in more ways than one : the effusion may for instance. sim])ly be part of a general anasarca, the accumulation of the ascitic fluid in the peritoneal cavity corresponding precisely with its accunmlatiou in the sTibcutaneous tissues ; ATAXY 55 or the Bright's disease may lead to aeute or chronic peritonitis of the types described above ; or. especially in chronic cases associated with pale or red granular contracted kidneys, there may be failure of the dilated and hypertrophied heart, with ascites, which may be very difficult to distinguish from that of primary heart disease ; especially as the greater part of the associated albuminuria is now the result of the heart failure rather than of the renal sclerosis : and easts may seem unduly few in proportion to the albinnin. If the blood- pressure is \ery high the diagnosis is more likely to be arteriosclerosis or granular kidney than primary heart-failure, though, curiously enough, the blood-pressure is generally above normal in heart-failure from any cause, even when the pulse is as irregular and feeble as it often is in the late stages of mitral stenosis. This terminal rise of blood-pressure in heart cases pr(ibal)ly results from the ]5artial asphyxia. Severe Aneemias often cause ascites, but they do not give rise to much difficulty in diagnosis, because the sub-acute or chronic peritonitis which is the cause of the ascitic exudate in these eases arises, as a rule, comparatively late in the disease, after the diagnosis has been made on other grounds, by blood-counts and otherwise. (See An.emia. p. 20 : .Spr.KEX. Enlargement of, p. 028 : Lv.mph,\tic Gland Enlargement, p. 376.) One need not do more here than refer to the huge enlargement of the spleen without lymphatic glan- dular enlargement, and the great leucocytosis with a large jjortion of myelocytes, in spleiio- midiitlari) leukcemia : the considerable leucocytosis. the enlargement of the lymphatic glands and probably of the spleen, and the great relative increase of the small lymphoc_\-tes, in lymphalic leukcemia ; the enlargement of the lymphatic glands and of the spleen, and the absence of any positive blood changes, beyond ana>mia of the chlorotic type without leuco- cytosis. in Ilorlskin'fi disease : the enlargement of the spleen, the absence of lymphatic glandular enlargement, and the occurrence of a progressive and ultimately severe an:rmia. of the simple chlorotic type without leucocytosis, but with an occasional myelocyte and basophilc corpuscle, in splenic ana'inia (which often, as the course of the disease goes on. turns out to be cirrhosis of the liver) ; the profound anaemia and the high colour-index without leucocytosis. in pernieious anmmia ; the severe aniemia suggestive of j)ernieious aniemia. but with a persistently low colour-index, in aplastic anwmia ; and the s])lcnic enlargement with profound chlorotic ana-mia without leucocytosis, in pseudo-lciika'mia irfaiilum. Ilerh'il French. ATAXY is tlic term used to describe voluntary movements which are imperfectly controlled or co-(>nlinatery allerenl iiupulses, so-cmHciI t)ee:iusc llicy ucxcr reacli (■(lusciiiusiiess, pa.ss from tlie pciiplicnil sinietincs coiicerued in niovenicul. hv wav of the pciiplieial nerves and the iiseendiiiL' ccrilu'lhir lra<-ts of the eoid. to the ccrchilliifii, and I'liincipMlly to the eerelellar lolic (if the same sier extremities must also be investigated with the same care. The jjatient may handle his stick in (piite a natural manner, but if asked to unbotton and button his coat, to touch the ti]) of his nose with the tip of his linger, to write, etc.. he may fail to convince the observer that his control of fine movements is up to the normal standard. Having ascertained the existence of ataxy, the next ste)) is to decide whether it is dependent on the loss of sensory or non-sensory afferent imiiulses, or on the imperfect function of the cerebrum or cerebellum. If the ataxy is due to loss of sensorj' impulses, it will lie increased by the loss of visual impulses brought about by closing the eyes. It will also be ])ossible to demonstrate the loss of sensorj' impulses by asking the jiatient to describe the position of a liml^ with his eyes closed after it has been moved by the observer. When these two tests are i30siti\c. it may safely be assumed that the lesion affects the first set of impulses or their cerebral destination. If. on the other hand, the ataxy is uninfluenced by closing the eyes and the patient is perfectly accurate in describing the position of his limbs, it is probable that the cerebellar tracts are at fault, or the cerebellum itself. For further localization of the lesion in any i)articular case it will be necessary to take into account concomitant phenomena. Interference with the passage of im|)ulses necessary for proper co-ordination may be l)rovokc. also referable to interference with the functions of the nerves. The gait is imsteady. and the patient keeps his legs apart in order to lessen the tendency to lose his balance. The clumsiness of the upper extremities may be demonstrated by his inability to bring the first finger of one hand accurately into ajiposition with that of the other, or to touch the tij) of his nose with either. Both the imsteadiness of gait and the awkwardness of the fingers are exaggerated if he attemj)ts to walk, or Qurry out movements with his hands ATAXY 57 when his eyes are closed. A tendency to high-steppage will be noticeable in walking if. in addition to the ataxy, there is well-marked paresis of the dorsiflexors of the ankles. In such a case the jiatient is obliged to lift the feet to an nnvisiud height in order to clear the ground . •2. Spinal Cord. — The ataxy due to disease of the s])inal cord is seen best in tabes iliiisfilis. in which malady degeneration of the (josterior colunm ascending tracts occurs early, and in wliicli. consequently, the patient does not receive the normal impulses from the muscles, tendons, and joints so necessary for the preservation of his sense of position and movement. Contrary to popular ideas, gross ataxy is met with only in a small pro- portion of the cases of this disease, and it is often necessary to apply delicate tests to demonstrate its presence. The patient's gait may not be remarkable in good daylight, but he may complain of its uncertainty in the dark, or he may be obviously ataxic with his eyes closed. Another patient may have noticed nothing amiss with his walking in the ordinary way, but if he is asked to follow a line on the floor, placing one foot exactly in front of the other, his impaired jiower of balance will become apparent, especially if he is directed to accomplish this test with his head raised and his eyes fixed on something in front of him instead of ujjon his feet. In