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NATIONAL LIBRARY OF MEDICINE
        Bethesda, Maryland

             Gift of
 The New York Academy of Medicine
from 


INTERNAL MEDICINE FOR  NURSES

%4-
BY CLIFFORD BAILEY FARR
ISSUED T<*
^ '
 
 
H 
0
 
OUTLINES
INTERNAL  MEDICINE

 FOR THE USE OF NURSES AND JUNIOR
        MEDICAL STUDENTS
BY
-V
 CLIFFORD BAILEY FARR, A.M., M.l).

PROFESSOR OF GASTRO-ENTEROLOGY, GRADUATE SCHOOL OF MEDICINE,
 AND ASSOCIATE IN MEDICINE, MEDICAL DEPARTMENT, UNIVERSITY OF
  PENNSYLVANIA; VISITING PHYSICIAN, PHILADELPHIA HOSPITAL
   FOR CONTAGIOUS DISEASES; ASSISTANT VISITING PHYSICIAN,
        PHILADELPHIA GENERAL, HOSPITAL.
THIRD AND REVISED EDITION
ILLUSTRATED WITH 70 ENGRAVINGS AND 6 PLATES










     LEA & FEBIGER
 PHILADELPHIA AND NEW YORK
\ ^^O 
!
  Copyright
LEA ct FEBIGER
    1920
   •V -* f) ' '  *  -
OCT 221346
LIBRARY 4
255065 
<tv
si
3
 >
4"
     TO
DR. JOSEPH SAILER 
PREFACE TO  THE  THIRD  EDITION.
   I\ many training schools for nurses systematic courses
 in  medicine are now being offered in  place of the desul-
 tory, haphazard  lectures formerly in  vogue.  This text-
 book is intended to supply the basis for such a course and
 in addition to serve as  a  work of  reference to which the
 nurse  may  turn  for  information concerning the  rarer
 ( ases which may come under her observation.  In practice
 the lecturer will very properly pass over many affections
 of  infrequent occurrence, and will emphasize and extend
 the description of the more important and typical diseases
 and disease groups.1
  The book is divided into ten  " Parts," eight  of which ,
 are  devoted to diseases of the various systems  and  two
 to harmful agencies (physical, chemical,  bacterial) invad-
 ing  the body from without.  Each "Part" is  introduced
 by  a discussion of the symptoms, signs, etc., most often
 observed   in  diseases  of  the particular  system  under

  1 For example: Neurasthenia and hysteria, epilepsy, chorea, neuralgia
 and  neuritis, locomotor ataxia,  hemiplegia (all causes), anemia and
 leukemia exophthalmic goitre, arteriosclerosis and aneurism, pericarditis,
 valvular heart disease and cardiac insufficiency, bronchitis and broncho-
 pneumonia, asthma and emphysema, pleurisy, ulcer and cancer of the
 stomach,  gastroptosis and gastric neuroses, diarrhea and constipation,
 gall-stone disease, cirrhosis of liver, diabetes and obesity, nephritis and
 uremia, arthritis, erysipelas, syphilis, malaria, diphtheria,  cerebrospinal
 fever croupous pneumonia, influenza, tuberculosis, infantile paralysis,
tonsUhtis and rheumatic fever, measles,  scarlet fever, typhoid fever
intestinal parasites. 
        PREFACE TO THE THIRD EDITION          V

consideration.  When infectious diseases  (Part X)  are
taken  up,  therefore,  the  student has  already become
familiar with the  widely  diversified clinical manifesta-
tions  which may be observed in this important class of
diseases.  Not only has the usual position of the infectious
diseases been changed but their sequence has also been
altered to conform with the requirements of prophylaxis,
as far as data for such an arrangement are available.
  In the preparation and revision of this book the author
has drawn as much as possible on his own experience  and
accumulated knowledge but  has of course freely con-
sulted original articles, abstracts, and standard text-books
(particularly Osier and McCrae,  Mackenzie, Ker, Sal.li,
and Rosenau).  He has not  thought it  necessary except
in occasional instances to insert  any references to original
sources.  In the  revision  an attempt has  been made to
include the  more important advances attributable to the
war.  The former introduction  on the  nature  of  disease
and  the relative  frequency  and importance of various
affections  has been omitted in the present edition. This
information, as far as essential, has been embodied in
the Preface  or under the appropriate subdivision.
                                           C. B. F.
   Philadelphia, 1920. 
C 0 N T E N T S.
                       PART I.
        NERVOUS  AND MENTAL  DISEASES
                     CHAPTER I.
General Considerations...........17

                     CHAPTER II.
Mental and Functional Diseases of the Nervous System   .   30

                    CHAPTER III.
Organic Diseases of the Nervous System......43
                  PART II.
DISEASES OF THE BLOOD  AND  GLANDS   C3
                      PART III.
    DISEASES OF THE CIRCULATORY SYSTEM
                     CHAPTER I.
Diseases of the Bloodvessels and Pericardium   ....   81

                     CHAPTER II.
Diseases of the Heart   ...                         07 
CONTENTS
vii
PART IV.
DISEASES OF THE UPPER AIR PASSAGES,
             LUNGS, PLEURA.....113
                     PART V.
   DISEASES OF THE DIGESTIVE TRACT  AND
                 PERITONEUM.
                    CHAPTER I.
Diseases of the Mouth and Esophagus.......137

    .                CHAPTER II.
Diseases of the Stomach............151

                   CHAPTER III.
Diseases of the Intestines...........168

                    CHAPTER IV.
Diseases of the Pancreas, Liver, Bile Passages, and  Peri-
   toneum  ................183
                  PART VI.
         DISEASES OF  METABOLISM ...  195

                  PART VII.
DISEASES OF THE URINARY PASSAGES AND
                  KIDNEYS......219

                  PART VIII.
 DISEASES OF THE MUSCLES,  BONES, AND
                   JOINTS.......237 
viii
CONTENTS
PART IX.
DISEASES DUE TO HEAT AND OTHER PHYSICAL

             CAUSES  AND TO POISONS  ...   247
                       PART X.




     INFECTIOUS  AND  PARASITIC DISEASES.




                      CHAPTER I.



                                                     9fi3
General Considerations............





                      CHAPTER II.




Infectious and Parasitic Diseases—Class I......285






                     CHAPTER III.
Infectious and Parasitic Diseases—Class II
305
                     CHAPTER IV.




Infectious and Parasitic Diseases—-Class III.....315






                      CHAPTER V.



Infectious and Parasitic Diseases—Class III (Continued)  .  337






                     CHAPTER VI.



Infectious and Parasitic Diseases—-Class III (Continued)   .  350






                     CHAPTER VII.



Infectious and Parasitic Diseases—-Class IV.....372






                     CHAPTER VIII.



Infectious and Parasitic Diseases—Class IV (Continued)   .  387 
 
PLATE   I
AVERAGE NO. OF
 DEATHS PER
  ANNUM

 PULMONARY
TUBERCULOSIS
KIDNEY DIS.
DIARRHEAL
DISEASES
 DIPHTHERIA

 TOTAL (INCL.
  VIOLENCE)
 ALL CAUSES
AVER. DEATH RATE
-- PER 1000
     The chart shows the average number  of deaths  per
annum  (1903-12)  in  Philadelphia  (population  1,800,000)
from ten of the most important  diseases or disease groups.
Also the deaths from violence.  During  the first six years
the deaths from typhoid averaged  812, during  the last four
years (filtration) 2S6.  In  1918 on  account of the influenza
(pneumonia)   epidemic  the  death-rate  rose  to  24.8  per
1000.  Meanwhile the typhoid  death-rate approached the
vanishing point (3 per 100,000). 
                     PART I.

NERVOUS  AND  MENTAL  DISEASES.
CHAPTER I.
GENERAL CONSIDERATIONS.
The Neurons.
Motor and Sensory Tracts.
Symptoms and Signs of Nervous
    Disease.
  Insomnia.
  Delirium and Confusion.
  Stupor and Coma.
  Aphasia.
  Headache.
  Vertigo.
  Hyperesthesia,  Anesthesia, and
    Pain.
  Sphincter Disturbances.
  Trophic Disturbances.
  Vasomotor Disturbances.
  Paralysis.
  Convulsions.
  Contractures and Spasticity.
  Tremors and Choreiform Move-
   ments.
  Ataxia.
  Reflexes.
  Special Senses.
Lumbar Puncture.
  Nervous  and  mental symptoms  play such a  large
part in many general diseases that an early consideration
of affections  of  the  nervous system seems  logical and
time-saving.  A brief survey of the commonest  symp-
toms which may be attributed  to  disturbances of this
system will be followed by sketches of the more important
diseases.   Psychological, physiological, and anatomical
considerations, essential  as they are to a full  understand-
ing of nervous diseases,  will receive scant attention.  It
will  only be  possible to supplement the  ordinary  stock
knowledge  of anatomy  and physiology which the reader
is assumed to possess, by a brief account of the "neuron,"
the ultimate nervous unit, and its function.
      2 
18       NERVOUS AND MENTAL DISEASES

                   THE NEURONS.

  The brain and cord consists essentially of gray matter
 (cells) and white matter (fibers), with investing and sup-
 porting  structures (membranes  and  neuroglia). _ Each
 fiber begins in a cell, and the two together constitute a
 neuron, the fiber being dependent for its nutrition on the
 healthy  condition  of the cell  ("trophic  influence").   A
 motor neuron is shown diagrammatically in Fig. 1, C-D.
 The  cell C  has  fine,  so-called protoplasmic processes,
 which interlace with similar fibrils from other cells, and a
Muscle.                  Skin.
           Fig. 1
main  or axis-cylinder  process which ends  in  a muscle
(D).  A sensory fiber  (A-B)  on the other  hand, begins
in the skin, e. g., and runs toward the cell B, from which
fibrils pass out and interlace with the processes of  the
motor cells C.  Such  a combination of neurons forms a
reflex arc.  If the skin is irritated at A an impulse is con-
veyed through  B to C, whence  a motor impulse  is sent
out to D, causing the muscle to contract. Certain typical
"reflexes" (e. g., the patellar reflex) are habitually tested,
by tapping, etc., to  determine the integrity of the sensory 
MOTOR AND SENSORY TRACTS         19
 and motor neurons or tracts.  If a motor cell (C) in the
 spinal cord is destroyed its axis-cylinder process and the
 muscles  which the latter  supplies will degenerate, as in
 infantile palsy.

           MOTOR AND SENSORY TRACTS.
   A motor  "tract" consists of at least two superimposed
 neurons  or segments (Fig.  2).  The  "upper  segment"
 begins in a cell (C) in the
 cortex of the brain, passes
 downward through a nar-
 row bundle called the in-
 ternal capsule, and crosses
 to the opposite side of the
 body, either at  the lower
 part of the brain or in the
 spinal cord. After crossing
 it ends  in  twig-like  pro-
 cesses D', which  surround
 the  cell  body   (C)  of  a
 second  neuron  ("lower
 segment").    The  latter
 continues to  its termina-
 tion in a muscle, as already
 described.   If any injury
 occurs to the upper  seg-
 ment  above  the  point
 where it crosses, paralysis
 follows on  the  opposite
 side of the  body, as  in
 hemiplegia  (see  Fig.  8);
 if below, on the same side
 of the body.   Since the
 lower segment is not di-
 rectly  involved,  its nerve
 fiber and muscle will not             FIG. 2
 degenerate or waste,  and
 after  the first shock has  passed,  reflex  action will be
found preserved.  Usually,  indeed, it is increased because
 
20        NERVOUS AND MENTAL DISEASES

the moderating  (brake-like) action of the upper segment
is removed, permitting a spasmodic or spastic condition
to develop.   This is seen typically in spastic paraplegia,
due  to  disease of the spinal cord,  and  in long-standing
hemiplegia.   Disease  or injury involving the  lower motor
segment causes paralysis and wasting of the muscles, and
loss of the reflexes.  It is observed, for example, in acute
poliomyelitis and neuritis.  The sensory tracts are similar
in principle, but there are three or more neurons between
the sensitive surface and the  center in the brain.   Motor
neurons are called "efferent" because the impulses travel
from  the  center  outward (ex), while  sensory fibers  are
described  as  afferent"  because  they  convey  impulses
toward  (ad) the brain.

  SYMPTOMS AND SIGNS  OF NERVOUS  DISEASE.

  Insomnia.—Sleep disorders are  extremely  common:
thus we have wakefulness  (insomnia),  disturbed  sleep,
and abnormal sleepiness.  The latter is a symptom of both
acute and chronic infections,  as in measles and "sleeping
sickness."  It also occurs in exhaustion,  neurasthenia,
etc.  Disturbed  sleep is characterized  by  restlessness,
dreams, nightmares,  night terrors, somnambulism, etc.
Insomnia frequently occurs as an isolated symptom.  It is
also a pronounced feature of delirium or insanity.  Patients
who are addicted to  morphin  anol  other  sedatives are
often tortured by intractable insomnia upon withdrawal
of the drugs. Simple insomnia, when  it is  not due to
pain,  is  perhaps most frequently  to  be attributed to
circulatory disturbances  (e.  g., cerebral congestion), to
worry, to  bad habits of sleep, or to beverages containing
caffein (tea, coffee, or allied substances).   Sleep may some-
times be induced by  gentle exercises which  will tend to
draw  the  blood  from the brain; by hot applications to
the  feet; by  warm drinks, such as hot milk; by diver-
sions or light reading; by the  formation of regular habits
and by  omission of tea, coffee, and  chocolate. 
     SYMPTOMS AND SIGNS OF NERVOUS DISEASE   21

     Delirium  and Confusion.—Pathological disturbances  of
  consciousness  are  described  by  the  terms  confusion,
  delirium, stupor, and  coma.  Delirium  is  of varying
  degrees,  from a mild form in which there is merely slight
  confusion, to  the  wild,  maniacal  variety.   Insanity  is
  marked  by symptoms which often differ very little from
  those of delirium, and are distinguished largely by their
  more or  less permanent character  and their  indepen-
  dence of acute bodily diseases.  Ordinary active delirium
  is characterized  by muscular  restlessness,  by  insomnia,
» by failure to recognize  surroundings  or friends, and by
  illusions, hallucinations,  and  delusions.  Illusions may
  be defined  as faulty perceptions,  that is, the  patient
  mistakes common  objects  and noises  for "shapes  and
  shrieks and sights unholy."  Hallucinations,  so common
  in delirium tremens, are pure figments of the imagination
  without  any material foundation.   Thus, dying alcoholics
  often fancy that they are driving  horses.1   Delusions are
  false beliefs; the patient, for example, imagines that some-
  one is trying to injure him, etc.   The "muttering" delirium
  of typhoid and other "low" states often verges on stupor.
  Shakespeare describes  it vividly in  Henry  the Fifth
  (Falstaff's death):  "After  I saw him  fumble with the
  sheet and play with  flowers and  smile  upon his fingers'
  ends, I knew there was  but one  way;  for his nose  was
  sharp as a pen; an a' babbled  of green fields."
     Stupor and Coma.—In stupor the patient is apparently
  unconscious, but may be aroused by shouting or shaking.
  In coma, unconsciousness is complete.   Stupor and coma
  are common  manifestations  of both febrile  and non-
  febrile conditions, and particularly of  diseases or injuries
  of the brain, of poisons, such as alcohol and opium,  and
  of toxemias,  such as uremia and the acid intoxication  of
  diabetes.  The coma of uremia is frequently accompanied
  by convusions and Cheyne-Stokes respiration,  and that
  of diabetes by rapid, deep breathing ("air hunger").  In
    1 The orderlies at  the Philadelphia Hospital, from long experience,
  attach grave prognostic significance to this particular hallucination. 
22       NERVOUS AND MENTAL DISEASES

hysteria, patients  at times  lie in an apparently  uncon-
scious  condition, but their appearance is that of  simple
sleep.  In cataleptic states the patient may assume fixed
or rigid positions,  or he may walk  about without  appar-
ently being conscious of what he is doing.
  Aphasia.—Aphasia (speechlessness) is  a  "partial  or
complete loss of the power  of expressing ideas by means
of speech or  writing."  It is associated with other para-
lytic phenomena  in cerebral hemorrhage,  softening, and
tumor, and is of value in locating the situation of the brain
lesion,  because  its  various forms are dependent on injury
to quite different  portions  of the cerebral cortex.   In
sensory aphasia spoken or written  words are not  under-
stood or remembered.   In motor aphasia  words may  be
comprehended,  but  on account of  cerebral  disease, the
power  of speech or writing is lost.   Defective articulation
due to peripheral palsy is not aphasia.  Not so long ago I
saw a  man with cerebral embolism and hemorrhage who
was unable to articulate on account of laryngeal paralysis
produced by  the pressure of an aneurysm.   This was not
aphasia, although at first so diagnosticated on account of
the associated paralysis.  Ordinary  loss of voice (aphonia)
is due  to mere local changes in the  larynx, such as con-
gestion or tumor of the vocal cords.  Hysterical aphonia,
however, is undoubtedly of  central  origin.   Other  speech
disturbances  which  may  be enumerated are stuttering,
stammering,  and  scanning  speech.  Patients  with the
latter  disorder  talk in a stilted manner as if they were
reading poetry.
   Headache.—Headache is a symptom of so many diverse
diseases that only a few of  the important causes can  be
noted:  (1)  Some  so-called  headaches are rheumatic  or
neuralgic affections  of the scalp.   (2) Headache may  be
due  to disease  in the bone or sinuses, as in syphilitic
osteitis or frontal sinus disease.  (3)  Headache may be due
to meningitis, brain tumor  (including syphilis), abscess,
etc.   (4) Headache may be  due to  disturbances of circu-
lation, either congestion or  anemia.  (5)  Headache may 
   SYMPTOMS AND SIGNS OF NERVOUS DISEASE  23

be due to various  toxic conditions (a typical example is
that found in Bright's disease and in uremia).  (6) Reflex
headaches are ascribed mainly to the eye and to the diges-
tive  and genital organs.   (7) Hysterical headache is often
compared to a nail being driven into the head.  (8) There
is a  specific  form of headache  known as "migraine;" in
typical cases this is confined to one side of the head and
recurs periodically; in women  it may begin at  puberty
and  end at the menopause.
  Vertigo.—Vertigo is also  attributable to a multitude of
causes, of which the most important are: disturbances
of the circulation  as in arteriosclerosis, disturbances of
the  internal  ear,1 cerebellar disease, reflex causes (ocular,
gastro-intestinal), toxic causes as in alcoholism and uremia.
Dizziness also occurs in hysteria and epilepsy.
  Hyperesthesia, Anesthesia,  and Pain.—Disturbances of
sensation  occur under  many  guises.  Hyperesthesia is
an  undue sensitiveness  to touch  or  to  other   stimuli.
Anesthesia is a condition of  insensibility to touch  or to
pain (analgesia).   The  latter is frequently observed in
hysterical  patients  who experience no  discomfort even
from pin stabs.  Paresthesia is a perversion of sensation.
Patients complain of numbness or burning, or of a sensa-
tion  as of ants crawling over the skin.  Actual pain may
vary in intensity from  a sensation allied  to discomfort
to the agonizing variety seen in "tic douloureux."  It is
described as  burning, throbbing, shooting, or stabbing.
Its fixed or radiating character is often significant.
  The condition of  sensation is determined by touch, by
applying heat or cold (test-tubes filled with hot or cold
water), or by pricking with  the needle.   In the disease
known as syringomyelia the sense of touch  is preserved,
while the appreciation of heat and cold, and of pain may
be lost.  The sense of form and  of position may also be
tested by appropriate methods.

  1 The Barany ("turning") tests, designed to detect disturbances of
the internal ear and of the corresponding centers, assumed great promi-
nence during the war on account of the importance of excluding vertigo
in prospective aviators. 
24       NERVOUS AND MENTAL DISEASES

  Sphincter  Disturbances •—Disturbances of  the  bladder
and rectum (sphincter disturbances) frequently occur in
organic nervous disease  on account of the loss either of
the normal  sensation or of muscular control (paralysis).
Retention  of  urine,  constipation, or  incontinence  of
urine and feces,  are the natural  consequences of these
conditions.
  Trophic Disturbances. — Trophic  disturbances  in  the
muscles, skin, and  other tissues result  from  disease  or
injury of the  nerve cells which control nutrition.  The
affected parts may  waste (atrophy), or ulcers, bed-sores,
and  destructive joint disease, as  in  locomotor  ataxia,
may develop.   One method of estimating the nutrition
of the muscles is by testing their ability to contract with
a battery (presence  or absence of the "reactions of degen-
eration").
  Vasomotor Disturbances.—Vasomotor disturbances  are
due  to abnormal functioning of the sympathetic nerves
which control the  bloodvessels.  Flushing or  blanching
of the face or other parts, and localized sweating or edema
are examples of abnormal vasomotor control.   The most
extreme  example of  vasomotor disturbance  is  seen  in
Raynaud's disease,  commonly known as "dead fingers,"
in which one  or more fingers or toes  become white and
bloodless, later blue,  and, finally in extreme cases, gan-
grenous.   In angioneurotic edema  intense  but transient
edema may appear.  An arm may swell suddenly to a
great size and as suddenly return  to normal.  Hives  or
urticaria is a  similar but less marked expression  of the
same tendency.  It may be  induced by  mild toxemia
(intestinal) or  infection; in other instances it is a mani-
festation of  "anaphylaxis."
  Paralysis.—By paralysis is meant loss  of power in the
muscles.   As types of paralysis we may refer to hemiplegia,
in which there is paralysis of one side of the body; para-
plegia, in which there is paralysis of both lower extremi-
ties; diplegia,  affecting all  the extremities, and  mono-
plegia, in which one extremity only is affected.  In some 
PLATE  11
Opisthotonus in a Case of Cerebrospinal Meningitis.  (Koplik.) 
 
  SYMPTOMS AND SIGNS OF NERVOUS DISEASE  25

affections  paralysis  may  be  irregularly   distributed.
Familiar examples of paralysis are ptosis (paralysis of the
upper eyelid), facial palsy, and wrist-drop.   (See Multiple
Neuritis—illustration.)
  Convulsions.-—In convulsions there is abnormal, involun-
tary activity  of the muscles.  In the "clonic" type the
contractions occur intermittently and irregularly, as in
infantile convulsions,  uremia, puerperal  eclampsia,  and
epilepsy.  This type is  simulated  by hysterical convul-
sions, which, however, are not accompanied by complete
unconsciousness.   "Jacksonian"  convulsions begin in, or
are often limited to, one part.   They point to a localized
irritation of some  motor area in the brain,  caused for
example by a tumor.   "Tonic" convulsions  are char-
acterized by a more or less persistent contraction  of the
muscles, causing retraction of the head, arching  of the
back, rigidity of  the  abdomen, etc.  Consciousness  is
usually  preserved.  These are seen typically in tetanus,
meningitis, and in strychnin poisoning.  Extreme retrac-
tion of  the  head with arching of the back  is known as
"opisthotonos."  Tetany is  a rare condition of tonic
spasm observed in  wasting  diseases of childhood, in dila-
tation of the  stomach,  etc.  The  elbows are  bent, the
thumbs turned into the palms of the hands,  and the feet
extended (straightened out).
  Contractures and Spasticity.—Contractures bear a  super-
ficial resemblance to tonic spasms but are more permanent.
In this condition there may  be a shortening of  the muscle
due to irritation, as in the familiar Kernig's sign of menin-
gitis (the leg  cannot be extended when the thigh is at
right  angles with the body),  or there may be an  actual
shortening,  as  in bed-ridden patients  with  chronic joint
disease,   in  whom  the  extremities  are frequently fixed
in a flexed  position.   Spasticity is characterized by an
undue reflex irritability, so that when the foot, for instance,
touches the ground, a spasmodic contraction of the  calf
occurs.   It is seen in spinal palsies and after brain hemor-
rhages.   Writer's cramp  is a disease  characterized by 
 26        NERVOUS AND MENTAL DISEASES

 spasm or cramp of the muscles of the hand when attempt-
 ing to write.  Other movements are preserved.   It attacks
 persons who write constantly and for its relief a change
 of occupation is  usually  necessary.  Cramps  of similar
 character attack  stenographers and telegraph  operators.
  Tremors  and Choreiform  Movements.—Tremors are an
 important  symptom  of nervous diseases.   In paralysis
 agitans there is a tremor which is more or less  controlled
 when the patient makes an effort, whereas in multiple
 sclerosis the tremor is absent or slight until the patient
 attempts to do something.   In the aged there is a tremor
 not  only  of  the  extremities but also of the  head.  In
 exophthalmic goitre and in nervous  patients the tremor is
 fine and rapid.  In alcoholism there is a tremor  of the lips
 and tongue in addition to that seen in the hands.  Chorei-
 form movements are involuntary, irregular, and excessive
 in degree.  The patient makes queer grimaces, the speech
 is jerky, and the arms are thrown about in an  irregular,
 purposeless manner.   Tics are somewhat similar but are
 limited to one group of muscles.  There is, for example, a
 twitching  of one  eyelid.  They are usually more or less
 permanent in affected persons.
  Ataxia.—Ataxia or lack of coordination is seen in many
 diseases, but particularly in locomotor ataxia. The patient
 lacks the  command of the muscles necessary to  accom-
 plish  particular  movements  in  a  normal  manner.  He
 cannot touch the tip of his nose with his finger without
 blundering, his gait is unsteady, and he is unable to stand
with his eyes shut.
  Reflexes.—The  condition  of the  reflexes is  of great
 importance  in  the diagnosis  of  nervous disease.   The
reflexes are dependent for their development on  a  normal
 condition of both the motor and sensory nerves and of the
 centers.  (See Neurons.)   Those most commonly deter-
mined are the patellar reflex or knee-jerk, the biceps-jerk,
ankle-clonus, and  certain  skin reflexes, particularly the
Babinski reflex.  The knee-jerk is brought out by tapping
the patellar  tendon below the knee.  It is  necessary for 
SYMPTOMS  AND SIGNS OF NERVOUS DISEASE  27
the leg to be relaxed, as when the knees are crossed.. The
Babinski reflex is elicited by stroking the sole of the foot;
this normally  causes flexion  of the toes, but in the new-
born and in certain nervous diseases may cause an exten-
sion of the toes.
  Special  Senses.—The  special  sense  organs  are also
investigated in nervous and general diseases.  The exami-
nation of the retina often gives early and positive indica-
tions of cerebral disease, arterial disease, nephritis, anemia,
and  even  tuberculosis.  In  brain tumor,  for  example, 
28        NERVOUS AND MENTAL  DISEASES

the condition known as optic neuritis or choked  disk  is
of great diagnostic importance.  The state of the pupils
and  of  the  external muscles of the  eyes, as well as the
conditions of hearing, smelling,  and taste,  are inves-
tigated  by suitable methods which we need not consider
further.
                 LUMBAR PUNCTURE.
  The  spinal canal  is  frequently  punctured,  at some
point below the termination  of the cord, to  withdraw
cerebrospinal fluid, for purposes of diagnosis, for  the relief
of intracranial pressure (in brain tumor, hydrocephalus,
etc.), or for the  introduction of drugs and serums.  Thus
cocaine, or one of its  derivatives, is injected by this route
to induce  spinal anesthesia,  while  tetanus antitoxin,
salvarsanized  serum and antimeningitic serum, are intro-
duced in a similar manner, after spinal fluid in an amount
at least equal to that of the fluid to be injected  has been
withdrawn.
  The lower lumbar region, on a level with the  crests of
the ilia, is " prepared" in advance by the  usual technic or
disinfected at the time of operation by  the  aid of soap
and water, alcohol, and tincture of iodin  (or by the latter
alone).  The patient's back is  arched as  strongly as pos-
sible to  separate the vertebrae; this may be accomplished
with the patient either sitting  or, as  is more usual, lying
on his side.   If  he is conscious local anesthesia may be
employed—cocaine or one of its derivatives, or the ethyl
chloride  spray.   A moderately large,  hollow needle or
trocar is then intoduced  in the middle  line, on a level
with the third or fourth  (second to  fifth) lumbar spine,
and is pushed forward and slightly upward between the
vertebrae for two inches more  or less until it enters the
bony canal  below the level of the  cord.   As soon  as the
canal is reached clear fluid  will escape,  either  drop bv
drop or in spurts, and should be collected in  sterile test-
tubes.1  In  some.cases a coarse  wire or stilet will be
  1 In meningitis the spinal fluid is cloudy and contains the causative
organism of the disease. 
PLATE   111
£/Al„«.
Lumbar Puncture.
Illustrates topography of the parts and method of holding patient.  In children the needle is frequently
                                 inserted in the middle line.  (Koplik.) 
 
LUMBAR PUNCTURE
29
required to clear the needle of bits of blood clot or tissue.
Occasionally the physician may measure the pressure of
the fluid by attaching a graduated glass tube by means
of a rubber connection and observing how high  the fluid
will  rise in the tube.  The puncture wound is closed by
sterile  cotton  and  collodion.  After the  operation  the
nurse should watch the  patient narrowly  for some time
to make sure that no untoward symptoms—such as those
of collapse—are developing. 
CHAPTER  II.
MENTAL AND FUNCTIONAL DISEASES OF THE
                 NERVOUS  SYSTEM.
Mental Diseases.
  Confusional Insanity.
  Senile Dementia.
  Mania and Melancholia.
  Dementia Precox.
  Paranoia.
  Psychasthenia.
  Mental Deficiency.
Functional  Diseases  of  the
   Nervous System.
  Neurasthenia.
  Hysteria.
  Infantile Convulsions.
  Epilepsy.
  Chorea.
  Paralysis Agitans.
  Neuralgia.
                 MENTAL DISEASES.
  Confusional Insanity.—Certain mental  diseases are of
common occurrence in medical experience.  Others are
only  remotely related to  medical  conditions, and  do
not often come under the  observation  of the  physician
or nurse  outside of  special institutions  (psychopathic
hospitals).
  Subacute or chronic confusion or  stupor  may follow
exhausting  illnesses such  as typhoid fever,  childbirth,
or prolonged lactation.  Alcoholics are also prone to lapse
into  a state of stupor with mental  confusion after  an
attack of delirium  tremens.  These toxic or confusional
insanities   are  characterized,   in  varying  degrees,  by
delirium, confusion, or stupor; there is a failure to recog-
nize  friends, loss of the sense  of  time and  place (see
Alcoholic Neuritis),  forgetfulness,  physical  unrest,  un-
cleanly  habits,  etc.   The  prognosis, particularly  after
typhoid fever, is good; the  symptoms after persisting for
weeks or months  eventually clear up.
  Treatment.—The  treatment  of insanity, as  it  occurs
after  typhoid fever, consists in prolonged mental and 
MENTAL DISEASES
31
physical rest, hypernutrition,  and  tonics; later  hydro-
therapy, exercise, and diversion (travel) are of value.
  Senile  Dementia.—Senile dementia  is  accompanied
by  symptoms not  unlike  those  of  confusional insanity.
Loss of memory is usually  the first deviation to be noted.
The patients frequently  believe that they  have  been
neglected or abused by those nearest of kin.  This may
lead to domestic misunderstandings.  During the day the
mental condition may be  good, but at night restlessness
and noisy delirium are common.  Since  the disease  is
due to arteriosclerosis, softening of  the brain, or other
degenerative changes, the prognosis is practically hopeless.
  Mania and Melancholia.—Mania and melancholia are
often considered as phases of a  single mental symptom-
complex (manic-depressive insanity).  This  t\-pe of in-
sanity has little bearing  on general  medical  conditions
although  it  may  be  accompanied   by disturbances of
digestion and nutrition.  Periods of  extreme  depression
(melancholia), during  which the patient  desires  to  be
let  entirely  alone and broods over imaginary faults, e. g.,
the  "unpardonable sin," may  alternate with  periods of
restlessness  and  excitement (mania),  characterized by
undue physical activity and an abnormal flow of more or
less  unrelated  ideas.  In  other  cases either  mania  or
melancholia may be dominant throughout.   Improvement
or even cure is possible: suicide is common and must be
kept  in mind and guarded against by   the  nurse  or
attendant.
  Dementia  Precox.—Dementia  precox, the  insanity of
adolescence, is due in most cases to congenital deficiencies.
The patients may be equal to  the strain of ordinary life
until  puberty,  or even  later,   but eventually  mental
deterioration becomes manifest.   They are "disoriented,"
that is, confused as to time and place, and evince mental
perversity by opposition to  everything that is proposed
by  others,  or  by  imitative actions  or sounds.  Some
patients remain in rigid  attitudes  for  hours at  a time
(catatonia).  I once saw a man with this affection who was 
32       NERVOUS AND  MENTAL DISEASES

so rigid that he could be  supported  by resting  his head
and heels on chairs.
  Paranoia.—Paranoia  or  delusional  insanity occurs  in
later adult life.   The patient may seem to be  perfectly
rational in most respects,  but  harbors  some  permanent
"fixed" delusion  which  affects  his  whole  "manner  of
thinking and acting."  Many of the assassins  of history,
e. g.,  Guiteau,  who  killed  President  Garfield,  have been
paranoiacs who have brooded over and sought revenge for
imaginary injuries (delusions of  persecution).   There is  a
paranoid type of dementia precox.
  Psychasthenia.—Psychasthenia is   another  type   of
mental  aberration, which,  unlike the  last  two, is closely
related to clinical medicine.  It will be referred to below
under  Neurasthenia. General  paresis is  also described
under Nervous Diseases.
  Mental   Deficiency.—Mental  deficiency (amentia)  is
usually  congenital in  origin—in   contradistinction   to
insanity  which  is   often  acquired—and is frequently
associated with physical  defects of greater or  less degree
(dwarfism,  e.  g.).   Mental impairment  may   also  be
dependent upon disorders of internal secretion as in cre-
tinism or upon cerebral  disease,  e. g., cerebral softening.
The  most extreme cases of mental deficiency  are known
as idiots.   They are characterized by  almost complete
absence of  mentality and in many instances by  inability
to attend to their simplest  physical wants.   Such persons
require  almost  as much care as newborn infants, while
even  the least stupid of this type  are incapable  of  an
independent existence.  Patients with less marked mental
defects are  designated as "feeble-minded" and  are graded
according  to their capacity  in  an ascending  scale with
imbeciles at one end and "morons" at the  other.  In the
case  of the latter the mental  impairment may not be
apparent to the casual observer and the physical  develop-
ment may be nearly  perfect.   In classifying feeble-minded
persons it  is customary  to speak of  them  as having  a
mental  development  appropriate  to  some  particular 
  FUNCTIONAL DISEASES OF NERVOUS SYSTEM   33

period  of  childhood.  Thus  a  patient  may apparently
develop normally until the tenth year but be quite incap-
able of progressing beyond that point either in the intel-
lectual  or the  moral sphere.1   Many of the less  marked
cases are chiefly notable for their lack of moral  sense and
from them a  considerable portion  of  the criminal and
vicious classes—thieves,  prostitutes,  etc.—are  recruited.
Institutional care  is  essential for idiots  and  is  highly
desirable for even the highest grades of morons.   The latter
are  quite capable  of useful work under supervision but
are prone to fall into want or crime if left to themselves.
As  they are often highly prolific and transmit their defects
to  their offspring,  it is of great advantage to  the com-
munity for them to be segregated.