cases of moderate ataxy the gait and stance of the patient are remarkable for the wide base he assumes, and his tendency to guide his feet by means of his vision. Romberg's sign can be obtained easily. This sign is not diagnostic of tabes, as is so often assumed, but is merely used for the purpose of ascertaining whether the removal of visual impulses will convert a condition of stability into one of instability. Many if asked to describe Uomberg's sign, reply, " You direct the patient to put his feet together and close his eyes ; if he sways or falls, the sign is present." This is obviously incorrect, because the patient may sway even before his eyes are closed. In order to test a patient for this sign, he nuist be directed to stand with his feet as near together as he is able to do with steadiness, and, having established his stability in that position with open eyes, he must be told to close the latter. If he sways or tends to fall, it is clear that he had been depending on his visual impulses, and that, without their aid, the im])idscs derived from his legs and trunk were insullicient for the jjreservation of his equilibrium. We have in this test, therefore, a valuable method of ascertaining whether the function of the posterior columns is being carried out normally. 'i'o judge from the descrij)tions given in some text -books, the typical gait of tabes is one in which the legs arc thrown into the air and the Icct brought to the ground with a more or less noisy stamp. As a matter of fact, this type of gait is seen only in a small proportion of cases, and is rarely observed cxcc))! when the |)alient is depending for sujiprjrt either on :i couple of sticks or on one or two attendants. In other wiirds. he has become so ataxic that he cannot walk unsupported, and, being suj)porteil. he no longer attempts to control the exuberance of his leg movements by means of his sight. Tabetic ataxia in its moderate and extreme degrees can be dcnKinstr.ded when the patient is at rest in bed. by asking him to carry out accurate movements with his hands and feet with and without the aid of his vision. In slighter degrees the fact that the ataxia is de|)endent on interference with his sense of position and movement may be proved by asking him to describe the position of a linger or toe which the observer moves in dilierent directions,^ .Sometimes it is as well in testing this sense in one limb to ask the patient ti) place the corresponding limb in llic s;nii<' positinn. when the error will be made more obvious. The diagnosis of tabes eaiiiml be in:ide Iroin I lie character of the ataxy alone, since in nllicv diseases, such as Krieiliar liiizuird. ATHETOSIS. -(See Contkactidn-s, Kil.) ATROPHY, MUSCLLAR.- Muscular atrophy is often merely part of a gcncnil hy. ])articularly as they also are Fiij. L'li.— Tuorh- iMTi-n ■;,1 tvp.-' ot nouro-nniscn ilystrophy— early ; tlir |.;ii iriit 1- thf voiitiger iM-otl of the girl in -/■'"/. '1. \'iti ilir iilantar-flexion the bin toes an-l Hir , t,.i'i>iii_- of the feet; t calves are not yci \\;i-!iil le boj- ill Fi:j. ajvnuced stage led to the calves, hereditary, begin insidiously at an early age. and slowly advance — arc Fii('(liricli\-: atd.ry, and Tootli's peroneal ti/ite (if jiroiire^siie niiisiiihir ahophi/. l^acli of these may cause talipes, moreover, and therefore shnulate infantili |KiiMlysis. i \(( |il that in the latter the talipes is ■ generally one-sided, whereas in the other two it is bilateral. In Friedreich's ataxy (see !>. 51".i) there is no real wasting, but rather a lack of development. Tooth's peroneal type of )irogressive muscular atrophy is apt to come on after some febrile malady such as measles or whooping-cough, the lirst thing noted being inability to dorsiflex the big toe, which hangs down in a way that is the exact converse of its erect position in Friedreich's ataxy (Fig. 20) ; the paresis takes months or years to spread to the rest of the legs, and finally to the hands (Fig. 21 ), the slowness of the ]5rogress and the absence of sensory symptoms showing that it is not peripheral neuritis, whilst the R.D. in the affected muscles excludes ATROPHY, MUSCULAR 61 ii primary muscular (lystr()])liy. The lesion is in the anterior eorniial cells and starts in the lumbar enlaruement. The knee-jerks are retained until the ()uadrice])s of the thigh is involved. Local muscular atro])hy may be due to tliscasc of the pnrls hciwatli. as in the case of the pectoralis major, the supraspinatiis, the deltoid, the infraspinatus, and other shoulder muscles when the imderlying luni; is the site of active phthisis. Similar local atrophy results very ([uickly from acute and subacute affections of joints, es])eeially in the muscles whose origin is above the affected joint. The gluteal atrophy associated with tuberculous hip-joint is well known : similarly, knee-joint disease leads to thigh atroi)hy, elbow disease to atrophy of the muscles of the upper arm, and so on. The same applies to the effects of fractures, new growths, sprains, and splints ; the atrophy is sometimes so rapid that some think it cannot be due sinijjly to disuse, but must have a neuro])athie factor also. The affected muscles present no R.D., however. One jjarticular form of paralysis associated with the use of splints merits special mention, namely. Volckmann"s paralysis of (he forearm. (See PAnAi.vsis op the Uppf.k Extremity, p. .508.) Hemiatrophy of the face or trunk is generally congenital, and the diagnosis is not diHieult (see p. 4<)4). If it can be decided deflnitely that there is some nervous cause for muscular atrophy, the best proof of which is the detection of partial or complete R.D.. the diagnosis lies between one or other of the following conditions : — 1. Causes in the Spinal Cord. — Progressive muscular atrophy A few cases of transverse I Tooth's peroneal ty|)e of )iro- Aniyotropliie hitcnil sclerosis i myelitis gressive muscular atro|)hy Syriiigomvclia | Acute anterior ])olioniycIitis •_'. Causes In the Peripheral Nerves. TaiiKMirs of the CMiula ('(iniua New growth (iummata, etc., involving the Pelvic tumours involving the Accessory cervical rlh. (((■., cranial or other nerves huiibo-sacral plexus pressing on the Inachial Injury to pcripluial nerves, Sciatica pk-xus I ineiuding the eUccts of callus Aneurysm after fractures Peripheral neuritis, of which the following are some of the causes : — Certain inorganic chemical Certain severe ana-mias : Mcii-hiri substances, notably Pernicious anaTnia Sy|ihilis I-ead " Splcno-nieilMllary leuUa'Uiia Typlioid lever .Arsenic I.