  FUNCTIONAL DISEASES OF THE NERVOUS SYSTEM.
  Neurasthenia.—Neurasthenia  is   brought  about   by
factors such  as  physical  or  mental  overwork  or shock,
loss of rest and sleep, anxiety, worry, anemia, malnutrition,
toxemia (infection), frequent child bearing, sexual excesses,
dissipation, etc., one or several of which may lead to fatigue
or exhaustion of the nervous forces.
  The strain, to which the patient is subjected, may be ex-
cessive or, as is more common,  the patient may have a low
initial resistance.   Thus there may be a congenital asthenia
 (literally lack of strength) with structural defects such as
flat  chest,  stooping shoulders,  downward displacement
 ("ptosis") of the stomach, intestines, and kidneys, and, in
women, maldevelopment or malposi ion of the uterus.  On
the other hand, many so-called neurasthenics are fat and
rosy.  Some of the latter class  are hypochondriacs or vale-
tudinarians whose whole  attention  is  focussed on their
bodily functions, to the exclusion of other ideas.  These are
not properly cases of neurasthenia.
  Certain cases  of neurasthenia manifest  distinct mental
  1 The mental capacity of these patients is usually gauged by their
ability to cope with definite intellectual tests appropriate to the variou s
 age periods (Binet tests).
       3 
34       NERVOUS AND MENTAL  DISEASES
 disturbances,   particularly   abnormal  fears,  known   as
 phobias.   For example,  a dread  of open places may
 develop  so that the patient may be absolutely unable  to
 cross the street or square; others suffer from a similar fear
 of high places.  These symptoms may reach such a degree
 as  to constitute  a  type  of  insanity  (psychasthenia).
 Patients with  neurasthenia are abnormally introspective,
 and complain  of symptoms which would not attract the
 attention of a  healthy person;  even normal sensations are
 at  times interpreted  as evidences of serious disease  and
 lead to great depression of spirits.
  Neurasthenic and psychasthenic states were very common
 among the soldiers of all armies during the recent war, being
 brought  about by shock,  suspense, fear, exhaustion,  etc.
 The explosion of shells or mines, aeroplane raids, gas attacks,
 etc., may be mentioned as inciting causes.  In a few of the
 "shell shock" cases there was actual  "commotion" of the
 brain  and cord (organic lesions) but in the majority the
 condition was functional.  A similar condition in civil life is
 called  "railroad spine."  In many instances the symptoms
 were more closely allied to hysteria than to neurasthenia.
 Common manifestations were: Mutism, blindness,  paralyses
 and tremors.   The  sudden disappearance of many of these
 symptoms, with or  without treatment, was characteristic.
  Symptoms.—The following are a few of the more com-
 mon symptoms of neurasthenia:
  Psychic and  Nervous.-—Irritability,  failure  of  concen-
 tration,  indecision,  headache, dizziness, vertigo, insomnia,
 indefinite pains, localized areas of tenderness.
  Circulatory.—General flushing, sweating, urticaria, pal-
 lor, blueness, palpitation, precordial distress.
  Gastro-intestinal.—Nervous  indigestion,   acid  eructa-
tions, belching, distention, constipation.
  Genito-urinary.—Frequent  urination,  transient  poly-
uria, menstrual disturbances, sexual manifestations, etc.
  A large fraction of all gastro-intestinal disturbances may
be traced to  neurasthenia,  and, conversely, the  majority
of neurasthenics present digestive symptoms. 
   FUNCTIONAL DISEASES OF NERVOUS SYSTEM  35

  Treatment.—The milder, or ambulant cases are usually
improved by regulation of the mode of life,  by tonics
(particularly cold affusions, strychnin, iron, and arsenic),
by sedatives (such as bromides, sumbul, and  valerian),
and by attention to the special local disorders of which
the patients complain.  Travel, or a long vacation in the
country  or  mountains, is  frequently required.  In  the
more  aggravated cases the "rest cure" of Dr. S. ^Weir
Mitchell is a most successful method of treatment.  The
patient is usually isolated in a hospital, or nursing home,
under the care of a competent nurse, wrho must be at the
same  time firm and  kindly.  If the nurse is able, during
convalescence, to entertain the patient by  cheerful  con-
versation or reading so much the  better, but medical
and  hospital  experiences  should  be  strictly tabooed.
Absolute rest in bed  and exclusion of friends are essential.
Many of the symptoms of neurasthenia are aggravated
by misplaced sympathy.   In order to improve nutrition
and accumulate an ample reserve in the form of fat, over-
feeding is practised.   To spare the digestive and elimina-
tive organs  the diet may  be at first limited to milk, or
skimmed  milk, but  after a certain time eggs  and other
bland food may be  added. Sleep is  promoted by warm
baths or  cold packs.  In connection with  rest and milk
feeding,  massage and  electricity form a prominent part
of the  treatment, the purpose  being  to  maintain  the
nutrition  of the  muscles during the enforced rest.  In
the wealthier class of patients these treatments will fall to
the masseur or masseuse;  in those less  able to pay,  the
trained nurse can fill the gap with success   At the same
time the  patient is  given  iron and  other  tonics.  After
several  weeks a  gradual return to normal life is  per-
mitted.
  Hysteria.—While neurasthenia is almost  equally com-
mon in both sexes,  hysteria is mostly seen in women.
Pronounced  cases are,  however, not unknown in men.
Characteristic cases  are quite  distinctive,, but  there  are
many intermediate forms, in which it is difficult to differ- 
36       NERVOUS AND MENTAL DISEASES

entiate hysteria  from neurasthenia.  It is still harder to
define in words  the difference between  the  two diseases.
Hysteria is a condition of nervous instability and lack of
inhibition,  rather than exhaustion,  in  which, according
to Osier,  "emotional  states control the  body."   The
predisposition persists throughout life, but symptoms are
more likely to be manifest during the adolescence or at
the menopause.  Faulty education and  indulgence  may
be responsible for, or aggravate this disease.  Hysterical
patients are cheerful, and suicide which  is not uncommon
in neurasthenia  is  rare.  Their general nutrition is ex-
cellent and their color good.  They frequently give the
impression  of being pleased  at the commotion  which
some  of their more  striking symptoms may  provoke.
The  emotional  loss of control,  is, as  everyone knows,
characteristic—thus laughing and crying may alternate in
rapid succession  without definite cause.
  Hysterical  paralysis is not infrequent, and may deceive
any but the most expert.  Some of the  remarkable cures
which are wrought  at famous shrines and  spas are  thus
capable  of  explanation.  A physician  of  the writer's
acquaintance, who  is  gifted  with a very sympathetic
personality, wTas called upon to  treat a case of this sort
and effected  a startling cure much to his  own surprise.
He was subsequently besieged by cripples and paralytics,
most, if  not  all of  whom were  suffering from incurable
organic  diseases. Suspicion  is  usually  aroused by  the
abnormal distribution of the loss of powrer, which is often
unlike that of organic  diseases, by the  absence of wast-
ing, and by  the presence of suggestive  symptoms,  such
as anesthesia.  Hysterical convulsions resemble epilepsy,
but the  movements are  sometimes purposeful; uncon-
sciousness  is evidently  simulated;  the  tongue  is  never
bitten; the patient always falls in a soft place, and never
suffers any  injury. Catalepsy—a condition not unlike that
seen is  dementia precox—is one of the most startling
manifestations of  hysteria.  The  limbs may  be  held
rigidly in unusual attitudes for along time. Anesthesia has 
  FUNCTIONAL DISEASES OF NERVOUS SYSTEM  37

been alluded to above.  It is frequently strictly limited
to one-half of the body, whereas the nerves of sensation
really overlap.   There are also areas of hyperesthesia and
certain definite tender points.  The vasomotor nerves are
also implicated, giving rise to local  or general  flushing,
pallor, and even hemorrhage.
  Treatment.—Patients should be  isolated from sympa-
thetic relatives  and friends, and treated with tact1 and
decision; their whims and fancies should not be humored.
A complete rest cure as described by S.  Weir  Mitchell
will occasionally be  necessary.  Suggestive therapeutics
sometimes produce surprising results;  bread pills  and
hypodermics of  sterile w-ater may relieve the severest pain
or most obstinate insomnia.  Hypnotism has not proved
to be of a permanent value but certain forms of hydro-
therapy occasionally  prove  of use.   The personality and
moral influence of  the physician or nurse  are frequently
the most valuable factors in the cure of the patient.
  Infantile Convusions.—In infancy and early childhood
convulsions  are frequent,  and  may result  from  com-
paratively simple causes, such as rickets, gastro-intestinal
disturbances,  the  onset of  acute  infections, and reflex
irritation  (phimosis, worms, and teething).  Intracranial
affections such  as  meningitis, hemorrhage, abscess, and
tumor may give rise to convulsions both in childhood and
in  adult  life.   True  epilepsy takes its origin  in  later
childhood and youth, but nearly 90 per cent,  of the cases
begin before the thirtieth year.   Uremia  and puerperal
eclampsia are common causes of convulsions in adults.
The former may be an occasional cause in infancy.
  The convulsions begin with staring of the eyes  and
twitching of  isolated  muscles, but the movements of the
extremities quickly become general, irregular, and violent,
differing very  little,  if  at  all, from  those observed in
epilepsy.  The convulsions  may be repeated frequently.
Holt has seen as many as eighty in one day.
  1 Dr. Mills advises the nurse not to make the diagnosis of hysteria, and
never to employ the term. 
38       NERVOUS AND MENTAL DISEASES

  Treatment.—The convulsions should be controlled by
the cautious use of chloroform and  at the  same time a
dose of chloral or bromide should be given by the bowel.
The tongue should be protected  by a cork or  piece of
wood between the teeth.  Cold may be applied to the
head and the child wrapped in a towel wrung out of hot
mustard water (a tablespoonful to a quart of warm water),
or a mustard bath may  be given  (5 to 10  minutes), in
which the mustard should be in the proportion of a table-
spoonful  to the gallon.  The temperature  of  the bath
should not  exceed  105° and should be tested by a ther-
mometer if possible.
  When  the attack  has been  controlled  the  physician
will proceed according to the cause.   If the child has eaten
indigestible  food or has  suffered from digestive  disturb-
ances, lavage of the stomach and irrigation  of the colon
are in order.  Emetics and purgatives may be used.  The
detection of albumin in  the urine  will point to uremia,
while lumbar  puncture may determine the  diagnosis of
meningitis.  The  treatment will  differ  with the  cause.
Children who have once suffered  from convulsions are
more prone to subsequent attacks,  but there is no neces-
sary connection with epilepsy.
  Epilepsy.—Epilepsy, as  before  stated, almost always
begins before maturity;  it is  rarely cured.  The  mild
form  is known as "petit mal" and  the severe  form as
"grand mal."  The former is often ignored or unsuspected
until more  severe attacks have supervened.  The patient
while sitting quietly or  conversing will become slightly
pallid, and the eyes staring, but in a moment may resume
conversation without realizing that he has  been uncon-
scious.  In  other persons major convulsions may  occur
only at night, and for that reason may be  overlooked for
a long period.  In "grand mal" the patient  may have
an  aura  or momentary intimation of the coming attack,
for example, the sensation of a flash of light.  The attack
begins frequently with a  wild cry, the patient falls to the
ground, the tongue is bitten, and there is a frothing  at the
mouth.   At the beginning the limbs are rigid, but almost 
  FUNCTIONAL DISEASES OF NERVOUS SYSTEM   39

immediately  this tonic phase passes into violent clonic,
convulsive movements.  The face is swollen and congested,
the pupils diated and fixed and the  eyes turned upward.
The urine and feces are passed involuntarily.   After a
few  seconds  or minutes the convulsions cease,  but  the
unconsciousness  which has  been present from  the first
is  often prolonged (epileptic coma).  When the patient
awakes he may feel well except for injury to the tongue.
Patients are often severely injured, for example, by falling
on  the stove, or tumbling from a  height.   Convulsions
may occur many times a day, once a month, or  even  less
frequently.
  Epileptic patients may be normal mentally, but in time
deterioration is the rule, in spite of the oft-quoted cases of
Caesar and Napoleon.  Gastro-intestinal symptoms  are
very common and patients are sometimes  improved  by
treatment of their digestive  anomalies.
   Treatment.-—Medicinal treatment  is unsatisfactory.  A
free use  of  bromides  will reduce the frequency of  the
attacks, but it brings undesirable symptoms in its train—'
mental torpor, skin eruptions, and digestive disturbances.
To secure intensive action bromides are sometimes used
to  replace common salt in  the diet.  Epileptics may
pursue ordinary occupations with  success,  but should
never be allowed  to  engage in dangerous trades.  The
more  pronounced  cases are  best treated  in "colonies,"
where suitable care and safe occupations may be pro-
vided.  The  diet should consist principally  of milk, eggs,
cereal foods,  vegetables,  and  fruits.  During the attack it
is necessary  to  protect the patient from  injury, while
avoiding restraint as much as possible.
   Chorea.—Chorea, or  St.  Vitus'  dance,  is a  disease
which occurs for the most part in childhood, but  occasion-
ally  attacks adults, particularly pregnant women.   In
pregnancy it may be so severe as  to induce abortion or
miscarriage.  Chorea is  associated  in medical experience
with tonsillitis,  acute articular rheumatism, and  endo-
carditis,  and it is possible, or even probable, that it is an 
 40       NERVOUS AND MENTAL DISEASES

 infectious disease, due to the same microorganisms that
 are responsible for those infections.
   Chorea is characterized in its fully developed form by
 irregular, jerky movements  of the extremities, twitching
 of the facial and other muscles, and resulting disturbance
 of rest and sleep.  There may be a slight fever, but usually
 this is not  a prominent feature.  In prolonged or aggra-
 vated cases there may be anemia and profound exhaustion.
 In mild cases, or in the insidious early stages, children are
 often thought to be nervous, fidgety, or even wilfully clumsy.
   Children with chorea should be taken out of school or
 awray from work.  If the condition is mild, it may suffice
 to limit exercise, and to keep them in the open air.   In
 severe cases,  rest in  bed should be prescribed, as  the
 movements  are  much  less  violent  during repose.  If
 endocarditis develops this   rest should be  prolonged.
 Salicylates are frequently used in the acute stages,  while
 arsenic, in the form of Fowler's solution is employed in
 ascending  doses  throughout the course of the disease.
 \Mien arsenic is being administered  in large or ascending
 doses, the nurse should watch carefully for indications of
 poisoning such as loss of appetite, nausea, diarrhea,  colic,
 puffiness about the  eyes in  the  morning, skin eruptions
 or  disturbances of sensation  (complaint  of numbness  or
 tingling).   If such are noted they should be immediately
 reported to the physician.   Quinin has also been used  to
 control the  choreiform movements.
   There  are other forms of  chorea occurring in adults
 which are, how'ever, entirely independent diseases.  As they
 are rare, we will not concern ourselves with them further.
   Paralysis Agitans.— Paralysis agitans,  or the "shaking
 palsy," is a disease  of the aged  characterized by a fine
 tremor,  general muscular rigidity, and  a peculiar  gait.
 The tremor does not usually involve the head, and becomes
 less with repose.   The muscular  rigidity  causes the face
to become expressionless, the l?ody bent forward, and
the arms flexed at the elbows.  When the patient walks
he has a tendency to go faster and  faster and finally to
fall forward, but usually saves himself by stopping short. 
  FUNCTIONAL  DISEASES OF NERVOUS SYSTEM  41

In advanced cases there is distinct loss of power.  The
tremor of old age is somewhat  similar, but involves the
head particularly.  The disease in itself is not fatal, but
is incurable.  Any treatment should be directed to im-
proving the nutrition of the patient by means of tonics,
massage, and hydrotherapy.
  Neuralgia.—Neuralgia is a term which is applied to a
paroxysmal pain  in the  course of one of  the sensory
nerves, for which there is no obvious  explanation.  The
pain is sharp and  shooting, but not constant.  It is limited
to a single nerve and its branches, or, at most, to a few
nerves.   Neuritis, on the other  hand, is characterized by
inflammatory changes  affecting either the sensory  or
motor nerves, or their  sheaths; if the  sensory or mixed
nerves are affected there is pain, but this  is less severe
and more constant than that of neuralgia.  It is accom-
panied by tenderness in the course of  the nerve, whereas
in neuralgia,  tenderness, if present at all,  is limited to
certain  definite  points  where the  nerve makes its  exit
from the bony canals.  In neuritis, if  the motor nerves
are attacked, there will be a  flaccid paralysis, usually
with absence of reflexes.
  Neuralgia is a common condition in  persons who are
neurasthenic, anemic, or "gouty,"  using the latter  term
in a popular sense to include a number of obscure toxic
conditions.   It may also be reflex, as from carious teeth,
or local pressure.  In one patient a persistent intercostal
neuralgia was attributed to neurasthenia until  an x-ray
showed  a small  bony outgrowth from  a rib pressing on
the nerve.   After the  bony nodule was  removed,  the
neuralgia disappeared.   In another case a severe sciatica
was found to be dependent upon a sarcoma of the sacrum
involving the origin of the  nerve.
  Neuralgia may affect any of the sensory nerves,  but
the following forms are especially  common  and severe:
trigeminal  neuralgia,  sciatica,  brachial neuralgia,  and
intercostal neuralgia.  Trigeminal neuralgia or tic doulou-
reux affects one or more of the three branches of the fifth
cranial nerve: the first, supplying the  forehead  and eye; 
42       NERVOUS AND MENTAL DISEASES

the second, the upper jaw, and the third, the lower jaw.
The disease  may begin in one  branch  and afterward
attack the other  branches, or it  may  be limited to one
branch throughout.  In its severest forms this is probably
the most painful affection in the whole realm of medicine,
and victims of the disease are willing to submit to any
operation, however severe, to obtain relief.  Many cases,
however,  are  comparatively mild.  Sciatica  is  usually
neuralgic  in  character, but there is  sometimes  distinct
neuritis.   True  sciatica  is  almost  always  unilateral,
whereas bilateral pain is more  likely to  be due to some
intrapelvic  pressure   Tumors  and  bony outgrowths,
such as are found in arthritis deformans,  are the common
causes of such pressure.  Intercostal neuralgia is  char-
acterized by pain at the exit of the nerve near the spine
and anteriorly where it comes forward and becomes super-
ficial.  In intercostal  neuritis tenderness  is found along
the whole course of the nerve: in  pleurisy and in myalgia
the pain is more  diffuse  and in pleurisy  accompanied by
the signs of that disease.
   Treatment.—The management of neuralgia is concerned,
first, with the discovery of the cause and  its removal, and
secondly, with symptomatic treatment.  Under the first
heading  would come  the removal of bad teeth and the
treatment  of  anemia, or of rheumatic  and gouty  con-
ditions.  Palliative treatment embraces the use of a large
number of drugs, most of them too well known, of which
phenacetin  and morphin may  be taken as types.  The
latter is  an extremely dangerous drug to  use in  this con-
dition (formation of  habit)  and only very exceptional
reasons would warrant its use.   Local measures are  fre-
quently  helpful.  These include  medicated  ointment,
hot applications,  blisters, actual cautery, and,  rarely,
electricity.  In tic douloureux, after other measures have
failed, injections  of  alcohol into the  nerves sometimes
give at least  temporary relief.   If this  fails the several
branches may be cut in succession.  Finally the Gasserian
ganglion  itself may be  removed.  This  is an  extremely
severe and mutilating operation. 
CHAPTER  III.
ORGANIC DISEASES OF THE NERVOUS SYSTEM.

Neuritis.                    I General Paresis.
  Facial Palsy.                ' Cerebrospinal Syphilis.
  Pressure Paralysis.            , Meningitis.
  Toxic Neuritis.                Hemiplegia.
  Multiple Neuritis.             Hemorrhage,  Thrombosis, and
Chronic Poliomyelitis.           Embolism.
.Herpes Zoster.                Subdural Hemorrhage.
Myelitis.                    , Hydrocephalus.
Disseminated Sclerosis.         Tumors of the Brain.
Locomotor Ataxia.            I Abscess of the Brain.