\ rn|ihatic Icuk'aiiiia Inllucnza Mercury Ilnd^kin's disease Oral sepsis Splenic auicinia Certain eoiistitntional diseases Certain or;!anie chcMiical conj- Certain niicroliial ay allied sonictiines attributed l.i pounds, notably liixins endogenous poisons : Alcohol I)i|ihthcria Gout Ktlier Leprosy I Diabetes mellitus Carbon bisnlpliide Malaria ! Pregnancy Nai'ldlia I Chronic pya-niia Other eauses as yet undeter- I Infective endocarditis niincil. In arriving at a diagnosis in a particular case, it is important not to use the term ' lutuitis ■ luitil all the other possible Icsiiuis have been excluded. Tooth's peroneal lyi)C ol progressive muscular atrophy and acute anterior ])oliom\ clil is have already been iliseusscd. The Udler is sometimes regarded as essentially a disease of early life, but it is important to renu^mber that it is by no means impossible for it lo affect an adult, in whom the symptoms and results may be precisely similar to what they wotdd l)c in a child. I'rdfiirnsivc muscular (ilid/ihi/ is a disease of adults. It shows no particular tendency to occur in several members of the same family. It begins insidiously, and advances slowly for months and years, affecting lirst the small nuiscles of the bauds, causing alrophv with H.I), iiijlhe interossei and in the muscles of the Ibcnar and h\pothciiar cmineuees : the p<'i-Mliar deformilv .|es( libcd as • main-ciinriHe ' results (p. to:)). In I lic' course of months Ibc paresis spreads from the bands to the forearm, and lalcr to llic upiicr arm. Disease of the pcripluTal nerves, such as the ulnar, is cxcludc' of the disease is analogous to the nuclear cell-degeneration in the medulla oblongata that leads to bulbar (labio-glosso-pharyngo-laryngeal) paralysis : and indeed, progressi\e muscular atrojihy may either follow or be followed by bulbar paralysis. If. at the same time that there are the signs of progressive muscular atrophy in the hands, there is also spastic paresis of the legs, with no wasting, but increased knee-jerks, ankle clonus, and extensor plantar reflexes, the onset having been quite gradual, without sensory disorder, and without bladder or rectal trouble unless the disease has reached quite a late stage, the condition is amyotrophic lateral sclerosis. It is important that the character of the onset and the absence of sensory symptoms be insisted on, in order to exclude syringomyelia and anomalous cases of transverse myelitis. Si/ringomyelia is rare, but it has one very characteristic feature, namely, the preservation of ordinary cutaneous sensibility with the loss of power of distinguishing heat from cold, or pain from touch, in some part of the limbs or trunk. There need be no other symptom than this dissociation of sensations, or skin lesions in the jiartesthetic parts may be a prominent feature — Morvan's disease ; if the enlargement in and around the central canal of the cord displaces and destroys the anterior cornual cells in the lower part of the cervical enlargement, progressive muscular atrophy is simulated : if at the same time the bulging of the central canal and the changes around it cause compression of the crossed pyramidal tracts, there will be all the motor symptoms and signs of amyotrophic lateral sclerosis, the diagnosis being only possible when the sensory symptoms are typical. It is generally stated that transivrse myelitis causes spastic paraplegia without muscular wasting or R.D. This is in the main true, because the few anterior cornual cells destroyed by the transverse softening of the cord in the commonest site, namely, the dorsal region, correspond to an iMtcrciistal or abdominal segment, the wasting of which is difficult to detect. If, howcxci. tin- Iransverse myelitis occurs so high up as to involve the lower part of the cervical eiilargnmnt — to involve the cord yet higher up is incompatible with lite, because both the intercostals and the phrenic nerves would be paralysed — a certain niunber of the anterior cornual cells sending motor nerves to the hands and arms would be destroyed, the result being a main-en-griffe like that of progressive muscular atrophy : and the simultaneous interference with tlie crossed pyramidal tracts would produce a picture identical at first sight with amyotrophic lateral sclerosis. Not only, however, would there very likely be impairment of all forms of sensation as well as paresis, in a case of transverse myelitis, but instead of the onset being gradual and the progress a steady advance downhill, as in progressive muscular atrophy or amyotrophic lateral sclerosis, the onset would have been comparatively rapid, followed by a cessation or even by an improvement if the jjatient lived. Similarly, if transverse myelitis occurs so low down as to involve the lumbar enlarge- ment of the cord, it would cause, not spastic paraplegia with increased knee-jerk, ankle clonus, extensor plantar reflex, no wasting and no R.D, : but absence of knee-jerk, no ankle clonus, no extensor plantar reflex, marked muscular atrophy of the legs, with R.D., ]jaraesthesia, bladder and rectal trouble. The involvement of the sphincters in such a case would be of considerable aid in excluding peri])heral neuritis ; whilst Tooth's peroneal type of prog^essi^'e muscular atrophy and acute anterior poliomyelitis would be excluded not only by the para;sthesia, but also by the history of the mode of onset and the course of the maladv. A timiour involving the caiida equina is rare, but it is not altogether diflicult to diagnose. It may be more diflicult to determine the nature of the mass — gunmia, glioma, primary sarcoma, secondary sarcoma or carcinoma — than its site. The onset of symptoms is generally gradual, and one leg is aflected either earlier than, or more than, the other. Weakness in the leg, together with severe pains both in it and in the lower part of the lumbar region of the spinal column, will be followed by muscular atrophy and R.D. Sciatica may at first suggest itself, until it is found that neither the pains nor the paresis correspond to one single nerve ; and when the disease progresses and the other leg is affected, anaesthesia supervenes upon the paralysis. The site of the pain over the region of ATROPHV. .ML'SCULAR 63 tlic Cauda cfiuina i^ an iin|jiirtant jjoint in tlu- diagnosis, whilst rectal and ]jossibly \aginal examinations arc essential for the exclusion of a pelvic mass — snch as carcinoma of the rectnm, uterus, or ovary, a flbromyoma, a cyst, a sarcomatous, gummatous, tuberculous, or inflammatory mass, or e\en a displacement of the womb — which, by interfering with the nerves at the back of the pelvis might produce very similar symptoms. Sacro- iliac joint disease can generally be excluded by the fact that the pains arc not definitely referred to the joint, whilst any wasting that might be associated with disease of that joint would not be accompanied by R.D. Srialicii (p. 438) does not always give rise to wasting of the corresponding muscles : but sometimes it does, and occasionally it nuiy do so bilaterally, with R.D. The localiza- tion of the pain, tenderness, and atrophy to the parts supplied by the great sciatic nerve, without affection of other nerves and muscles in the leg or calf, would point to sciatica, especially if the lesion was unilateral, and if the patient, though imable to flex his thigh to a right angle with his abdomen at the same time that lie keeps his knee extended, can extend his leg backwards at the hi])-joint in a way that would be impossible if he had a psoas abscess ; and if he is able to bear firm backward pressure on the knee when the leg of the -affected side is flexed and outwardly rotated in such a way that the foot lies across the opposite knee — a test which will exclude hip-joint disease. When the lesion is a thoracic (nieiiri/.im or neoplasm, or :.n accessory cenical rib pressing on or involvinti the brac)iial plexus, the wasting is almost certain to affect one arm only, or one arm mudi more than the other, and the diagnosis will be made by j)hysical cxamina- tioM of the thorax, assisted by the .r-rays. The only cranial nerve paralyses that are likely to be associated with marked atrophy of muscles, are those of the seventh with facial atrophy (]>. tOU). and of the twellth with atrophy of the tongue. Injaries io periplicral nerves, or inclusion of the latter in callus, will generally be diagnosed by the history, and by the fact that in distribution the nuiseular atrophy and H.l). eorres])ond accurately with one or more of the peripheral nerves that may have been di\ided or otherwise injured. If all the conditions described above can be excluded, it is probable that the cause of the nuiseular atrophy is some variety of peripheral neuritis. To merit this diagnosis, the affected muscles shoukl be multiple and .symmetrical : partial or com|)lete R.D. should be obtained : there nuiy or may not be sensory changes ; the reflexes, both superficial and deep, are for a short time exaggerated, and then become deficient or develop in the fluid as tlii' drop descends. Arseniciil nvurilis has been mentioned above (p. Gl) ; it may arise in patients who are 66 ATROPHY, .^lUSCULAK taking arsenic in medicinal doses, for instance for chorea or peniicions ana'mia, or the j)oison may be taken unawares, as in the Manchester e]3idemic. in which fatal results foUowerl contamination of beer with ai-senic. It has even been held that alcohol itself is no cause ot peripheral neuritis, and that those patients who have developed it as the result of lonjj- continiicd drinkini; to excess — possibly without a single actual intoxication in the popular sense — owe the nerve trouble and generalized muscular atrophy, not to the chemical sub- stance C„H,.0, but to other bodies associated with it. Clinically, however, it is sufficient if the diagnosis of the cause of periplieral neuritis can be narrowed down to alcohol in some form or other, and for this to be possible an accurate history is essential. The greatest difliculty arises in the ease of secret drinkers, especially women who may ajjpear to be above suspicion. The neuritis is ushered in with pains and cramps in the limbs, followed by wasting which may reach an extreme degree : the trinik and limbs sometimes look like those of a i)erson who has been starved to death : if arsenic is suspected, a portion of hair should be sent for cliemieal analysis ; the hair of a ])erson taking arsenic stores the latter in proportions sufficient to allow of its detection. It only remains to add that there will alwa\s be some cases in \\hich the cause of the peripheral nem-itis fails to be found. Herbert French. ATROPHY, OPTIC— (See ()pnTn.\i.MOscopic Appearances. Notes on. p. 416.) ATROPHY, TESTICULAR.— When one testis is smaller than the other, it is first necessarv to determine which is the abnormal one : for when one is slightly enlarged, it may be regarded erroneously as normal and the other as too small. Some inequality may be jjliysiological. as is the case with paired organs generally. Physiological atrophy of the testes is apt to occur in advanced life ; it may begin as early as fifty, though many old men have testicles of normal size. A testis in an abnormal position, in the inguii\al canal f>r elsewhere, is subject not only to such causes of atrophy as may affect one normally situated, but ma>- also be inhibited in growth from compression by surrounding parts. The causes of atrophy of a normally situated testis may be grouped imder three main headings, as follows : — 1. Interference with the Blood Supply: — Compression of the spermatic cord, as by an inguinal hernia, a spermatocele, or an ill- tittina truss. C(iiii|ir(ssiiiTi of the testicle by affections of tlir liniica vaginalis, such as hvdrocele or hainaldcrle. Venous stasis, tlie resuh of varicocele. .\s a sequel of operation in the region of the spermatic coril, such as those for the cine of varicocele, spermatocele, or hernia. Elephantiasis. 2. Atrophy, after Orcliitis or Epididymitis, due to such causes as — (ionorrlicea I Mumps I Gout Tubercle .Y-rays Syphilis Injury | Typhoid fever | Influenza (?) 3. Neurotrophic Causes, especially after injury to the brain or spine. It has been stated that the atrophy may residt from iodide of potassiimi : this is dillicnlt to prove, for it seldom hapjjcns that this drug is given unless there is already some oilier possible cause, particularly sy]ihilis or orchitis. In the differential diagnosis between the al)o\c causes the history is in most instances \cry important. The cause in any of the cases in Group 1 will generally be ob\'ious. It is only necessary to bear in mind that an operation for varicocele, for instance, may have been performed successfully, and the patient may thereafter contract an orchitis followed l)y tcsticidai atrophy for which the operation may be blamed unjustly. As regards Group 2. it is very doubtful whether influenza ever really ])rodueed either orchitis or testicular atrophy. There may be a definite history of gonorrhoea, followed b\ orchitis, which preceded the atrophy, and then diagnosis is easy. It is to be remembered however, that by no means every orchitis is gonococcal. If miunps, typhoid fever, goul and injury are borne in mind, these causes of orchitis and testicular atrophy will 1" recognized more often than they are. JMiunps is particularly apt to be overlooked : orchitii AURA 67 may be the sole e\'idence of this complaint. If the patient is seen when the orcliitis is active, bacteriological examination of any urethral discharge is essential to the dia- gnosis, which depends on whether gonococei are detected or not. If gonorrlura can be excluded, then the diagnosis of the nature of the orchitis is arrived at by considering