  Neuritis.—The diseases thus far considered  have been
largely functional  in  nature.  In  neuritis,  as  mentioned
under  Neuralgia,  there  are well-marked  pathological
changes.   Neuritis may be localized, affecting  any one
of the cranial or spinal nerves, or there may be a more or
less general involvement of many nerves, the  so-called
multiple  neuritis.  Simple neuritis  is frequently due  to
injury  (for example, pressure),  exposure  to  cold, etc.
Multiple  neuritis is  usually the result of some  toxin  or
poison.  Thus it may be due to certain infections such
as diphtheria, influenza, and leprosy, to metabolic poisons
as in gout and diabetes,  and finally, to extraneous poisons,
the most  important being alcohol, lead, and  arsenic.   The
neuritis of beriberi is probably consequent on a deficiency
in  certain nutritive  principles ("vitamins") in  the diet
and not the result of infection as  formerly believed.  A
few of the common varieties of neuritis will be briefly
described as types.
  Facial Palsy.—Bell's,  or facial palsy, affects the seventh
cranial (facial)  nerve on  one side,  and usually begins
suddenly without obvious cause  other than exposure  to 
44         NERVOUS AND  MENTAL DISEASES

cold ("draught").  There is no pain, but the side of the
face affected is smooth and expressionless.  The eye can-
not  be completely closed, the mouth is drawn to  the
opposite or healthy side, food collects in the cheek, and
the saliva flows from the corner of the mouth.  In some
cases there is loss  of taste.   It is possible to determine
wThat portion of the nerve is  affected by the presence or
absence of this or other symptoms.   After a few weeks the
paralysis usually clears  up.   This  does  not apply, how-
ever, to cases which are  due to some distinct injury, such
as may occur, for example, in the course of operations for
mastoid disease.
Fig. 4.—Facial palsy.  The affected side of the face is smooth and the
       eye cannot be completely closed.  (White and Jelliffe.)

  Pressure Paralysis.-—Drunkards frequently  go to sleep
with their heads on their arms, and on awakening  are
found to have  a paralysis of the extensor muscles of  the
forearm, causing unilateral  wrist-drop.  In this instance
pressure on the nerve trunk is  the obvious cause of  the
neuritis.  A similar palsy may result  from the pressure 
     ORGANIC DISEASES OF NERVOUS SYSTEM    45

of shoulder braces or straps  during prolonged operations
(Trendelenburg position).  In the latter case the deltoid
muscle is most often affected.
  Toxic Neuritis.—Diphtheria is followed by symptoms
of neuritis (diphtheritic  paralysis) in more than 15 per
cent, of the cases.  Symptoms may be  very slight, being
limited  to nasal voice, double vision, and weakness of the
extremities (loss of knee-jerks), or, as is more usual, there
may be  marked difficulty in swallowing,  with regurgitation
of food  through the  nose, due to paralysis of the muscles
of the  soft  palate and pharynx. In the severest cases
the paralysis  may affect  the muscles of respiration,  and
even the heart. In the latter  case the nerve which controls
the heart, the vagus, is  probably involved.  Death may
occur very suddenly from heart or respiratory failure, but
recovery is the rule.
  Lead neuritis is usually found in painters and white lead
workers, but there is a multitude of occupations in which
exposure to the poisonous action of this metal is  possible.
Patients may have had lead colic, or the neuritis may be
the first manifestation of the disease.  The poison usually
picks out certain groups of muscles.  The most  common
variety is wrist-drop, which in this case is bilateral.  The
upper arm, the legs, and the eyes are  also more or less
commonly affected.
  Arsenical neuritis is less common. It occurs occasionally
from too  prolonged  medicinal use of Fowler's solution or
other arsenical preparations, as in  a case of pernicious
anemia, which I saw last year,  or it may be due to an
accidental contamination of foods, beverages, wall papers,
etc.  Arsenical neuritis is characterized by peculiar changes
in the skin, particularly  thickening and pigmentation.
  Multiple Neuritis.—The commonest  form of  multiple
neuritis is that due to  alcohol; usually the etiology  is
obvious, but  occasionally cases  are seen in women who
have been secret topers. Alcoholic neuritis is characterized
by involvement of both  the sensory and motor nerves.
The patients complain of numbness, tingling, burning, and 
46       NERVOUS AND  MENTAL DISEASES

other abnormal sensations (paresthesia)  in the limbs and
are frequently attacked by severe muscular cramps which
may compel them to jump out of bed.
  In fully developed cases of multiple neuritis the patients
are helpless, with paralysis of the extremities and double
wrist- and  foot-drop.  The muscles waste away and the
reflexes are lost.  There is usually tenderness over all the
nerve trunks and the muscles are sensitive.  The skin may
be glossy and even edematous.  When the patient is able
to wralk he lifts his feet high so that his toes will not scrape
the floor.  In certain alcoholic cases mental symptoms may
develop, with loss of memory, and confusion as to time
Fig. 5.—Multiple neuritis.  Double wrist-drop and double foot-drop.
                        (Lloyd.)
and place.   Such patients, in addition frequently describe
recent experiences which have no basis  in fact.  These
more severe cases frequently die,  but the majority  of
patients slowly recover when the alcohol is withdrawn.
   Treatment.—The more severe forms of multiple neuritis
are treated by rest in bed.  Splints, sand-bags, etc., are
employed to maintain the correct position of the limbs
and  to  prevent the  development of  permanent con-
tractures.  In many cases it is wise to put the patient
upon an air-bed to avoid  the  possibility of  bed-sores,
which are prone to develop because of interference with
the normal trophic influences.  During the acute stage 
     ORGANIC DISEASES OF NERVOUS SYSTEM    47

the local measures mentioned under Neuralgia are usually
employed,  particularly heat.  In convalescence  passive
movements,  massage, and  electricity are all of great
value.  In this stage strychnin may be used in large doses
for its effect on  the  muscles.   It is obvious that in all
cases the cause should be removed whenever possible.  The
diet should be liberal, except in certain constitutional  con-
ditions, in which  suitable restrictions may be necessary.
   Chronic  Poliomyelitis.—In  poliomyelitis the  disease
process does not  affect the motor nerves themselves but
the  cells in  the  anterior part of the spinal cord which
control their nutrition.  (See Lower Neurons.)  The injury
to the  ganglion cell may be slight or there may be total
destruction.   In  the latter  case the  nerve degenerates,
the  muscles  it supplies become paralyzed and atrophied,
and the reflexes  are lost.  Acute poliomyelitis  is due to
infection and will be discussed under Infectious Diseases.
Chronic poliomyelitis, or progressive muscular atrophy,
occurs in middle life and is characterized by atrophy of the
ganglion cells  of the anterior  horns of the spinal cord.
The upper extremities are usually symmetrically involved.
The muscles, particularly the smaller muscles of the hands,
slowly  waste  away,  so  that the latter finally  come to
resemble claws.  The muscles of the lower limbs, chest,
throat, face, etc., are not involved until late in the disease.
There is a type known as glossolabiolaryngeal (!) paralysis,
in which the  muscles of the tongue, lips, pharynx, and
larynx are principally involved.  The  ordinary  form  of
chronic poliomyelitis is not in itself fatal.   The last-named
type, on  account of interference with swallowing and
respiration, is  usually far more serious.
   Herpes Zoster.—If the  ganglia  on  the posterior  or
 sensory roots  are involved,  a  condition known as herpes
 zoster develops.   This is characterized by neuralgic pains
 in the area supplied by the affected segment of the spinal
 cord, followed in a few days by the localized eruption of
 blisters or vesicles surmounting an area of inflammation.
 The pain  is frequently very severe, and in the weak and 
48        NERVOUS AND MENTAL DISEASES
aged I have seen burning and other abnormal sensations
persist for many months after the disappearance of the
eruption.   The vesicles may appear in the course of any
sensory nerve  (more accurately in any area supplied by an
affected spinal segment), but are commonly seen on the
  Fig. 6.—Herpes zoster.   Diagram showing  different  positions  in
which the eruption may occur.  These areas correspond to the distri-
bution of certain nerves or to definite spinal segments; 6, 5, and 1 are
the most common types.
lateral aspect of the chest.  They may also appear on
the upper arm, on the forehead, etc.  The disease is almost
invariably  limited to one  side.  The  ordinary herpes on
the lips and nose, seen in pneumonia, malaria, meningitis,
and common colds,  is  probably due  to toxic injury of
minute nerve filaments. 
     ORGANIC DISEASES OF NERVOUS SYSTEM    49

  Treatment.—There  is no treatment for  chronic polio-
myelitis, aside from general hygienic measures.   Herpes
zoster is also uninfluenced by treatment except in a pallia-
tive sense.  Sedatives in the form of  dusting powders,
ointments, or solutions in collodion, may be applied along
the affected nerve.  After the disappearance  of the erup-
tion, electricity in the form of galvanism will  sometimes
relieve neuralgia.
  Myelitis.—Myelitis is a term applied to inflammation
or softening of the  spinal  cord.  This may occur in both
acute and  chronic forms,  and  may involve the  cord
throughout, or be limited to one level.   The latter form
is called transverse myelitis and may be compared in its
effect to a cutting  across  of the cord.  This results in a
paralysis of all the muscles below the area of disease, with
anesthesia.  The superior centers are cut off so that the
affected muscles  ultimately become stiff  or  spastic  and
the reflexes  are increased.   As a rule the patient  experi-
ences a "girdle" sensation at the  level of  the disease.
With the paralysis there is loss of  control  of the  rectum
and bladder, with incontinence or retention of urine,  and
incontinence of feces, or obstinate  constipation.   In  the
severe cases, in wdiich  loss of power is complete, the patient
is confined to his  bed  and  is subject to the dangers  of bed-
sores and cystitis.
  Symptoms.—The onset is frequently rapid  and may be
attributed to  injury,  tumor, or disease of the  bones,  but
more commonly to nothing more definite  than exposure
to cold or wet.  In the latter case some infection or toxemia
is usually responsible  for the condition.  Early symptoms
are numbness, tingling,  and a sense of  weight  in  the
extremities.   The course, depending on the cause, may be
short or  extremely chronic.  There are  a  great  many
varieties of the disease which cannot  be considered in
this brief survey.
  Treatment.—The   treatment of  bed-ridden patients
requires the greatest  care on the  part of the nurse or
attendants.  The  patient  should  be kept scrupulously
     4 
50       NERVOUS AND MENTAL DISEASES
clean and should be frequently turned to avoid any danger
of bed-sores.   An  air- or water-bed is to be preferred.
   Particular attention must be directed to the prevention
of irritation from incontinence of urine and feces.  Absorb-
ent  cotton, oakum, or specially  adjusted  bed-pans and
urinals, one or all, may be employed with  advantage for
this purpose.   When catheterization is necessary,  careful
asepsis will be required to prevent cystitis.  Massage and
passive movements are necessary and useful  to maintain
the  nutrition of the  muscles.  In some cases, after pro-
longed invalidism,  great improvement  occurs;   in the
majority the prognosis is not very hopeful.  In mild cases
the  paralysis  is never complete and the patient may be
able to get about.
   Disseminated  Sclerosis.—Spinal sclerosis is character-
ized by  fibrous  changes  in  the  cord which  may injure
either the motor (e.  g., lateral sclerosis) or  the  sensory
(e. g.,  locomotor ataxia) tracts, or may affect  both. Dis-
seminated or multiple sclerosis is a disease in young adults,
characterized  pathologically by  small areas  of  fibrosis
widely scattered through  the brain and cord.   The cause
of the disease is unknown.   It begins with weakness in
the  legs with subsequent loss of power and spasticity.
The reflexes  are increased.  In  typical cases there  is
tremor upon effort,  lateral  oscillation  of the  eyeball
(nystagmus), and a peculiar  form of speech in which the
syllables are stressed as in scanning.  The disease is very
chronic and may ultimately lead to considerable  loss of
power and mental deterioration.
  Locomotor  Ataxia.—Locomotor  ataxia  and  paresis,
though diverse in their  manifestations, are closely related
in their causation.  Both  are  the  ultimate results of
syphilis and the difference in the  symptoms presented
is owing to the localization of the diseased process.  In
locomotor  ataxia the spinal  cord is  principally affected;
in paresis (as general paralysis is commonly termed) the
brain  bears the  brunt  of the disease.  There are occa-
sionally cases of so-called "taboparesis," in which these
conditions  overlap, but usually  they are distinct. 
ORGANIC DISEASES OF NERVOUS SYSTEM    51
  Locomotor ataxia is so-called because of the peculiar
disorder  of  gait which characterizes it.  The synonym
"tabes," refers to  the "wasting" or sclerosis of the pos-
terior or sensory columns of the spinal cord.  The disease
is very  insidious in its onset and attention may be first
called to it by the occurrence of  so-called "crises"  or
"lightning"  pains  felt in the larynx, the internal organs
(stomach),  or  the  extremities.  Sometimes  the  first
symptom noticed  by the  patient is inability to walk in
the dark, or staggering when  he  attempts to wash his
face.  On questioning, he will usually complain of peculiar
sensations in the feet, as if he were walking on cotton,
and sometimes of abnormal  sensations in the rectum.
The knee-jerks on examination, are found to be very much
diminished or absent. The pupils are  small and do not
respond  by contraction  on exposure to a  strong  light.
They do get  smaller, however, when the patient  looks
at some near object.  Sometimes loss of vision or double
vision is an early symptom.  If the patient is asked to
touch the tip of his nose with his finger, or one knee with
the heel of the opposite foot, he has difficulty in doing it
quickly and accurately.  If he  stands with his eyes shut,
he sways, or even falls.  W7hen he walks he lifts his feet
high and separates them widely,  so as  to be sure of not
stumbling or falling.  This is due in part to the fact that
the sensation in the feet has been impaired, so that he is
dependent on  sight  to maintain  his equilibrium.   The
disease  is extremely chronic;  after a  lapse of possibly
twenty   years  or  more,  the patient may  become  bed-
ridden  and  paralyzed,  and suffer  from incontinence of
urine and feces.  Finally, mental symptoms supervene.
Death occurs from exhaustion or from some  accidental
disease.  The excruciating pain suffered by some of these
patients drives them at times to  suicide, as happened in
two cases with gastric crises which  I had under observa-
tion.  In addition to the complications already mentioned,
trophic  conditions, including perforating ulcer of the foot
and degenerative changes in the  joints (knee, as a rule),
are seen. 
52       NERVOUS AND MENTAL DISEASES
  Tabes is relatively rare in the colored race; it  is more
common  in  men than in  women.   The disease is incur-
able, frequently stationary for long periods of time and
susceptible to great improvement by treatment.
                            K---------31 ct.----*-^>
Fig. 7.—Footprints on floor for practice in walking. (White and Jelliffe.)

  Treatment.—Treatment is chiefly by physical measures;
it is doubtful if medical treatment is of much value.   The
disease seems to have  progressed beyond the reach  of 
     ORGANIC DISEASES OF NERVOUS SYSTEM    53

ordinary syphilitic treatment, but in recent years, intra-
spinous injections of salvarsanized serum have been used
with some success.  The physical measures consist largely
in reeducation of the  muscles, so that precision of move-
ment may be restored.   Other sense organs are educated
to take the place of  the impaired sensory nerves.  The
patient practices walking a chalk line, putting his feet into
ruled spaces, inserting pegs into holes, etc.
  General Paresis.—In  general paralysis  of the insane,
as this disease is more explicitly called, mental symptoms
predominate,  though evidences  of  paralysis  may  exist
long before  the  former  are apparent.  The  pupils are
contracted  and usually  irregular, the face is  immobile,
and there is an irregular tremor of the tongue, so that the
enunciation  is indistinct.  Tremor of the hands leads to
characteristic changes in writing.  In the early stages in
addition to  the  symptoms  already  noted,  the  patient
exhibits changes  in conduct and character.  He becomes
careless in  his personal habits,  unreliable in business.
and perverted in the moral sphere.  With further develop-
ment of the disease, delusions of importance or grandeur
become dominant, be  becomes  extremely  extravagant
and  engages in  foolish  business ventures in which his
fortune, if  he has one,  is  sometimes  lost.  Finally, the
mental  powers begin to wane and the case progresses
to complete  dementia.   At  the same  time the paralysis
becomes more and more extensive  until the patient is
helpless, unable to feed himself and w ith no control over
his sphincters  (incontinence of urine and feces).   Bed-
sores frequently  develop and  complicating diseases are
not at all unusual.
  Treatment.—Treatment is largely  institutional,  prin-
cipally directed to the  care, comfort, and protection of
the patient.  If  the case is recognized at a  very early
stage the patient may be placed in the care  of  a nurse
or other attendant, and the  course of the disease  may be
somewhat retarded.
  Cerebrospinal Syphilis.—Under this heading we include
a large  number of cases  which are more directly  due to 
54        NERVOUS AND  MENTAL DISEASES

the syphilitic virus than tabes and paresis.   This disease
may  attack the  small bloodvessels causing  obstruction
to the circulation and consequent  injury to the nervous
tissue; there may be patches  of meningitis  causing local-
ized pressure on  the  brain or cord; or finally tumor-like
masses known  as gummata may be the  exciting factors
in producing the symptoms.  The symptoms, as may be
easily imagined, are as diverse as the  distribution  of the
lesions which give rise to them.
  If the disease attacks the brain, there  may be mental
deterioration,  and  in  many cases  paralytic phenomena.
If a gumma is present, the symptoms of  brain tumor, as
described later on, will be manifest. When  the cord is in-
vaded, there will be, in addition to inequality of the pupils,
loss of power,  rigidity, spasm, and  increased reflexes.
  In cerebrospinal  syphilis, tabes,  etc., lumbar puncture
is of considerable importance; the fluid which is obtained
shows a characteristic increase  of  certain cells (lympho-
cytes).
  Treatment.—In early cases, particularly in  gumma of the
brain, brilliant results are occasionally obtained by the use
of inunctions of mercurial ointment, large doses of  potas-
sium iodide, or intravenous injections of salvarsan or neo-
salvarsan.  The technic of the last-named procedure will
be described subsequently.  (See Syphilis.)
  Meningitis.—Meningitis  may  attack the  membranes
either of the brain or cord, but generally both are involved
at the same time; hence we speak of cerebrospinal menin-
gitis.   Syphilitic meningitis  of the  cord and of the brain
have  been mentioned.  Other forms of local meningitis
may depend on injury or abscess.  Cerebrospinal menin-
gitis may be due to tuberculosis.   It is a frequent terminal
infection in miliary tuberculosis, and in chronic bone and
joint tuberculosis.   It is also common in children without
obvious cause.  True  tuberculous cases  are  almost in-
variably fatal.  In children the disease may  begin with
irregular fever, irritability,  increasing stupor, and con-
vulsions.  In the early stages a child may utter  sharp 
    ORGANIC DISEASES OF NERVOUS SYSTEM      55

cries which are  characteristic when once  heard.   In the
stage of coma, extreme degrees of retraction of the head,
with curving of the back (opisthotonos),  are seen.  The
disease may last for several weeks, and emaciation become
excessive.  It is sometimes  spoken of as acute  hydro-
cephalus on account of the increase of fluid in the cavities
of the brain,  but it has nothing to do with the chronic
disorder of the same name.
  Epidemic cerebrospinal meningitis is due to a specific
organism and wTill be discussed with the infectious diseases.
Similar symptoms  result from  infection  with  a variety
of microorganisms which are not specific  to this disease,
the  most  important being the  pneumococcus  and  the
streptococcus.  In the pneumococcic variety the disease
may be  associated  with pneumonia.  The prognosis in
all these types is serious but not absolutely hopeless.
  Hemiplegia.—Hemiplegia or paralysis of one side of the
body is commonly  due to hemorrhage or softening,  but
the  converse  is not true, as hemorrhage  or  extensive
softening may exist without  paralysis.  The  manifesta-
tions depend  upon  the situation of the lesion.   Certain
areas of  the cortex, or gray  matter investing the brain,
control the motor functions, while others have to do with
psychic and sensory functions.  The fibers that  come
from the motor areas of the cortex are arranged on either
hand like the ribs of a palm leaf fan (Fig.  8).  They con-
verge near  the base of the brain, pass through the narrow
spaces on each side known as  the  internal capsules, in
the peduncles (or stems) of  the  brain,  and then unite
with their  fellows from the  opposite side  to  form  the
medulla and spinal  cord.  The  peduncle  corresponds to
the handle  of the fan.  In the  pons and medulla,  the
majority of the fibers pass over to the opposite side and
end  about  the nuclei (cranial nerves)  in  that region, or
pass downward  and  end about  the motor cells in  the
anterior gray matter of the spinal cord.  A few fibers pass
directly into the spinal cord, and cross over in a similar
manner lowrer down.  The above-mentioned nuclei  and 
56         NERVOUS AND  MENTAL DISEASES
cells form  a part of the lowrer  motor neurons and belong
to the cranial  and spinal nerves respectively.   The former
Lesion of cerebral mo-
 noplegia (brachial)
Lesion of ordinary
 hemiplegia
Lesion of cross paralysis
 (face of same side with
 limbs of other side)
A lesion causing paraplegia
A lesion causing hemi-
 paraplegia
Cortical centre for op-
 posite leg
Cortical centre for op-
 posite arm
      Cortical centre for op-
       posite side of face