the evidence as to gout, mumps, and so on. It is sometimes stated that orchitis may result from strain, atrophy resulting in due course. There are a few cases in which, apparently as the result of great bodily exertion, es])ecially the lifting of heavy loads, inflammation of the testicle follows : but it is difficult to say that in these cases the strain alone produced the symptoms ; there is the possibility that there may have been residual gonorrhcca in the jjrostate or jjosterior urethra, the action of the strain being merely to light u)) the latent inflammation. It is possible that sometimes the latent infection is not gonococcal, but due to other organisms, such as staphy- lococci or streptococci, whilst recent observers record the bacillus coli comnumis as the causal organism in some cases of " spontaneous ' orchitis. There remain a number of cases, however, in which there is no clear history of orchitis, the latter having been relatively slight. Testicular atropliy will then seem to have arisen idiopathically, and it is important to remember how often it is the result of former injury, such as a kick at football, a blow from a cricket ball, contusion from falling astraddle on a fence or bicycle, and so on. The injury may date back to boyhood, many years before testicular atrophy is noticed, and it will often be difficult to ))rove that the latter was really due to the former. r.1 A])art from obvious tuberculous epididymo-orchitis. transient enlargement of a testis is to be observed, if looked for, in tuberculous subjects ; whether this can be regarded as a dcMnite tuberculous orchitis or not. it sometimes results in atrophy. Tlie j'-rays are a possible cause of testicular atrophy, and all users of .r-rays should be careful to have a suitable lead shield. That sterility can result from repeated applications of these rays is well known. .\s regards (Jroup 8. the history as a rule gives the diagnosis. Remarkable instances have been recorded in which, within a few months of injury to the brain or spinal cord, particularly after injury to the hmibar vertebrje, or the occipital region of the skull, the glandular elements of the testicle have disappeared. A case of Kocher"s exemplifies this: A man. age 41. the lather of four children, fell on his head from a considerable height. .\t lirst he did not ajipear to be greatly damaged, but ])resently twitchings occurred, and the patient became unable to work. From this time on Iiis sexual powers diminished greatly, and his beard and iiubic hair fell out. Eighteen niontlis later this hair was gone compklcl\ . and about five years after the accident the left testicle was tbc size of a hazel nul. the right the size of a bean. llnhirt J'rnirli. AURA is the term applied to the inunediate prelude of an cpiUplic seizure. It is recognized in some form or another in about ;i() or 40 per cent of epilcplics, and with rare exceptions always takes the same shape with every attack in each indixidual. An aura may be motor, .sensory, ])sychical, visceral, or related to some special sense. A motor aiua may he rcpresenled by an involuntary movement of a limb or a part of a limb ; in othei' cases it talTcs the form of a general movement such as rumiing. .\ si'iisori/ aura is conmion. and is described as a pain, a numbness, or a tingling in some part of the patient's body. .\ psj/rliical iuna is often expressed as a vague apprehension, or an indescribable feeling, or a sense of unreality. .\ Tisreral aura is fre<|uent. usually as an •epigastric sensation" or queer feeling starting in the region of the stomach and rising to the throat, or less often as a pcremjjtory desire to go to stool. An aura of special sense may be olf/KiDii/. -riKiiiil. iKidiloi-i/. m fiii.ilnloij/ : a pleasant or unpleasant (iridui- m flavour may be pincJNcil b\ llie patient, or some alleralion in vision may warn liini u\' llu' onset of a sci/mc. or he may hear voices or some parlieular kind of soimil. The aura of epilepsy is. in relation to diagnosis, imporlani fr al Icasl I wo points of view. Ill llic lirsl place, it olleli affords a clue to the parliiular hiealily in llie brain froie whicli tlic ' III ' or • sloiin ' originates and spreads. This ma\ not he ol iiiiieli value in the case of idiopathic epilepsy, because there is no method at present known lo us by which the seal of the disease can be treated successfully. In tlu' ease of .buksonian epilepsy, on the other hand, the knowledge of the locality in which a (il is generated some- 6K AURA times, although unfortunately not often, allows of benefit being obtained from surgical assistance. For instance, an aura may be the first symptom of the presence of an intra- cranial groivth. A tumour of the uncinate region of the temporo-sphenoidal lobe may be revealed by the presence of signs of increased intracranial pressure and the repeated occurrence of an olfactory aura, followed by a vague, dreamy state of consciousness. A lesion of one occipital lobe may be suspected from the occurrence of epileptiform fits immediately preceded by an ain-a in which there is loss of sight in the opposite visual field. An aura of pain starting in the left foot, spreading up tlie left side of the body, and terminating in a generalized convulsion, suggests a lesion in the post-RoIandic region of the right parietal lobe. Such instances of the importance of an aura as a localizing sign in diagnosis might easily be multiplied, but a general knowledge of the functional anatomy of Ihe brain will suffice to supply other examples of a similar kind to the reader's mind. In the second place, the importance of recognizing a subjective sensation as an aura, and so recognizing the existence of epilepsy in its simplest and sometimes earliest form, can hardly be over-estimated from the point of view of treatment. VMien a patient describes himself as being liable to subjective sensations occurring at intervals, and for which he cannot account, careful inquiry should be made as to their nature. The chief characteristics of an aura are: (1) Its spontaneous development without cause, generally during good health : (2) The suddenness of its onset ; and (3) The identity of each sensation with the last. It should be understood clearly that an aura may occur alone, or may be followed by momentary loss of consciousness (petit mal), or by loss of consciousness with convulsions (grand mal). In some cases an aura may be repeated with frequency for many months before a typical epileptic seizure supervenes, and if recognized as such during this stage, it is reasonable to expect that treatment will have more chance of success than at a later period, when the " habit " of convulsions has been established firmly. Finally, it should be emphasized that in cases of epilepsy the recurrence of an aura, even without further manifestations of the disease, is evidence that the morbid tendency is not controlled completely, and that discontinuance of treatment will lead to the reappearance of more serious attacks. E. Fanjubar Buzzard. BABINSKI'S SIGN — consists in a modification of the plantar reflex. In testing the latter the j)atient should be lying upon his back, with his legs very slightly flexed and each foot everted so that its outer border lies comfortably in contact with the bed or couch : the sole should be warm and dry ; the ankle should be gently but firmly grasped by one of the observer's hands, to prevent the undue dorsiflexion of the whole foot which often makes it difficult to decide which way the toes themselves move, wliilst the outer side of the sole is firmly and steadily stroked from the heel forwards with some such instrument as the butt end of a pencil. In healthy adults the big toe and the other toes will become plantar-flexed : when the great toe becomes dorsiflexed instead, it presents tlic extensor plantar reflex, or Babinski's sign, ^^liichever way the other toes move, it is with the direction of movement of the big toe alone that Babinski's sign is concerned. It is noteworthy that if Babinski's sign is present, the fact is usually ascertained with ease ; when there is any doubt as to which way the great toe moves, the plantar reflex is seldom really extensor. The great value of the sign is in distinguishing between functional and organic affections of the nervous system. If the patient is a fully conscious adult with paresis of one or both legs, the existence of an extensor plantar reflex is proof that the lesion is organic. The converse is not true ; for with locomotor ataxy, and with lower neuron affections such as infantile paralysis. Tooth's peroneal tjpe of progressive muscular atropliy. perijiheral neuritis, Landry's acute ascending paralysis, and primary nniscular dystropliics, the plantnr reflex is flexor if it is obtainable at all. Babinski's sign is seen best when there is a lesion in the crossed jiyramidal tract. Thus it is present in cases in which tumour, abscess, hsemorrhage, thrombosis, or embolism have caused hemiparesis or hemiplegia by affecting either the pyramidal cells themselves in the motor cortex or the pyramidal fibres in the internal capsule ; in cases of cerebellar tumour, owing to the fact that this, by compressing the medulla, nearly always causes lateral sclerosis of the cord as well ; and in cases of disseminated sclerosis, transverse myelitis, either primary or due to compression, ataxic paraplegia, Friedreich's ataxy, amyotrophic lateral sclerosis, primary lateral sclerosis, some cases of syringomyelia, and in those cases BACTEKIURIA 69 of irregular sclerosis of tlie cord that may be associated with sc\erc ohgocytha?mias such as pernicious anjeniia. Tlie differential diagnosis of these conditions wilf be found under Hejiiplegia (p. £02) and Paraplegia (p. 310) and elsewhere. Babinski's sign is not found in those cases of hysteria that sometimes sinnilate one or other of the above conditions ; provided always that the ])atient is a conscious adult. This proviso is important, because the plantar reflex may be extensor without there being any decided changes in the cord or brain in infants and (luite young children : also in a considerable proportion of older children suffering from chorea : and also sometimes in adults during deep sleep, or under conditions of nnnatural unconsciousness such as that due to a general ana;sthetic, or acute alcoholic intoxication, or such affections as epilepsy, uraemia, concussion, saturnine encephalo- pathy, and in some other forms of coma. These exceptions, however, scarcely detract from the great value the sign has as a means of distinguishing between organic and functional paralysis of the legs of the upper neuron type. " " " Herbert French. BACILLURIA.— (See Bacteriuria. uifra.) BACTEHIURIA (see Plate XXVIII. p. Ol-i) is a comjjreliensive term employed to indicate that the urine when freshly voided contains micro-organisms. Bacilluria is a term of similar imjiort, but is restricted to those cases in which rod-shaped bacteria are present. The \:iginal segment of tlu^ female urethra and the anterior portion of the male urethra are n<)rniall>- inhabited by certain non-])athogcnic bacteria (chiefly cocci, such as Streptococcus brevis. StapliijIoioccK.s ulhiis. also varieties of Bacillus xerosis, etc.), which are, of course, present in urine obtained under ordinary conditions, and so constitute what may be termed physiological bacteriuria. Bacteriuria as a pathological condition tlue to some lesion of the urinary system posterior to the urethra can only be recognized with certainty by the examination in the laboratory of a catheter specimen of the urine collected with the most scrujiulous attention to asepsis : for, on the one hand, a perfectly clear acid urine may be hea\ily loaded with bacteria, and. on the othei-. a mine may owe its turbidity cither to purely physico-chemical causes, or to the growth in it of bacteria which have gained access after its exit from the urethra. Moreover, although the identity of the infecting organism may be suspected from general clinical considerations, cultivation exijcriments are essential in order to settle the matter beyond doubt. Bacteriuria may be jxrsistent and may indicate either general or local infection. It is a rare symptom of general infection, save one of such intensity that an acute ne])hritis, as.soeiated with a definite luematuria. has supervened. I'sually its appearance indicates a local infection of the urinarj- tract : it then occurs with greatest frequency in young children and ])regnant women, when the micro-organism concerned is usually B. cofi, and the site of the infection the pelvis of the right kidney. It is, however, met with at all ages and in both sexes, and many djlfercnt bacteria have been recorded as the causative faetoi's, and whilst the itilccliun is commonly due to some partieulav micro-organism, the possibility of multiple infection nuist not be forgotten —the most usual being a double inlVction due to H. roll communis and Streptococcus pijoneiies lotigus. When Intermittent, bacteriuria may indicate a general inleclion. or a local inreetion of some area , loii^r„s Sl:i|.li ylneoeciis pyojrcncs ail- 15. coli einnoet ininunis H. (iMial vpliosus M. typluiMis I .Micincocens niclilerisis /'? Local Infections : »e|ihritis, pyelonephritis. ,„■ ureteritis due to: — "•^"'' . H. |.neinn.mi;r (Kriedliin.ler's Sla|.l,yl.i H. luherciildsis M liacillus) Strcplocdceiis py(i;;cMcs Iciml'Ms Pn. 70 BACTERIURIA Cystitis due to : — B. coll I B. typhosus I Staphylococcus pyogenes au- B. tuberculosis