I y----Internal capsule (pos-
       terior limb)
Motor nerve to face

Decussation of pyra-
 mids
Crossed pyramidal tract
Motor nerves to upper
 limb
Crossed pyramidal tract
Sensory nerves entering
  cord, and decussating
  soon after entry
Motor nerves to lower
 limb
Fig. 8.—Diagram showing the general arrangement of the motor tract
        and the effect of lesions at various points.  (Ormerod.)
supply the eye and its muscles,  the face, tongue, etc., and
the latter, the muscles of the trunk and  extremities. 
     ORGANIC DISEASES OF NERVOUS SYSTEM    57

  The arrangement of the circulation of the brain is such
that the arteries which supply the internal capsules are
peculiarly  liable to  disease  and  rupture,  particularly
on the left side, causing localized hemorrhage or clotting
in the vessels  (thrombosis).   Emboli  (floating particles)
in the blood are also likely to lodge in this region.  A
lesion  in the  internal capsule destroys the motor fibers
on that side and causes paralysis on the entire opposite
side of the body, with the exception of certain muscles of
the face and forehead which have a nervous supply from
both sides.  A similar injury in the pons will cause paralysis
of the arm and leg on the opposite side, plus paralysis of
the muscles controlled by one or more of the cranial nerves
on the same side (paralysis of the face).  This is explained
by the crossing of the  fibers described above.
  Hemorrhage, Thrombosis,  and  Embolism.— Cerebral
hemorrhage is found as a rule in those past middle age,
because in them the  vessels  are prone to  be weakened
by arteriosclerosis.  High blood-pressure which frequently
accompanies arteriosclerosis and nephritis increases the
liability to this accident.   Thrombosis, or clotting in the
bloodvessels, may occur at any age.  Typically it is char-
acterized by a more gradual onset of paralysis and uncon-
sciousness, but the  differentiation is probably not  as easy
as is often supposed.   Some authorities hold that  throm-
bosis rather than hemorrhage is the usual lesion.  Em-
bolism occurs frequently in younger persons, particularly
in infectious diseases, in the course  of acute and  chronic
endocarditis, and in  aneurysm.  It is  due  to fragments
of clots, or  vegetations  from  inflamed  valves,  getting
into the blood and plugging the terminal arteries in the
brain.  It  leads  to localized clotting  (thrombosis) and
softening.  In  many cases hemorrahge or softening which
was at first of small extent may be succeeded by secondary
hemorrhage causing widespread paralysis and death.
  The attack  comes  on  suddenly, usually  without pre-
monition, but  is  sometimes preceded by  vertigo,  numb-
ness,  or convulsions.   The patient is deeply unconscious 
58        NERVOUS AND  MENTAL DISEASES

(comatose), the extremities are relaxed, the pulse is full
and strong, and the  respiration deep and  snoring  (ster-
torous).   Urine and  feces  may be passed  involuntarily.
On careful examination the arm and leg on one side are
usually found  to  be more relaxed than on  the other,
one side of the face  is  puffed  out in breathing, and the
pupils are  unequal.  At  this  stage there  is  difficulty
in  distinguishing  the  attack  from alcoholism, opium
poisoning, or head injuries, unless the previous  history
of the patient  is known.
  In fatal cases the patient passes into  deeper  coma, and
loud, bubbling  rales presage the development of edema of
the lungs.  In  those  less serious, consciousness gradually
returns and the distribution  of the  paralysis  becomes
evident.   When the  paralysis  is on the right  side the
patient may at  first be unable to express himself (aphasia),
but in time speech is usually recovered.  Recovery may
be due to relief of pressure, etc., or to the education of the
centers on the opposite side.  In left-handed persons par-
alysis of  the right  side is not accompanied by aphasia.
  In convalescence the leg recovers more rapidly than the
arm, but some loss of power  usually persists.   Wasting,
except from disuse, does not  occur, because the disease
is in the  upper motor segment and leaves the ganglion
cells  which control   nutrition  uninjured.  The reflexes
on  the affected side  are increased.  When the patient
walks he swings the affected leg from the hip and supports
the  paralyzed  arm   with  the  opposite  hand.  Elderly
patients who have suffered one stroke are liable to sub-
sequent attacks.   Sometimes these may be very slight,
and it is  not rare for the patient  to die of some com-
plicating disease.
  Treatment.—If the  patient  is  found  in the  comatose
state, he should be placed in bed with the head elevated.
If the clothing is tight it should be loosened;  cold may be
applied to the head and heat  to the extremities.  If the
pulse is full and the blood-pressure high, it is good prac-
tice to bleed the patient freely with the purpose of lowering 
     ORGANIC DISEASES OF NERVOUS SYSTEM    59

 the  blood-pressure  and  checking the hemorrhage.  At
 this stage croton oil,  1 minim, or elaterin, -^  grain, is
 frequently  administered  to  produce  purgation.    The
 treatment  in  other  respects is  symptomatic.   During
 convalescence massage may be of some use in maintaining
 the  nutrition of  the  muscles until  their  functions  are
 restored.   Careful nursing is necessary to avoid the forma-
 tion of bed-sores.  Patients should be tilted from side to
 side to prevent congestion of the dependent portions of the
 lungs.  In  the  early  stages care  should be used in the
 administration of food, as  there  is  danger of aspiration
 pneumonia, from solid particles "going down the wrong
 way."
   Subdural Hemorrhage.—Any circumstance which will
 cause  a rupture of one of the bloodvessels on the surface
 of the brain  will give rise to  hemorrhage  beneath the
 membranes and,  if this is not  too  extensive, to localized
 pressure.   Such  hemorrhages  are common  in  surgical
 practice as the result of injury.   In medical practice  we
 see them  most often in children, sometimes as a result of
 birth injuries, at other  times in consequence of excessive
 congestion, such  as occurs in whooping-cough or convul-
 sions.   The pressure is likely to involve parts of the motor
 area, and leads either to hemiplegia or monoplegia, more
 often the  latter.   Thus if  the arm  center is pressed upon,
 there  is  paralysis of   the  corresponding  member  (see
 diagram).  At first the paralysis may appear to  be  very
 extensive  but it  usually clears  up to a  certain degree.
 Subsequently  the affected limb  ceases to grow, becomes
 stiff and   rigid,  or exhibits  peculiar,  slow, spasmodic
 ("athetoid") movements.
  Treatment.—Treatment  consists  in an effort to restore
function in the temporarily affected muscles by massage
and  electricity, and in the prevention or correction  of
deformity by  orthopedic apparatus and operations.
  Hydrocephalus.—Hydrocephalus  or  "water  on  the
brain," is  a term  used  to designate  an increase  of fluid
in the ventricles  or cavities of the brain.  This may be 
60       NERVOUS AND MENTAL DISEASES

due to many causes: meningitis, tumors, and the atrophy
of old age.  In the last named the fluid takes the place of
the shrunken brain substance; in the others the accumula-
tion is due to obstruction  which prevents the normal
drainage  of the cerebrospinal fluid into the spinal canal.
  The  disease usually designated by this name, however,
is chronic congenital hydrocephalus.  Children affected with
this  disease  have  large, rounded  heads and relatively
small, narrow faces.   There may be some weakness in the
extremities.   The mind may be clear, or there may be a
certain degree of mental impairment.  As the condition
begins  before birth,  it  may interfere writh  labor, and
sometimes the spinal  cord or  the  ventricles have to be
drained to permit delivery.  Hydrocephalic children are
usually weakly and do  not often  survive to  adult life.
In some cases lumbar puncture has been of great benefit.
Aside from this there is no treatment.
  Tumors of  the  Brain. — Syphilis may  give  rise to
gummata which present all  the signs and symptoms of
brain tumor.  Unlike other tumors they are amenable
to treatment.  Benign and malignant growths also occur,
and produce, first, symptoms common to  all brain tumors,
and  second, localizing  symptoms,  depending  on  the
situation   of  the  growth.  The  primary symptoms of
brain tumor  are headache, vomiting,  and optic neuritis
("choked disk").  The latter refers to inflammation and
swelling of the optic disk or nerve head (as viewed through
the ophthalmoscope), due to increased intracranial press-
ure.  Localizing symptoms include disturbances of  the
various senses, paralysis, vertigo, disturbances of gait, etc.
  Abscess of the Brain.—Abscess of the brain produces
symptoms which may be similar to those seen in tumor,
but  are  more  sudden in onset,  and are  accompanied
by fever, leukocytosis, and  the signs and symptoms of
the primary disease.  Abscess of the brain is usually due
to disease of the middle ear and mastoid, or to infection
from the  nose and its sinuses.
  Treatment.—If an accurate localization can be made,
and  the  tumor is in a situation where  it can be safely 
     ORGANIC DISEASES OF NERVOUS SYSTEM    61

reached,  removal  is  often  attempted  by a  trephining
operation.   In other  cases  trephining  and  drainage
(decompression)  are undertaken to relieve the  intense
headache  and to save the eye-sight.  This operation is
a palliative one only.  In brain abscess, operation is more
urgent, as it may be a  life-saving measure and usually
offers the only hope of saving a patient's life. 
 
PART  II.
DISEASES  OF  THE  BLOOD  AND
                 GLANDS.
Diseases of the Blood.
  General Considerations.
  Anemia.
  Chlorosis.
  Pernicious Anemia.
  Splenic Anemia and  Polycy-
   themia.
  Leukemia.
  Hodgkin's Disease.
  Purpura.
  Hemophilia.
Diseases of the Lymphatics and
  Lymphatic Glands.
Diseases  of  the  Ductless
   Glands.
  Simple Goitre.
  Myxedema and Cretinism.
  Exophthalmic Goitre.
  Thymic Asthma, Thymus Death,
   etc.
  Addison's Disease.
  Infantilism and Acromegaly.
DISEASES  OF THE BLOOD.
   General Considerations.—Pallor of the skin is not  a
trustworthy evidence of anemia, as persons with thin,
delicate skins may have a rosy hue, although the blood
is decidedly impoverished, while in thick-skinned persons
the opposite is true.  The color of the mucous membranes,
lips, tongue and conjunctiva, is a more  reliable index of
the condition of the blood.
   The color of the blood may be roughly estimated by
comparing a drop of the patient's  with a drop of the
examiner's blood  on a handkerchief, or a printed scale
of colors  may  be used for  more accurate comparison.
Physicians commonly  employ some form  of hemoglo- 
64     DISEASES OF THE BLOOD AND GLANDS
binometer for this purpose.  One of the simplest is that of
Sahli which consists of two  tubes, one containing colored
            A       fluid as  a standard and  the other
                    a  measured  quantity  of the blood
                    to be  tested, and sufficient  diluting
                    fluid to make the tubes look alike.
                    When  the tubes match perfectly the
                    percentage  of hemoglobin may be
                    read off on the scale.
                       Blood counts are made by dilut-
                    ing the blood in graduated pipettes,
                    and then counting the cells  under
                    a  microscope.   For this purpose  a
                    drop of the diluted blood is placed
                    on an  accurately ruled slide (count-
                    ing chambers)  and covered with  a
                    glass  slip.  From the figures thus
Fig. 9.—Sahli's hemoglo-
  binometer.  (Simon.)
Fig. 10.—Blood counting chamber
      (ruling).  (Simon.)
obtained the  number of cells in a  cubic  millimeter is
calculated.  Usually the number of red corpuscles varies
from four to five million.  In the "severest" anemias the
number of "reds" may fall below one million.  The white
blood cells usually  number  from eight to ten thousand.
In typhoid fever and measles they are reduced below this
minimum (leukopenia) but in most infections, e.  g., pneu-
monia, they are increased to fifteen,  twenty, thirty thou-
sand,  or more (leukocytosis).  The greatest increase is 
PLATE  IV
      BLOOD

  (Ehrlich triple stain.)

(Prepared by Dr.  Lyon.)


         Fig.  1
                 TYPES  OF  LEUKOCYTES.

  a. Polymorphonuelear neutrophile.   b. Polymorphonuelear
eosinophile.   c. Myelocyte   (neutrophilic).   d.  Eosinophilic
myelocyte   e.  Large- Lymphocyte  (large mononuclear).  /.
Small  lymphocyte (small mononuclear).
Fig. 2
            VARIETIES  OF RED  CORPUSCLES.

  a.  Normal  red corpuscle (normocyte).   b, c.  Anemic  red
eorpuseles.  d-g. Poikilocytes  (irregular cells),  h.  Mieroeyte
(small cell).   i. Megaloeyte (large cell),  j-n. Nucleated  red
eorpuseles.  j, k. Normoblasts.  I.  Mieroblast.  m, n.  Megalo-
blasts. 
 
DISEASES OF THE BLOOD            65
seen in leukemia ("white blood") in which  disease they
may be numbered by the hundred thousand.  To make a
"differential"  count,  a drop of blood is spread upon a
slide or cover slip and strained, after which the various
kinds of white blood cells are noted and recorded in per-
centages.  In  normal blood of adults, about  70 per cent.
of the white cells have irregular nuclei and fine granules
which stain a purplish color with ordinary stains—these
are  known  as  polymorphonuclear cells.   The  small
lymphocytes,  which have  regular,  deeply stained  nuclei
and no granules,  constitute about  25 per cent,  of  the
cells.  The remaining cells consist of large cells with single
nuclei (large lymphocytes),  and cells with large, bright
pink granules  (eosinophiles). The latter, which normally
do  not much  exceed  1 per cent., are increased in certain
diseases (e. g.,  trichinosis).    In leukemia  special cells
known as  myelocytes make their  appearance.  The red
cells are also  inspected for the  detection of changes sug-
gestive of  anemia,  etc.  The normal  red cells are of a
uniform size and color but in  anemia they may be pale
(throughout or in the center), irregularly stained, or vari-
able in size and shape.   Sometimes  in  severe anemias
some of the red cells may be nucleated.  Large nucleated
red  cells  (megaloblasts) are characteristic of  pernicious
anemia.
  In acute secondary anemia (hemorrhage) and rarely in
pernicious anemia it may be necessary or wise to attempt
to supply the deficiency in the volume  of the blood  by
hypodermoclysis, intravenous infusion, direct transfusion,
or  enteroclysis.   These measures  are  also of  value  in
"shock,"  in uremia (when combined  with venesection),
in toxemias, and in infections.  In the operation of hypo-
dermoclysis a  pint or more of fluid (usually physiological
salt solution)  is  injected into the loose connective tissue
beneath the breasts, in the axilla, or elsewhere.   These
injections  may be and often are repeated.  The operation
is very simple and no apparatus is required except a large
hypodermic needle and a fountain syringe.  The most
      5 
66     DISEASES OF  THE BLOOD AND GLANDS

scrupulous cleanliness and asepsis is, however,  essential
as the infiltrated  tissues seem to be prone to infection.
I have seen severe and even fatal consequences follow this
simple operation.   In the operation  of intravenous infu-
sion a large vein, usually at the bend of the elbow, is laid
bare  by incision  and careful  dissection.  Ligatures  are
placed about it, above and below, and the lower one is
tightened.   The intravenous  needle, which  has  a  dull
flanged tip, is introduced through a  slit in the  vein, in
the direction of  the heart, and the upper ligature is tied
about it.  The salt solution, since it goes directly into  the
circulation, should be accurately made,  sterile,  and  not
below the  temperature of the blood,  98° to 100°.  When
sufficient fluid has been introduced, the needle is removed,
the upper ligature tied, the section of the vein completed,
and the wound  closed by suture.  A simpler method is
to thrust a sharp  needle  directly into the vein without
preliminary incision.  Transfusion is a more difficult oper-
ation and less often required in medical cases.  By means
of special cannulas the surgeon connects the bloodvessels
of the  "donor" with those of the patient, or  blood is
alternately withdrawn from the bloodvessels of the former
and injected into those of the latter.  Special tests  are
necessary to determine  the  suitability of the donor  (s).
Enteroclysis is discussed on page  142.  In most cases it is
a very efficient, safe, and painless  substitute for the above-
mentioned procedures.
  Anemia.—Anemia  is  a deficiency  in  the quality  or
quantity of the blood, with a reduction in the number of
red cells and in the percentage  of hemoglobin (coloring
matter).   Anemia may  be  local  or general,  acute   or
chronic, primary or secondary.  Local anemia is really a
circulatory disturbance and has  nothing to  do with the
composition of the blood;  we have an example in transi-
tory anemia of the brain causing syncope or "fainting."
Acute anemia is generally the result of a profuse hemor-
rhage, as in injury, accidents of childbirth,  gastric ulcer,
cirrhosis of the liver, typhoid fever, or phthisis.  The most 
DISEASES OF THE BLOOD            67
important  anemias- are  chronic  and  either primary or
secondary.  The primary anemias are, as far as we know,
definite diseases involving  blood formation and  destruc-
tion; the  secondary anemias are symptomatic of other
conditions  and diseases: repeated  hemorrhages,  internal
parasites, acute and chronic infections, poisons, malignant
tumors, wasting diseases, etc.  Most secondary  anemias
are like chlorosis and are therefore spoken of as chlorotic.
In these cases the red cells are moderately diminished in
number but it is the coloring matter which is especially
deficient so that even the individual cells, like the patients
themselves, are pale.  The cells may be very little altered
in other respects from the normal.  Some of the red ones,
while of normal  size, may be nucleated (normoblasts).
Other secondary anemias resemble the pernicious variety.
In this type the red cells are greatly reduced in  number,
irregular in size, shape, and coloring  (when  stained),  and
many of them are nucleated.  Although the patient may
have an  intense pallor the individual cells may be darker
than normal. This sort of anemia  is observed in "essen-
tial"  anemia,  in  the  so-called  cancerous  cachexia, in
chronic Bright's disease, etc.  The patients do not respond
readily to treatment  and arsenic is usually of greater use
than iron.
  Chlorosis.—Chlorosis, or the  "green sickness," occurs
in young girls and is associated  with menstrual  disturb-
ances,  constipation, improper diet, overwork, and unhy-
gienic conditions.  The cheeks may be red in spite of the
general pallor and the  nutrition may not  be markedly
affected.  The blood changes have been described above.
The disease  was formerly very prevalent but has practi-
cally disappeared in this locality, due no doubt to shorter
working  hours, improved  diet,  etc.   It is  possible  also
that many cases which we now label incipient  tubercu-
losis,  intestinal  toxemia, hookworm  disease, etc.,  were
formerly called chlorosis.
  Treatment.—Treatment consists in proper hygiene  and
diet, laxatives, and iron, the latter usually in the form of 
68     DISEASES OF THE BLOOD AND GLANDS