i Streptococcus ])yoaeues loufjus | reus Prostatitis due to : — B. coll I Staphylococcus ijvogcucs au- Streptococcus pyogenes longns tJonococcus I reus Urethritis due to : — Conococcus < Pneiunococcus j Micrococcus catarrlialis Sta|)hylococcus aureus or albus ' Streptococcus pyogenes longus , In tlie above table the various micro-organisms are, speaking generally, arranged in the order of their frequency. Finally, a slight and transitory bacteriurla due to B. coli commioiis, and one usually passing off without any treatment, can frequently be observed following operative measures upon the rectum or anus, or the organs of generation. In general infections the urine is either normal in appearance, or by reason of its admix- ture with blood may present any tint from " .smoky ' to bright red. The reaction is usually acid; often a degree of acidity is recorded which if present in an artificial culture medium would inhibit the growth of the infecting micro-organism. Albumin is present, varying in amount from a trace to 7, 8, or more parts per thousand, and microscopical examination of the centrifiigalized deposit shows blood-cells, renal tube-casts, and renal epithelium, in addition to the infecting bacterium. The clinical sym|)tonis ])resented by the patient are those of the general systemic infection. In local infections of the genito-urinary tract where infection is due to one species of micro-organism only, the urine jjresents a somewhat similar appearance ; blood, liowever, may be entirely absent, while pus when measured by the centrifuge may vary in volume from a trace to 10 or 20 per cent of the total bulk of urine. In the early .stages of a local infection, however, microscopical examination of the deposit may merely show the presence of leucocytes slightly in excess of normal, so that without the use of the microscope the fact of pyuria may easily be missed altogclher. Occasionally, and particularly in adult cases, it may be noted that the urine passed during the day is neutral or faintly alkaline — the change in reaction then being due to |)hysioIogical causes. In those cases where the urine is strongly alkaline the alkalinity is due to annnonia resulting from the decomposition of urea, not by the jiathogenic infecting organism but by non-pathogenic saprophytes which have gained access to the urine, either after it has been voided or whilst still intra vesicam. In the latter instance the contamina- tion may have taken place as a residt of careless instrumentation, or (as in the female) by continuity of surface, but it also fretjuently occurs owing to the passage of micro-organisms through the inflamed bladder wall from the lumen of the adjacent large intestine. The clinical symptoms associated with bacteriuria due to local infection vary enor- mously with different patients. Frecjuency of micturition, scalding, didl aching pains in one or both loins, with tenderness on deep jjressure over the kidney or meters, pains in the perineum and hypogastriiun (according to the situation of the jirimary infection), severe rigors, pyrexia {Fig. 193, p, 456), anorexia, nausea, and vomiting are amongst those commonly observed. It is important to remember its relatively common occurrence in children, in whom there may be hardly any symptoms at all, or perhaps general delicacy or ill-health, or gastro-intestinal disturbance, without any special urinary symptoms attracting notice. The urine generally contains only a trace of albumin, and no obvious ]}us ; the diagnosis then depends upon bacteriological investigation of a catheter specimen, the need for which will be suggested by the discovery of a decided excess of leucocytes in the centrifugalized deposit from the specimen first collected during the routine examination of the patient. .Inn. Ejire. BALDNESS. — Alopecia, or baldness, may vary in degree from slight thinning to: complete loss of the hair. There are three main varieties of simple baldness or alopecia namely: (1) CoiigciiHal. (2) Senile, a.nd (3) Premature. Congenital Alopecia is seldom complete, and the hair may be laiuigo-like. In tin latter case the diagnosis is certain, as it also is when the baldness is accom])anied 1)\ developmental defects in the skin or its appendages. Wlien there is comjilete absence o BLACK SPECKS BEFORE THE EYES 71 the hair, not only of the head but also of the eyelids, faee. trunk, armpits, and jiubie regions, tlie diagnosis is obvious. Senile Alopecia needs no description. Premature Alopecia may be (a) idiopathic or (b) symptomatic. The former, much less fre<|uent than tlie latter, and due to no recognizable cause except heredity, usually begins between the ages of twenty and thirty-five ; in many cases at the vertex, like senile baldness, but often at the teni])le, when it extends backwards elliptically. Symptomatic premature baldness may be either temporary or permanent, gradual or rapid, and is dependent upon a great variety of local or constitutional causes, including seborrhcea of the scalp, psoriasis, chronic eczema, erysipelas. ritigiLonn.favus. lupus, erythematosus, syphilis; it is also a sequela oi fevers or other acute systemic diseases, and sometimes of a severe shock to the nervous system such as inay result from a sudden and imexpected bereavement or the like. When it occurs as a sequel to fevers, in sjT)hilis, ringworm (except after severe kerion), erysi]3elas, and ec/.ema, the loss of hair is usually but tenijiorary : in seborrhcea, favus, lupus erythema- tosus, morplitta, and folliculitis decalvaiis, it is generally ])ermanent : it is always so when the hair-follicles have been destroyed. The most important form of symptomatic balilness is that which is associated with seborrliiea. whether of the oily or of the dry kind. Seborrluric alnprcia lias the same distribution as idiopathic baldness. Another form of symptomatic baldness is the condition known as alopecia areata, in which the hair falls out in more or less circular smooth white patches, generally of irregular distribution. I'sually the patches continue to spread for a time, and may run into others, denuded areas of irregular outline thus lieing formed, with a surface white and smooth as a billiard ball. The hairs at the edges of the patches are looser than the others, and among them may be seen short stinnps that have atrophied dose to the root, so that they resemble a note of exclamation (!). In rare cases the hair falls out not in patches but more generally and very rapidly ; and sooii the whole scalp may be bared, and even the hair of the whole body may be lost, and with it the nails of the lingers anrl toes. The affection with which alopecia areata is most easily confoimded is riui'icorui of llic trichophytic variety : the differential diagnosis between the two alTections will be found under hi xc.ors .