"Blaud's" pills.  Organic preparations of iron, such as the
albuminate  and  various  proprietary  preparations, are
preferred by some physicians.
  Pernicious Anemia.—Essential or  pernicious  anemia
is characterized  by a  progressively  downward  course,
often with periods of temporary improvement, and a fatal
termination.  The patients may not lose much weight
but  become extremely  weak and acquire  a pale  lemon
hue.  There may be irregular fever.  The red blood cells
fall to a million or two, or even less, while the coloring
matter is reduced to a less degree.  The  red cells are very
irregular in size,  shape,  and coloring, and  many of them
(after staining) are stippled with blue dots  (also seen in
lead poisoning).   Nucleated red cells (normoblasts), par-
ticularly if  very large  (megaloblasts)  or small (micro-
blasts) are suggestive of this form of anemia. In hemor-
rhagic anemia normoblasts alone are seen.
  Sometimes irritation or inflammation  of the gums and
tongue may be found, or the  stomach and intestines may
show evidences of complete atrophy.  The former may be
a cause of the anemia; the latter, like the spinal symptoms
which occasionally appear, is doubtless the result of it.
The heart  is  very frequently  enlarged with associated
symptoms: breathlessness,  soft  pulse,  etc.   Edema,  if
slight, may be due to anemia alone.  Many cases  which
have been considered pernicious anemia during  life have
been found at autopsy to be due to latent cancer, Bright's
disease,  etc.
  Treatment.—The  treatment is not hopeful,  although
great temporary improvement  often occurs either spon-
taneously  or after  the  use of  iron, bone-marrow,  and
arsenic.   The  last named is  the most valuable remedy
and is given by the mouth as Fowler's solution or arsenic
trioxide,  and hypodermically as sodium  cacodylate or
atoxyl,  frequently combined with citrate  of iron.  Its
action should be carefully watched as already mentioned
under Chorea.  Transfusion is frequently performed  and
may be of great temporary and  possibly  permanent bene- 
DISEASES OF THE BLOOD
69
fit.   Prolonged rest in bed, careful feeding, and fresh air
are  all essential.
  Splenic Anemia  and  Polycythemia.—Splenic  anemia
is a rare disease, characterized by great enlargement of
the spleen, anemia, and later by cirrhosis of the liver with
ascites.  In the latter stage, it is known as Banti's disease.
Excision of the  spleen  is sometimes carried out  with
benefit  to the patient.
  In  contrast to  anemia, there is  a group of diseases,
mostly rare, characterized by cyanosis (blueness), enlarge-
ment of the spleen, and enormous increase in the number
of red cells.  This group of  symptoms is described as
polycythemia.   Severe cyanosis  of  a  totally different
character is sometimes brought about by acetanilid  and
similar drugs which have a destructive action on the blood
(avoid headache  "cures"!).
  Leukemia.—In  leukemia  there is,  sooner  or  later, a
pronounced  anemia in addition to an enormous increase
in the number of white blood cells.  The latter, which
normally  amount to  less than ten thousand  per c.mm.
may increase  in this  disease to three hundred thousand
or more.  The white cells which under normal conditions,
as we have  seen, are  of several varieties may  be  present
in unusual proportions (e. g., an excess of lymphocytes
in lymphatic leukemia), or there may be a large number of
abnormal cells (myelocytes  in myeloid  leukemia).   The
lymphocytes in leukemia are often unusually large; the
myelocytes  are large  mononuclear  cells with granules
which stain red, blue,  or purple.
  Patients with leukemia come to the  physician for bleed-
ing from  the gums, epistaxis, or  other  forms  of  hemor-
rhage, for a tumor in the  abdomen (large spleen),  for
enlarged glands, or merely  for  general weakness.   In
myeloid or  splenomyelogenous leukemia, the  commoner
variety of the disease, there is tremendous enlargement
of  the  spleen; in  lymphatic leukemia, the  superficial
lymphatic glands  are  enlarged.   The diagnosis is made
by  examination of the blood and  if this is neglected, the 
70     DISEASES OF  THE BLOOD AND GLANDS
disease is likely to be overlooked.  The course is usually
chronic and eventually fatal.  Acute lymphatic leukemia
is occasionally seen.  In a case recently under observation
death occurred within a week of admission to the hospital,
although the glands were only slightly increased in  size.
Fig. 11.—Hodgkin's disease. Notice the enormous enlargement of the
       lymphatic glands of the neck and axillae.  (Hare.)
  Treatment.—Treatment  consists  of  rest,  good  food,
attention to the general hygiene,  and the administration
of arsenic.   The  x-rays are often  useful.   Temporary
improvement as in pernicious anemia is not at all unusual. 
DISEASES OF THE BLOOD            71
  Hodgkin's   Disease. — Hodgkin's   disease  (pseudo-
leukemia), like leukemia, is characterized by anemia and
enlargement of the lymphatic glands and spleen, but there
is no increase in the number of the white cells. The liver
is moderately enlarged. The enormous spleens so common
in leukemia, are not observed.   The enlargement of the
lymphatic glands, on the  other hand, is  usually more
pronounced  than  in  leukemia  and  often  gives rise to
localized pressure.  Frequently  the glands of the  neck
form  an enormous collar causing great deformity  and
venous congestion of the face.  At other times the intra-
thoracic  glands  are  first  and  predominantly affected,
causing pressure on the bronchi, etc., with resulting cough,
dyspnea, and cyanosis. Ultimately most of the lymphatic
groups become involved.  The disease is very chronic and
the outcome doubtful.  Treatment is along lines similar to
those found useful in leukemia.  The x-ray treatment is
temporarily very  efficacious; sometimes glands  may be
excised with benefit.
   Purpura.—Hemorrhage into the skin or mucous mem-
branes is spoken of as purpura.   The hemorrhagic patches
may  be  large and diffuse  (ecchymoses) or minute  and
discrete (petechia).  At first they are purple in color but
as they clear up they assume the colors of a bruise.  Severe
types of measles,  smallpox,  and other  infections may be
associated  with hemorrhagic  or purpuric eruptions; in
typhus  fever  and epidemic meningitis petechia?  are  a
characteristic  feature.  In the  latter disease  cases occur
in which the eruption is the  dominant symptom.  Certain
drugs and poisons such  as quinin and belladonna may
also cause purpura.  Purpura occurs in scurvy, in Bright's
disease, in debility, and in old age (slight injuries).  Cases
in the newborn are marked by bleeding from the umbilicus
and by bloody urine.
   Rheumatic  purpura is  closely related to acute  articular
rheumatism; there is either a history of the latter disease,
or a swelling of the joints accompanies the eruption.  The
purpuric spots are usually confined to  the lower  extremi- 
72     DISEASES OF THE BLOOD AND GLANDS

ties; they may be simulated by hemorrhagic dots due to
fleas or lice (pediculi).  The disease  is usually mild with
very  slight fever, and  is treated in the  same  way  as
rheumatism.
  Purpura hemorrhagica,  on the  other hand, is a severe
disease  characterized  by extensive hemorrhages into  the
skin and  mucous membranes.   Hemorrhages  from  the
nose, stomach, intestines, and bladder show that the affec-
tion is  not confined  to the visible  mucous membranes.
Although there is, as a rule, no fever or other constitutional
symptom,  nevertheless  the  hemorrhages continue,  and
death ensues in a few hours  or  days.   Fortunately  the
disease is rare.
   Hemophilia. — Bleeders are  persons  who   have  a
hereditary  tendency  to  attacks  of  severe hemorrhage,
either as the result of slight injuries or without obvious
cause.   The blood is  presumably lacking in certain con-
stituents which are  necessary to  prompt coagulation.
This  disease which is known  as hemophilia is seen  in
males only, but, curiously enough, is  transmitted through
the female side, i. e.,  a bleeder's sons do not suffer from
or transmit the disease  but his daughters pass  it on  to
their male offspring.
  The traditional  treatment of hemorrhage consists  in
absolute rest,  sometimes  secured by  a hypodermic  of
morphin, and in  the  administration of  astringents  and
styptics such as gallic and tannic acids.   Ergot is used
to contract the bloodvessels and nitroglycerin to dilate
them  as circumstances seem to indicate.  At the present
time, while we  still use these measures, we depend more
on the following:  packing, syringing with hot water, the
application of adrenalin, the internal use of calcium lac-
tate, and the subcutaneous administration of blood serum.
After  the  administration of normal horse serum, as after
diphtheria  antitoxin,  urticaria may develop  or,  very
rarely, severe or  even fatal collapse.  If the physician
cannot be reached immediately a hypodermic of  morphin
and atropin should be promptly  administered. 
       DISEASES OF THE DUCTLESS GLANDS      73


  DISEASES OF THE LYMPHATICS AND LYMPHATIC
                      GLANDS.

  General and local enlargement of the lymphatic glands
may result from  tuberculosis, syphilis, and other infec-
tions  as well as from mechanical irritants such as coal
dust.   The last-mentioned irritant often gains access to
the bronchial glands from the air  passages and from the
lungs. Tubercular glands are most  often found in the
neck  (infection from the tonsils), in the neighborhood of
the bronchi, and  in  the  glands of  the mesentery (the
membranous sling which supports the small intestine).
Enlargement of the bronchial glands is usually associated
with tuberculosis of the lungs.  Occasionally the condition
may exist alone and give rise to intractable cough.  Tuber-
culosis of the mesenteric  glands occurs in children and
causes excessive wasting (tabes mesenterica).   In syphilis
there is  a slight general  enlargement of the superficial
lymphatic glands, particularly significant when it involves
the glands at the inner side of the  elbow (epitrochlear)
and at the back of the neck.  The lymphatic glands are
also enlarged in many other infections, in certain anemias,
and in the neighborhood of  malignant growths.  Fre-
quently the irritation caused by head lice leads to enlarge-
ment of the glands at the back of the neck.

       DISEASES OF THE DUCTLESS GLANDS.

  The  spleen,  thyroid,  thymus, suprarenal capsules,
pituitary  body, etc.,  are spoken  of  as ductless glands,
because they have no outlet for  their secretions except
into the circulation.  The spleen has to do with the forma-
tion and  destruction of the red blood cells, and perhaps
with  the production of immunity to infection.  It is not,
however,  an organ which is essential to life.  The remain-
ing ductless  glands as well as the testicles and ovaries
which have an internal secretion in addition to their more
obvious function, have a  regulative influence on growth, 
74     DISEASES OF THE BLOOD AND GLANDS

nutrition, sexual characters, blood-pressure, etc.  Some of
the glands seem to have opposing actions, so that if one
is overactive or another underactive,  pathological symp-
toms may develop.  The suprarenal causules have to do
with the  maintenance of blood-pressure.   If their influ-
Fig. 12.—Sporadic cretinism, aged twenty-one years. Before treatment.
                        (Dock.)

ence is  removed the pulse becomes soft and  small.  If
the thyroid is overactive, the pulse is rapid, full, and soft;
if  its function is  depressed, the  pulse  is slow  and the
mental  processes dull.  The pituitary regulates growth.
If  its function is disordered, there is either overgrowth of
bones and tissues, leading  to gigantism on the one hand, 
        DISEASES OF THE DUCTLESS GLANDS     75

or the retention of the characters of infancy with obesity
(infantilism) on the  other.
  Simple Goitre.—An undue, persistent  enlargement of
the thyroid is known as goitre.   The slight, temporary
enlargement which occurs  in many women at  the  men-
Fig. 13.—Case of Dr. Hermon Sanderson.  After four months' treat-
              ment with thyroid extract.  (Dock.)

strual  period is not  abnormal.  Simple goitre,  which
occurs epidemically in Switzerland and in other moun-
tainous countries,1 and sporadically  in other places,  is
characterized by an  enlargement of  the  gland which  is
usually asymmetrical  and may reach grotesque propor-
  1 Goitre is prevalent in certain " goitre belts" in the United States,
e. g., in the lake states and in the northwest. 
7(>     DISEASES OF THE BLOOD AND GLANDS

tions.  The disease is not usually accompanied by symp-
toms, except those of local discomfort or of  interference
with breathing or swallowing.  If the growth  reaches any
great size or produces dangerous pressure symptoms, par-
tial but not total excision is advisable.  Complete removal
will  cause the development of symptoms of myxedema
on account of the loss of the thyroid secretion.
  Myxedema and Cretinism.—Myxedema, whether result-
ing from removal of the thyroid or  from  spontaneous
atrophy or loss of function of the gland, is characterized,
as the name  implies, by deposits of so-called  mucoid
tissue beneath the skin which  in  some respects resemble
edema.   The  swelling,  however, is  firm and does not
"pit" on pressure like true  edema.  These  deposits are
most often seen above the clavicles.  The patient becomes
mentally  torpid  and sleepy, the  pulse is slow, the hair
brittle, and the  skin dry.  Myxedema usually occurs in
women after middle life.  Cretinism, on the other hand,
is due to congenital, thyroid insufficiency and manifests
its symptoms in childhood, although  the patients may
survive until  adult life.   They retain  the  fat,  chubby
appearance of infants, largely  as a result of extensive
deposits of mucoid tissue. The tongue is large and lolls
out of the mouth and a high degree of idiocy is present.
If they learn to walk they only do so imperfectly.
  Treatment.—The treatment of myxedema and cretinism
by thyroid extract has been one of the triumphs of modern
therapeutics.   If  the  extract is administered to cretins,
mental improvement occurs in a short time with restora-
tion  of  normal  development  and  growth.   Excellent,
although less striking results are  obtained in myxedema
by the aid of the same remedy.  Iodin and  the  iodides
are usually beneficial in simple goitre and myxedema.  It
is an interesting fact that the thyroid itself contains an
unusual proportion of iodin.
  Exophthalmic   Goitre. — Exophthalmic   goitre,   or
Graves' disease is apparently due to, or associated with,
oversecretion of  the thyroid.   The pulse is rapid,  the 
      DISEASES OF THE DUCTLESS GLANDS       77

mind alert  and overactive,  and all the vital processes
stimulated,  so that the patient tends to lose weight and
strength instead of  accumulating deposits of fat, as in
the last-named  conditions.   The thyroid is  only moder-
Fig. 14.—Exophthalmic goitre.  (Dock.)
ately enlarged, and is frequently symmetrical.  The chief
diagnostic signs of exophthalmic  goitre are: (1)  promi-
nence  of  the  eyeballs and widening of the  aperture
between the eyelids, so that when the patient looks down-
ward, the white of the eye  is seen above the  iris;  (2) 
78     DISEASES OF THE BLOOD AND GLANDS

a "fine,"  rapid tremor  of the hands; (3) moderate  en-
largement of the thyroid gland; (4) rapidity of the pulse.
The symptoms may  come  on acutely but  are  usually
subacute or chronic.  In addition to the so-called cardinal
symptoms  the patient may exhibit general nervousness,
loss of strength, attacks of indigestion, diarrhea, etc.
  Treatment.—Medical treatment is unsatisfactory in  the
above-described condition, because we have no  specific
drug, and the only method of limiting the oversecretion
is  by removing part  of  the gland by operation, or  by
limiting the blood supply by tying one or more of  the
bloodvessels which enter it.   Medical  treatment is some-
times successful and almost always helpful.  It consists
essentially  in partial or complete rest.  If the symptoms
are at all active  the patient should be confined to bed
for a number of weeks, until the cardiac irritability has
disappeared.  He should also be shielded from anything
which might cause worry or excite attacks of tachycardia
(rapid pulse). Surgeons  are so mindful of this fact that
they frequently do not allow their patients to know when
operation is intended.  The patient may be given a whiff
of ether repeatedly on successive days before it is consid-
ered opportune to push  anesthesia to  a degree sufficient
for operation. Sodium phosphate is used to secure regu-
lar movement of  the  bowels and may have some other
therapeutic value.  Drugs which  retard  the pulse, such
as digitalis, are not of much use.  An ice-bag over the
precordium is usually more  effective.   Iodides and iodin
preparations  are  usually contra-indicated, but in some
mixed cases they  may be of benefit.
  Thymic Asthma and Thymus Death.—Diseases of the
thymus are rare,  and can receive only a passing notice.
This gland, situated beneath the upper part of the sternum
is  larger during childhood, but with  the beginning of
adult life  it wastes away  and practically  disappears.
Children in whom the  thymus is enlarged may suffer
from  symptoms  of obstruction, due to pressure  of the
enlarged gland on the air passages—thymic asthma.   At 
       DISEASES OF THE DUCTLESS GLANDS     79

other times, there may be no asthma but the subjects
of the enlargement are liable to sudden death from the
most trivial causes—thymus death.  Children, apparently
healthy, may die after a few whiffs of chloroform or in
the midst of a simple operation, such as that for adenoids.
  Addison's Disease.—Addison's disease is due to defi-
cient secretion of the adrenal glands and may result from
tubercular  infiltration, tumors, etc.  The symptoms are
pronounced pigmentation  of the skin and mucous mem-
branes, excessive weakness, and soft pulse.  The patients
almost invariably die of cardiac failure. This  disease is
extremely  rare.   I performed an autopsy in  one case
(tubercular), and have seen but one or two others during
a period of more than fifteen years.
  Infantilism and Acromegaly.—Diseases of the pituitary
body in  pronounced  forms are  rare.  Mild disturbance
of the pituitary are probably responsible for many cases
of obesity, particularly when these are associated with
faulty development of the sexual characters, as in " infan-
tilism."  Diseases of the pituitary are  at present attract-
ing a great deal of attention, perhaps out of due proportion
to their frequency and importance.
  Acromegaly is the  most  definite disease  produced  by
the enlargement and overaction  of the pituitary gland.
It is characterized by progressive enlargement of the bones,
particularly of the face, hands, and feet.   The features
become so large and  gross  that the patient resembles a
gorilla, while the fingers and toes appear  like sausages.
The hands are  thought to resemble  spades because of
their square form.   On account of the enlargement of the
gland, the patient may also suffer from  symptoms of
brain tumor, particularly headache.  Until  recently there
was no treatment.   At the present time  surgery is a
possible recourse in some cases. 
 
PART III.
DISEASES OF THE CIRCULATORY
                  SYSTEM.
              CHAPTER I.

DISEASES OF THE BLOODVESSELS AND
             PERICARDIUM.
General Symptomatology.
  Pulse.
  Blood-pressure.
  Pulse Tracings.
  Syncope.
  Dyspnea.
  Dropsy.
  Cyanosis.
  Pulsations.
  Capillary Pulse.
  Thrills.
  Murmurs.
  Heart Area.
Diseases of Bloodvessels.
  Arteriosclerosis.
  Aneurysm.
  Embolism.
  Thrombosis.
  Infarction.
Pericarditis.
  Hydro pericardium.
  General Symptomatology.—The Pulse.—The pulse was
formerly the most important index of a patient's condition
which was available to the physician, and although it has
fallen from its high estate it still yields important infor-
mation, especially  when interpreted by  modern  instru-
mental methods.  The accurate observation and recording
of the pulse-rate and rhythm is one of the  most important
duties  of the nurse.  In taking the pulse certain char-
acteristics,  most  of which are within  the scope  of the
nurse,  are to be noted: (1) the rate; (2) the  size;  (3)
the celerity; (4) the tension;  (5) the rhythm;  and  (6) the
condition of the vessel wall.
     6 
 82      DISEASES OF THE CIRCULATORY SYSTEM

   The normal adult pulse-rate ranges between 05 and 80,
 varying with the  individual and the position, whether
 reclining, sitting, or standing.  It is  markedly  affected
 by exercise,  and in nervous persons and children,  by
 excitement1.  In keeping records, care should be employed
 to  take the  pulse  under  uniform conditions;  the best
 time to take a baby's pulse  is during sleep.  In infancy
 the pulse-rate varies from  140  at birth to 100 at two or
 three years, after which it  gradually declines, reaching
 the adult rate at about the time of puberty.  In fever
 the pulse-rate ordinarly increases in proportion  to  the
 temperature;  in  uncomplicated typhoid the  pulse   is
 relatively  infrequent, in scarlet  fever  it is relatively
 rapid.
   A persistently rapid pulse-rate is designated as tachy-
 cardia.   Paroxysmal tachycardia is  a nervous  affection
 of  the heart characterized  by periods of extremely rapid
 pulse.  Tachycardia  may or may  not be accompanied
 by the  sense of palpitation.  A persistently slow pulse is
 spoken  of as bradycardia.  In some individuals the normal
 pulse-rate may be 40 or  less.  A very slow pulse is one of
 the symptoms of "heart block."  Fatty heart, jaundice,
 and meningitis are widely  differing conditions which are
 characterized by an infrequent pulse-rate.
  The pulse is spoken of as large or  small, depending on
 the apparent  size of the pulse wave  as estimated by the
 palpating fingers.  To estimate the celerity of the pulse,
 attention is directed to the way in which the  pulse wave
 strikes  the  fingers.  If  it  strikes quickly and  recedes
 rapidly the pulse is spoken of as "quick."  If the pulse
 wave appears  to reach  its  maximum  gradually and  in
 the same fashion recedes, the pulse is technically described
 as "slow,"  In this sense "slow" has nothing  to do with
 pulse-rate.  The " Corrigan" pulse, as seen in insufficiency
of the aortic valves, is at the same time a "large" or full

  1 Recumbent, 72, standing 82, immediately after climbing a flight of
 steps 92, one minute later 82.  In abnormal hearts exaggerated responses
 to changes of position and exercise occur. 
GENERAL SYMPTOMATOLOGY          83
pulse, and a " quick" pulse.  In aortic narrowing (stenosis)
the pulse is "small" and "slow."
  The force or tension  of  the  pulse may  be estimated
by the amount of pressure required to obliterate the pulse
wave;  this may require  one, two, or three  fingers.  The
method is crude and has now been largely supplanted  by
instrumental methods (blood-pressure).   If  the tension is
high the pulse is described as "hard," for example, the
small, hard ("wiry") pulse of peritonitis; if low, as "soft."
The dicrotic pulse of typhoid fever is one of  extremely low
tension giving the deceptive sensation of a double  impulse.
  The rhythm of the pulse is  another  quality which we
detect imperfectly by the finger, but more accurately  by
simultaneous tracings (see below) from  the  radial artery
(or heart) and from one  of the large veins of the neck.
The following are the arrhythmias which most commonly
come  under the observation  of  the  nurse.  In many
young persons with low tension the pulse becomes more
rapid during inspiration; this is not of serious importance.
Another  variety  of common occurrence is  the partially
irregular pulse in which  a beat appears to be dropped at
more or less regular intervals without interfering with the
general regularity of the pulse.  Pulse tracings have shown
that,  as  a matter of fact, a "premature"  beat  ("extra-
systole"), which may not be felt at the wrist, interrupts
the regular  sequence.   The  long pause before the  next
regular beat gives the impression of a lost wave.   This
form of arrhythmia is common in middle-aged and elderly
persons, and often is of no  serious  significance, although
it may be a sign of myocarditis.   It usually disappears
if  the  heart  becomes  rapid.  Complete irregularity
or total  arrhythmia  is found in  failing heart  (cardiac
insufficiency), and is usually of serious significance.  After
the use of digitalis in large doses, and in  some cardiac
conditions,  strong  beats  may alternate  regularly  with
weak; at other times beats occur in pairs, triplets, etc.
  The condition of the arterial wall should properly  be
determined  at  the beginning of the examination, for  if 
S4     DISEASES OF THE CIRCULATORY SYSTEM

the arteries are sclerotic (hardened), or calcareous ("pipe
stem"), much allowance must be made  in estimating the
qualities of the pulse.
  The Blood-pressure.—The blood-pressure is principally
dependent on the force of the heart and  the resistance
in the  bloodvessels.   The  latter varies with the  state
of dilatation or contraction of the arteries; thus, during
digestion the abdominal vessels are dilated, while during
exercise  more blood  flows to  the  muscles.  In any one
individual these factors compensate  for  each other, so
pIG  15.—Determination of blood-pressure by auscultation, or by
         palpation of the radial pulse.  (Musser.)
that the pressure remains fairly constant.  After severe
hemorrhage the volume  of the blood may be  reduced to
such  a  degree as to diminish the  blood-pressure.  The
pressure in the artery varies constantly with the alternat-
ing contraction and relaxation of the heart; with the pulse,
or systole, the pressure increases; with  the interval, or
diastole, it diminishes.
  The systolic blood-pressure is measured by determining
the force required to shut off the pulse completely.  The
instrument  which  is used  for  the purpose is  styled  a
sphygmomanometer  or  blood-pressure  instrument.  It 
GENERAL SYMPTOMATOLOGY         85
consists of a hollow rubber cuff connected by tubing with
a pump and a column of mercury graduated in millimeters
(manometer).  The  cuff is placed about the upper arm
and  the mercury  raised by  means  of the pump, until
the pulse disappears at the wrist.  The pressure is then
gradually lowered  until the pulse reappears at  the  wrist,
or better, until a rhythmic tap is heard in the artery at
the bend of the elbow.  At this  point the height of  the
mercury in millimeters is noted  and  recorded.  This is
the systolic pressure.   Nurses, if called upon to  make
the examination,  may determine the systolic pressure
(which is the more important) by using the pulse, with
which they are familiar, as an indicator.  The diastolic
pressure is fixed by  the sudden diminution in the pulsa-
tion of the mercury or by the disappearance of  the  sound
in the  artery.  In  normal  young  adults the  systolic
blood-pressure is usually about 120 mm., and the diastolic,
75 to 85 mm.  In older persons the systolic pressure is
somewhat  higher.   Under  pathological  conditions  the
blood-pressure shows great variations.   In nephritis, e. g.,
the systolic pressure frequently exceeds 200 mm.
  Pulse  Tracings.—The sphygmograph is an instrument
which  makes graphic  tracings of  the pulse, often  on
smoked paper, recording the variations and irregularities,
so that  they  may be subsequently studied.  The  modern
instruments  (polygraphs) not  only  record the pulse at
the wrist but also the heart beat and the pulsation  of  the
veins in the neck.  Similar data are obtained  by  the
electrocardiograph, an elaborate  instrument with  which
only a few large hospitals are supplied. Tracings are often of
great value to the physician in the diagnosis and prognosis
of doubtful cases.  In heart-block, for instance, the  upper
part of  the  heart (auricle) may be found—by tracings
taken from the veins—to be pulsating at a different and
more rapid rate than the lower (ventricle)-—as  shown  by
tracings  from the  apex of the  heart.   This  symptom is
characteristic of the  rare Stokes-Adams disease, in  which
bradycardia, attacks of syncope, and convulsions occur. 
86    DISEASES OF THE CIRCULATORY SYSTEM

  Syncope.—Syncope or fainting is a circulatory symptom
due to anemia of the brain and is frequently brought about
by  nervous  influences (excitement, fright, pain), defective
local  blood  supply (disease of heart  or bloodvessels), and
acute anemia (hemorrhage).  In  itself  it is not  serious
and is readily relieved  by the  horizontal position, fresh
air, and  diffusible stimulants (whisky, aromatic spirits of
ammonia, or Hoffman's anodyne).  In hemorrhage or in
cardiac disease it may be of serious  moment.
  Dyspnea.—Cardiac dyspnea (see Part III, Chapter II)
is aggravated by exertion  and,  as  a rule,  relieved  by
rest.  Distressing nocturnal dyspnea with precordial pain,
particularly in  aortic  disease,  sometimes  compels the
patient   to  sit  up  in bed  (orthopnea).  Cheyne-Stokes
respiration  was originally described in connection with
disease of the  heart muscle, but is more  characteristic
of nephritis.
  Dropsy.—Cardiac  dropsy typically begins in  the feet
and extends  upward,  successively   involving the legs,
thighs,  genitals, body, etc.  The  pleural,  pericardial,
and abdominal cavities are  often filled with  fluid (hydro-
thorax,  hydropericardium, and  ascites).  The dropsy  of
liver  disease begins with ascites  and  that  of nephritis
with edema of the eyelids and subcutaneous tissues with-
out reference  to gravity.  It is not rare,  however,  for
cardiac effusion to begin with ascites or hydrothorax.
  Cyanosis.—Cyanosis or blueness  is common in heart dis-
ease though not at  all  unusual  in diseases  of the  lungs,
blood, etc.   It is most intense in congenital heart disease
in which the cyanosis  may be continuous,  without any
immediate risk of death.   In dilatation of  the heart an
equal degree of  cyanosis may rarely  be observed,  but if
it is not promptly relieved by bleeding or other treatment,
death usually ensues in a short time.  In the ordinary
cardiac case the hue is dusky, rather than distinctly blue.
Very  marked cyanosis  occurs after  certain  poisons, for
example  after the prolonged use of  acetanilid and other
coal-tar products.  The cyanosis of  pulmonary disease is 
DISEASES OF THE BLOODVESSELS        87
seen in pneumonia, emphysema, etc., as well as in obstruc-
tive disease of the larynx (diphtheria).
  Pulsations.—Closely connected with cyanosis is venous
repletion (fulness) and venous pulsation.  The former is
most frequently  observed in  the  neck and is suggestive
of cardiac  insufficiency, respiratory distress,  or pressure
by  tumors, etc.,  within the chest.  The  latter is a cir-
culatory phenomenon not always to be distinguished by
inexpert observers from pulsation of the arteries (carotids)
which is often very prominent in  nervous persons and in
cases of aortic insufficiency.  Cardiac pulsation is normally
seen at the apex and abnormally over a wider area.  In
aneurysm the pulsation is outside the limits of the normal
heart area.
  Capillary Pulse.—The capillary  pulse  is seen in aortic
insufficiency, less often  in normal persons.   If the fore-
head is rubbed  until reddened or the finger-nail pressed
until slightly blanched, a faint blush will be noticed with
each pulsation of the heart.
  Thrills and Murmurs.—Thrills are vibratory sensations
felt over the heart or bloodvessels; one type is diagnostic
of mitral stenosis.  Murmurs are  abnormal sounds of the
heart and  are of  value to the physician in the diagnosis
of valvular lesions.   In pericarditis the  murmur is desig-
nated as a friction or rub.
  Heart Area.—The  size and position  of the heart  are
determined by percussion (dulness), palpation (pulsation),
or by the x-ray.

         DISEASES  OF  THE BLOODVESSELS.

  Arteriosclerosis.—Thickening or  "hardening" of the
arteries is  known as  arteriosclerosis.  As  the  minute
capillaries  are also involved,  the  condition is sometimes
called arteriocapillary fibrosis.  Thickening of the  veins
(phlebosclerosis)  is not so common, or, to casual examina-
tion, so evident.  In arteriosclerosis the vessel wall may
be  thickened and leathery, or little bony plates like beads 
 SS     DISEASES OF THE  CIRCULATORY SYSTEM

 may be felt in the artery.  The affected vessels are elon-
 gated  and tortuous ("snake like")  so  that  they appear
 too long for their beds; this tortuosity is easily seen in the
 temporal, and felt in the brachial arteries.   On the inner
 surface of the aorta and other large arteries,  yellowish
 patches  which eventually  become bony plates are fre-
 quently observed at autopsy.  This condition is  known as
 atheroma.
  Arteriosclerosis is a  natural  condition in  old age, but
 the time of onset  is much affected  by heredity, mode of
 life, and disease.  I have seen it less marked in  a woman
 of a hundred  years than in a fifteen-year-old boy of bad
 heredity.  An advanced degree of sclerosis is common at
 middle age in laborers, while in those of sedentary habit,
 if they  have  avoided  excess, it  may be postponed for
 several  decades.  Arteriosclerosis  is  also   induced by
 toxemia  and  strain.  Toxemia may be due to  acute or
 chronic  infections,  above  all  to  syphilis,  to   external
 poisons,  such  as  lead and mercury, and to the metabolic
 poisons of gout,  or nephritis.  Excess in food and drink
.(alcohol1) is  distinctly  harmful.  Strain may be mental
 (worry)  or physical (excessively heavy  labor).
  Arteriosclerosis is associated as a rule with high blood-
 pressure, enlargment of the heart, and signs of involve-
 ment of  many organs.  In the variety present in old age,
 the  blood-pressure  is  normal.  Since  the  arteries and
 capillaries reach  all organs and tissues, some or all of the
 latter are involved in the disease.   Occasionally one organ
 will be especially "hard hit."   If the  blood-pressure is
 high, the heart dilates and eventually becomes insufficient.
 Under these circumstances shortness of breath, dropsy,
 and effusion of fluid into the large cavities occur, a con-
 dition which is difFcult to distinguish from that of primary
 cardiac disease.  The urine almost always shows a little
 albumin  and  a few casts, and frequently the symptoms
 of nephritis dominate the case; other types are associated

  1 Siime authorities deny the injurious effect of alcohol in this condition. 
          DISEASES OF THE BLOODVESSELS        89

with apoplexy, aneurysm, or excessive involvement of the
peripheral arteries, causing intermittent lameness (claudi-
cation) or gangrene.
  Treatment.—The advance  of  the disease may best  be
checked and its bad effects minimized by a quiet, regular
life with moderation in exercise, food, and drink. Worry
and mental  strain are deleterious.  The action of the skin
should be favored by warm baths, the secretion of the urine
should be kept up by the free use of water except in cases
of high blood-pressure, and constipation should be avoided.
Fig. 16.—Saccular aneurysm.        Fig.  17.—Fusiform aneu-
       (Ashhurst.)                 rysm.  (Ashhurst.)
In recent years great  stress has been laid on the use  of
buttermilk and other beverages containing lactic acid and
lactic acid bacilli.  These are supposed by their advocates
to diminish fermentation and putrefaction in the intes-
tines, and  to prevent the  formation and absorption  of
injurious poisons.  The diet should contain only a moder-
ate amount of meat  and should be free from cabbage and
other coarse vegetables which often cause excessive flatu-
lence in arteriosclerotic patients.  Milk  and eggs, cereals
and green vegetables may be used freely.
  Potassium iodide, in  small  doses, apparently  has  a 
90    DISEASES OF THE CIRCULATORY SYSTEM

favorable influence on  the course of the disease.  Other
specific medicaments have been suggested but are seldom
employed.
  Aneurysm.—An aneurysm is a localized dilatation of an
artery.  This may be  symmetrical, involving  the whole
circumference, when  it is spoken of as either a  fusiform
(spindle-shaped) or a  cylindrical aneurysm; or  it may
project from one side  of the vessel, when  it is  styled a
sacculated  aneurysm.  Aneurysms may  develop in  any
artery, however minute; such minute aneurysms are the
common  cause of cerebral  hemorrhage.  Aneurysms of
the peripheral  arteries, for  example of the popliteal at
the back of the knee, are discussed in books on surgery.
  In medicine we are principally concerned with aneurysms
of the aorta and its primary branches.  Aneurysms are
most  commonly observed  at the beginning  of the aorta
as it  arches up from  the heart, in the transverse part
of the arch of the aorta, and again as it descends  near the
spine through the thorax and abdomen.  As will be seen
later the symptoms vary greatly with the situation of the
tumor.  The causes of aneurysm are in general  those of
arteriosclerosis.   Age  is less of a factor, and excessive
strain and syphilis are  of chief importance.  Evidence of
the latter disease is found  in a vast  majority  of cases
(Wassermann reaction, vide  syphilis).  The patients, as
a rule are males under  fifty and  often negroes.
  Symptoms.—The symptoms of  aneurysm per se are those
of pulsating tumor.  This is expansile when accessible to
palpation, as in the  abdomen.   In  the chest the ribs or
interspaces may be seen to heave and  an abnormal area
of dulness may be found on  percussion.  If the  hand is
laid on the  aneurysmal tumor,  a vibratory sensation or
thrill is appreciated. Dilatation of the artery in itself occa-
sions  more or less pain, but the  severe pain of aneurysm
is principally due to pressure upon, and erosion of,  sur-
rounding structures.  If the  aneurysm is progressive the
wall will finally become  so attenuated that oozing of
blood occurs, or sudden rupture with dangerous  or fatal
hemorrhage. 
          DISEASES OF THE BLOODVESSELS        91