\i'i-i;CTiONS OF nil; Skin (|j. 24fi). Alopecia areata may also be confused with another form of symptomatic bahlness, namely, alopecia cicatrisata, the pseudo-pelaite of Hroeq, in which depressed islands of baldness, round or of irregiilar shape, occur on the scalp, the |)atches usually spreading and coalescing into large, smooth, shiny areas : these are cicatricial : there is destruction of the follicles so that the hair is never restored ; there are normal-looking hairs on the bald areas, and the notc-of-exclama- tion stumps of alopecia areata are absent. The bald jiatchcs sometimes met with in secondary sy/jtiilis may be dislingiiishcd from those of alo]>ecia areata by the co-existence of oilier syphilitic symptoms, by the positive Wasscrmann's serum reaction, iind by the effects of s])ecific treatment. The bald areas of lupus erythematosus arc in greater or less degree cicatricial, there is destruction of the follicles, and a border which is slightly or distinctly inllanied. luillirulilis deadvinis is cii atricial also, and at the edge of the bare patches a small rc look ;il : \(l wlicii he tries lo liiciilr tlniii (IcHnilciv !iy looking directly at llicui, llic\ iininciihilclv llnal aw;i\-. as il were, IVoiii liis diiccl livid iif \ision to a peripheral part, lie can never locus llicm. aiidvcl he nia\ lieconscioiis of seeing them all the time. Only lew ))ersons in pmorihages. The diagnosis is suggested by the diet history, and confirmed by the benefit that follows the addition of fresh milk and. in older children, fresh vegetables. A similar condition may arise in adults whose circumstances compel them to live on tinned foods. There are, however, many other causes of bleeding of the gums besides scurvy. The differential diagnosis is generally easy, but sometimes very dilTicult. The first point to determine is whether the gum condition is due to local changes only, or whether it is part of a more general condition. (.1). Bleeding Gums due to General Conditions or preceded by Lesions else- where than in the Mouth : — Scurvy Splciionicdiillary leuk.'emia Lympliatic IciiUu'iniu Hodykiii'N disease Perniciiius aiianiia Aplastic auiemia Splenic ana-mia Harnophilia (B). Bleeding Gums due Injury, e.g., by toutli bnisli Dental caries Tartar Pyorrhoea alveolaris Alveolar abscess Pa])illonia Epulis Myeloid saroonia Purpiua (see Pl'rpi'R.\, p. o.32) Syphilis Mercurialism Iodide poisoning Phosphorus poisoning Arsenic poisoning Lead poisoning to purely Local Conditions :- Epithelioma Actinomycosis Acute or chronic stomatitis not obviously due to any of the causes already men- tioned, e.g. : Aphthous stomatitis T_'leerativc stomatitis Febrile or asthenic states accompanied by sordes, e.g., pneumonia, ty]ilioiil fever, the later stages ol' nialiyiuiiit cachexia, general paralysis, acute yellow atrophy ol' tlie liver, and so forth Dyspepsia Gannrenous stomatitis (cancrum oris, phage- da;na oris, noma oris) Tuberculous gingivitis Erythema bullosxim, dermatitis herpetiformis, |)empliia;us, affecting the mouth as well as the epidermis A. Bleeding Gums due to General Conditions. — iMan\- of the above conditions arc discussed under other and more prominent symptoms, so that here we need refer to them but briefly (see Spleen, Enl.\rgement of, p. 628; An^mi.\, p. 20 ; Purpura, p. 552; etc.). BLEEDING GUMS 73 A blood-eount is required to diagnose or exclude letikwmia or pernicious ancemia. Tlie family history may suggest hcemophilia. Splenic anwmia, Ilodgkin's disease, and aplastic anamia attract attention more on account of the enlargement of the sjjleen (p. 628), or of the lymphatic glands (p. 376)^ or of the ana?mia (p. 20), than because of spongy gums. Purpura (p. 552) is itself a symptom and not a disease. Syphilis, particularly in its secondary stage, may produce stomatitis, pharyngitis, lar>-ngitis, and gingivitis, with bleeding, even when no mercurial treatment has been adopted ; the secondarj' roseola may still be present, or the history may be obvious. Dilliculty arises mainly in women and children, and when the chancre has been extragenital (Fig. 23). ^Vasse^nlann■s serinn test may be tried, or the Spiro- f clmta pallida (Plate XXVIII, Fig. J. p. (il4) looked for in scrap- ings from the mucous lesions. Mercury is very liable to cause profuse salivation and acute ^^^^B ^^^Wmi^^' ? stomatitis, with distressing and ^ ^ . _ painful swelling of lips, gums, tongue, and cheeks : swallowing may become impossible, the glairy ^,V,. ^S.-PrUnary syplulitic soie on ti.e lower li|.. saliva hangs in strings from the protruding tongue and bulging lips, the mucosa bleeds on the slightest touch, and tlie patient is the picture of abject misery. Some persons are far more intolerant of mercury than others, but its worst effects have occurred when the remedy has been employed when the teeth arc carious, or the mouth unclean, and when there is albuminuria (syi)hilitic nephritis). The diagnosis depends upon a knowledge of the drugs that are being given or. in occupation cases, of the chemicals that the patient has been working with. Iodides may cause profuse coryza, due to conjuncti\al, nasal, and oral catarrh, but the amount of bleeding that accompanies it is slight. The nature of the drugs being taken will suggest the diagnosis, or if there is doubt as to the drugs, the urine may be tested for iodides. Phosphorus used to produce very severe stomatitis, going on to necrosis of the jaw — • pliossy jaw ■ — not infre<|uently ending in death as the result of fatty degeneration of the li^■er antl heart : this is unconnnon since restrictions have been laid upon the use of crude yellow ])ho.sphorus in the manufacture of matches. The oecu])ation generally serves to suggest the diagnosis. fc^Kp t*' Arsciiir and lead are both rare causes oT hlii-ding gums ; (ic( iipalioii. or medical l)r(seriptioii, or habits as regards drinking, may suggest the diagnosis, and there may be other signs of the |)oisoning, particularly |)igmentation of the skin, vomiting, diarrhd'a, hyperkeratosis of the soles and palms, and generalized i)erii)heral neuritis in the ease of arsenic' ; and the symptoms given elsewhere (p. :; t) in the case of lead. Arsenic may be found in excess in the hair, or lead may be detected in the faces or in llu- lesidue from a bulk of urine. Febrile' nnd asthenic states only cause sordes and bleeding gmns when the i)atienl has already been ill some while, or wlu'ii the nursing has been remiss ; the diagnosis will depend on syniptoins other than those comiected with the gums. H. Bleeding Gums due to Local Conditions. Wlmi eai( has been laktii lo exclude Ijeiieral causes of bleeding of (he giuns, (liHei'enl iai ion between the ^■arioUs local causes is nf)t diiri