  Most of the  symptoms  and  signs of  aneurysm are
attributable to  pressure or  dragging upon  surrounding
structures.  In aneurysm at the beginning of the aorta,
the ribs and chest wall may be gradually  eroded or per-
forated.   In the thorax and abdomen the aneurysm may
erode the spinal  column, causing  intense  boring  pain
and finally paralysis of the lower extremities.  Pressure
or traction on the larynx, trachea, or bronchi may cause
difficulty in breathing,  tracheal tug, loss of voice, or cough.
Tracheal tug is a rhythmic movement transmitted to the
larynx by the aneurysm dragging on the trachea.  Press-
ure on the nerves  of the larynx causes spasm or paralysis
of laryngeal muscles and often lends a " brassy" character
to the cough.  Pressure on the bloodvessels causes dila-
tion of the veins of the neck and inequality of the pulses.
Pressure on the gullet interferes with swallowing.  Still
another  symptom, due to  pressure on the nerves,  is
inequality of the pupils.  Aneurysm many perforate into
the air passages, the pleura, the gullet, and other structures
as well as externally. In any case the resulting hemorrhage
is likely to prove fatal.
   Treatment.—The object of treatment in  aneurysm is to
stay the progress  of the disease, to  promote clotting and
consolidation  in the  sacculated variety, and  to  relieve
symptoms.  If the disease  is  progressing, and the pain
severe,  absolute rest with the use  of the bed-pan, etc.,
is required.  If an attempt is to be made to cure the
aneurysm, a dry  diet, containing not over  eight ounces
of  fluid,  may be  instituted  and  kept up for  a long
period of time.  The class of patients ordinarily attacked
by aneurysm  will rarely submit to  such privation, as no
definite promise of cure can be given. Clotting may also
be  brought  about by introducing  many yards  of fine
gold  wire through a  hollow  insulated  needle  into the
aneurysmal  sac.  Before the needle is  withdrawn  an
electric current is sent  through the wire to hasten the
• process of clotting.  Opinions are divided as to the desir-
ability of this operation.   Potassium iodide is a favorite 
02    DISEASES OF THE CIRCULATORY SYSTEM
remedy in aneurysm as  in  arteriosclerosis.  Morphin is
often required  to  relieve pain or  to  calm  excitement
in  threatened  hemorrhage.   Ocasionally  slow  bleeding
occurs,  but in the majority  of cases the  hemorrhage is
sudden  and rapidly fatal, and therefore not susceptible
to treatment.
  Fig. 18.—An infarct of the kidney.  An embolus lodging in the artery
(a) has caused infarction in the shaded area.   There is a surrounding
zone of congestion.  (Orth.)
  Embolism, Thrombosis, and Infarction.—As the arteries
pass to  their  distribution,  they divide  and  subdivide,
so that, if we select a small artery, we shall  find that its
area of ultimate  distribution is cone-shaped, and may be
compared to  the trunk  and branches of an  elm  tree. 
PERICARDITIS
93
Usually there is more or less  communication between
neighboring areas,  but  this  is not  invariable  (brain).
If a small fragment of fibrin  ("vegetation"), or a minute
clot plugs one of these small  arteries,  clotting or throm-
bosis occurs in the branches beyond, and the whole area
may lose  its vitality.  These triangular  or  cone-shaped
areas are  known as  infarcts  and  occur in the kidneys,
spleen, brain, lungs, etc., in diseases such  as endocarditis,
phlebitis, and pyemia. They may be pale or  red, depend-
ing on the richness of the neighboring blood supply.   In
the brain,  infarction  is followed by softening; elsewhere
it is often accompanied by  hemorrhage  and terminates
either in scar formation, or, if there  is infection, in abscess.
Infarction  may  result from thrombosis without preceding
embolism.   Infarction of the lung causes sudden pain,
hemorrhage, and symptoms of consolidation.  In  the
kidney and spleen it may occasion pain, and in the former,
bloody  urine.  Embolism of the mesenteric  vessels sup-
plying the  small intestine causes pain, bloody  stools,
obstruction, gangrene, and peritonitis.
  Thrombosis may also occur in the  veins as the  result
of  inflammatory change in  the vessel wall (phlebitis),
pressure, or any cause leading to slowing of the current
or increasing the coagulability of the blood.  Thrombosis
in a vein interferes with the  return circulation, and if a
large vessel is involved causes edema, cyanosis, and venous
repletion.   After a time adequate circulation is usually
reestablished by collateral  branches (anastomoses).  The
thrombus may  be absorbed  or converted into a  fibrous
mass.   The femoral (left) and subclavian veins are com-
monly  affected; less   often internal veins,  such  as  the
pulmonary vein and vena cava, etc. Femoral thrombosis
is common in infections, e. g.,  typhoid and pneumonia.
Thrombosis of  internal veins, if of any size, is usually
fatal.
                    PERICARDITIS.

   Pericarditis is a term applied to inflammation of the
enveloping membrane of the  heart.  The pericardium is 
94    DISEASES  OF THE CIRCULATORY SYSTEM

a serous  membrane  similar to that  lining the pleural,
peritoneal, and joint cavities.  It  covers  the body of the
heart (visceral pericardium)  and  is  reflected  from the
great vessels at the base to form a hollow sack (parietal
pericardium)  enclosing  that organ.  Pericarditis  is  of
three general  types.—(1) Fibrinous pericarditis  in which
the adjoining  surfaces of the membrane are covered by a
      Fig. 19.—Fibrinous pericarditis (hairy heart).  (Adami.)

soft, sticky exudate. If the layers are separated the exudate
is rough like pieces of bread and butter which have been
laid  together and then drawn apart.    (2) Pericarditis
with effusion in which  a  greater or less amount (200 to
2000 c.c.) of fluid is thrown out, either clear, purulent, or
bloody.  (3) As a sequel to either of the above forms, the
pericardial  layers  may become adherent,  partially  or
completely, and in severe cases  adhesions may also form 
PERICARDITIS
95
between the pericardium and the  anterior and posterior
chest walls, greatly restricting the  movements of the
heart.
  Pericarditis  seldom arises independently but is usually
secondary to other diseases, principally  infections.  The
milder cases are due to rheumatism.  The condition may
produce no symptoms, but is discovered when the heart
is  examined, as it always  should  be in  rheumatism, for
evidence of endocarditis.   Children develop these compli-
cations in the mildest  joint cases, too often dismissed as
growing pains.  Other acute infections may give rise  to
pericarditis; of these the most important  is pneumonia.
This variety is often purulent and  is likely to prove fatal.
Pericarditis  occurs as a complication in  many  chronic
disorders, such  as Bright's disease  and diabetes.  It is
due to the particular infection which terminates life and
is  seldom recognized.  Chronic pericarditis with effusion
or adhesions is  frequently tuberculous.   Sometimes the
pericardium, pleura, and peritoneum are involved at the
same time.
   Symptoms.—The  symptoms of  fibrinous  pericarditis
may be of the slightest; pain, though present, is  not so
severe as in pleurisy, and the fever is seldom  high.  The
to-and-fro scratching murmur or rub is very characteristic.
With  effusion,  particularly  if purulent, there is  pain,
oppression,  insomnia, restlessness,  delirium,  etc.  The
heart dulness  is increased  and in children the chest may
bulge.  When the pericardium becomes  adherent, symp-
toms may be  absent, but  if the heart is bound down to
surrounding structure, it  works against great obstacles,
so that  in  time it  becomes greatly hypertrophied and
dilated.   Finally, symptoms of cardiac insufficiency ensue.
The interspaces between the ribs near the apex and in the
back are sometimes drawn  in with  each  contraction of
the heart.  This is due to adhesions to the diaphragm, etc.
   Treatment.—The  treatment of  acute pericarditis de-
mands absolute rest,  the  use of  the bed-pan, and the
administration of food by the nurse.  The diet should be 
96    DISEASES OF THE CIRCULATORY SYSTEM

similar to that used in fevers.  The physician sometimes
restricts  the amount of  fluid in  the  hope of  limiting
effusion.   The  nutritive value of milk may be increased
by  the addition of  cream, sugars,  and  cereals.   Pain
or overaction of the heart may be relieved by an ice-bag
which should be applied intermittently.  A piece of flannel
should be placed between the bag and the chest,  and the
bag should be supported from a cradle.  Hot applications,
blisters, and leeches  are  also used.  If the pericarditis
is of rheumatic origin the free use of salicylates is  of great
importance  as  a curative measure, otherewise  medicinal
treatment  is limited to mild  laxatives and to  cardiac
stimulants and sedatives, as circumstances may  require.
In effusion, if the quantity  of fluid is sufficient to  cause
shortness  of breath, oppression, and cyanosis, or if the
exudate becomes purulent, the fluid should be withdrawn
by paracentesis.  The technic of this operation is similar
to that employed in  tapping  the chest.   The treatment
of adhesive pericarditis is the treatment of cardiac insuffi-
ciency; operation is  sometimes undertaken for the relief of
adhesions  (rare).
  Hydropericardium.—Effusion of fluid, non-inflammatory
in character,  into  the  pericardial  sac, occurs in heart,
kidney, and liver diseases.   If excessive in amount,  para-
centesis is required. 
CHAPTER  II.
DISEASES OF THE HEART.
Angina Pectoris  and Precor-
  dial Pain.
Soldiers' Heart.
Hypertrophy and Dilatation.
Cardiac Insufficiency.
Myocarditis.
Valvular Heart Disease.
  Acute Endocarditis.
  Chronic Endocarditis.
  Individual Valve Lesions.
Treatment of Acute Endo- and
  Myocarditis.
Treatment of  Cardiac Insuffi-
  ciency.
  Angina Pectoris and Precordial Pain.—Angina pectoris
in its typical  form is  characterized by intense pain over
the heart and down the inner side of the left arm,  by a
sense of constriction in the chest, and by a fear of impend-
ing death.  In the painful area there is  usually  hyper-
algesia  (if the  skin  or muscles are  pinched  they are
unusually  sensitive).   The  attacks  come  on  suddenly
and  are  of brief duration  but they  may  be frequently
repeated.  They are  sometimes  followed by free eructa-
tion  of gas.   Similar  but less intense  attacks of pain are
common in young persons of the neurotic type; they are
sometimes called pseudo-angina.   Attacks of angina may
be induced by  an exciting  cause  which  throws  addi-
tional work   on  the   heart, for example,  worry,  anger
physical  exertion, tobacco, and excessive eating or drink-
ing.   True angina is generally  believed  to be due  to
atheroma of   the coronary  arteries  (the  vessels  which
supply the heart muscle itself),  obstructing their lumen.
This induces an acute anemia of the heart muscle and a
cramp-like pain which is analogous  to that experienced
in the legs by elderly persons with arteriosclerosis.   Some
authorities believe that angina is due, in addition, to any
disease involving extreme exhaustion of the heart muscle,
      7 
98
DISEASES OF THE HEART
and would even include the functional  exhaustion com-
monly seen in nervous persons.   Certain it is that we often
find  our cases of aortic  aneurysm and  aortic valvular
disease  suffering from nocturnal attacks of intense pre-
cordial pain.
  Treatment.—The  prophylactic  treatment  consists  in
restricting  the work of the heart within its  capacity.
The degree of rest, etc., will depend upon the individual;
his life should be as free from care as possible and exercise
should be strictly  limited.  If attacks are brought on by
eating,  meals  may be made lighter  and more  frequent.
Bromides may be  prescribed to tranquillize a susceptible
nervous system.  The attack itself may usually be relieved
by nitrites which  may be  given in various forms, hypo-
dermically  as nitroglycerin,  by the mouth  as spiritus
glycerilis nitratis,  and as  an inhalation  in  the form  of
amyl  nitrite pearls.  Hot drinks, for example brandy
and water, may be given for immediate relief.   Morphin
and chloroform are of great  use, the former particularly
in the precordial  pain of aortic disease.   Treatment will
naturally include  attention to  the causative factors  of
atheroma; for example, syphilis.
  Soldiers' Heart.—Under the strain and effort of  army
life  persons of feeble constitution  and unstable  nervous
system  frequently develop symptoms suggestive of ex-
haustion of the nervous and circulatory systems ("neuro-
circulatory asthenia").  The commonest symptoms are:
dizziness, f aintness, exhaustion on moderate exertion, short-
ness of breath, palpitation, rapid pulse, and precordial pain
or distress. A severe type of the latter has been described
above as pseudo-angina.   Organic  heart  disease  must
be excluded.  Persons of this type had to be discharged
from  the army or assigned to  light or sedentary duties.
In civil life they automatically  choose the lighter occupa-
tions  as a  rule.   It  is essential to convince the patient
that the heart is unaffected.
  Hypertrophy and  Dilatation.—-The heart is  a  pump
whose function is  to force  the blood through the general 
DISEASES OF THE HEART            99
 and pulmonary circulations.  The force required for this
 purpose varies greatly, depending upon position, exercise,
 and so on.  To meet these varying demands the heart
 has  a wide reserve power.  If the load  on the heart is
 permanently increased, the reserve is diminished or the
 heart  undergoes  hypertrophy to  meet  the  increased
 requirements.  If  because  of poor  nutrition,  infection,
 or  excessive work, hypertrophy  fails  or the reserve  is
 abolished,  the heart dilates, and heart failure or cardiac
 insufficiency  supervenes.  Hypertrophy  of  the  heart
 muscle is almost always accompanied by increase in the
 size  of the heart  cavities, but in dilatation,  properly
 speaking, the muscle walls become thin and lose their
 tone, and  the size of the cavities is disproportionately
 large.   Hypertrophy  in itself  is a useful condition,  indi-
 cating that the heart is successfully meeting the demands
 placed upon it while dilatation is an evidence of failure
 in the  same respects.  Hypertrophy may  affect one or
 all of the cavities of the heart, and in the case of the left
 ventricle is characterized by  enlargement of the dulness
 to the left, displacement of the apex in the same direction,
 and a powerful heaving impulse.  The pulse is full  and
 strong and often of high tension.  In dilatation the heart
 is also enlarged, but  the apex impulse is  indistinctly felt
 as a feeble tap.  The heart sounds are faint (clicking),
 and  the pulse is of a correspondingly poor  quality.
  Cardiac  Insufficiency.—Symptoms.—The  symptoms of
 cardiac insufficiency are more or less similar in all forms of
 heart disease, and  may therefore be enumerated at the
 beginning.  The modifications peculiar to particular lesions
 will be mentioned later.  The symptoms are as follows:
 breathlessness, sometimes amounting to orthopnea, cyan-
 osis, precordial distress,  dropsy,  dyspeptic  symptoms,
enlargement of the liver, edema of the  lungs, and scanty
 urine.   The dropsy begins in the dependent parts, for
example the ankles when the  patient is on his feet,  and
extends upward.  It may become so extreme that the skin,
distended to the bursting point,  will require puncture. 
100
DISEASES OF THE HEART
The enlargement of the liver  is due to "passive" conges-
tion.  The heart is unable, so to speak, to "forward" the
blood as fast as it is  received from the great veins (the
inferior vena cava  receives  the blood from the liver and
portal system) so that the liver becomes enlarged to accom-
modate it,  acting  as a temporary "storehouse."  Con-
gestion of the liver is often accompanied by slight jaundice
and ascites  (effusion into the peritoneum).  The passive
congestion  of the lungs leads to edema and  frequently
to effusion into the pleural cavities, particularly the right.
The edema is  detected by the  occurrence  of  fine rales
at the base of the  lungs.  The intense congestion of the
kidneys causes not  only scanty urine, but the presence of
albumin and casts.
  Causation of Heart Disease.—The causes of heart disease
are legion,  but Dr. Cabot has recently shown  that four
—rheumatism, syphilis,  arteriosclerosis, and nephritis
are responsible for  more than 90 per cent,  of the  cases.
Other infections and intoxications (goitre)  and congenital
disease account for a small number of cases.  Congenital
diseases include malformations due to faulty development
and intra-uterine infections.   The latter, unlike those  of
adult life, affect the valves on the right side of the heart,
the pulmonary, and less often the tricuspid valve.  Acute
articular rheumatism,  with  the associated conditions,
tonsillitis, and  chorea, is by far  the  commonest cause of
heart disease,  particularly  in the  young.  Both  heart
muscle  and  valves are damaged  ("carditis"),  but the
permanent changes are principally apparent  in the  latter
(chronic endocarditis).  The mitral  valves  are most fre-
quently attacked.   Syphilis is principally  operative  in
adults, and particularly in males.  It injures  both the
myocardium (muscle) and  endocardium  and is particu-
larly prone to attack the aortic valves.   Arteriosclerosis
and nephritis account for the largest number of cardiac
cases in middle  and  advanced  age.   Nephritis  induces
increased  blood-pressure,  arteriosclerosis,  and  hyper-
trophy of the left ventricle of the heart.  If the heart fails 
VALVULAR HEART DISEASE
101
under the strain all the symptoms of cardiac insufficiency
ensue,  and  it is  often impossible  to name the primary
lesion.   In  arteriosclerosis there  is  either  coincident
sclerotic change in the heart muscle, with  stiffening and
shrinking of the valves, or the  changes in the arteries and
kidneys initiate the disease and are followed by the same
train of symptoms described for nephritis.
  Myocarditis.—Acute  or  chronic  degenerative  and
sclerotic affections of the heart muscle are grouped rather
loosely  under the term myocarditis.   Acute degeneration
of the  heart  muscle  accompanies  all the more serious
infections,  c.  g.,  typhoid  fever  and  diphtheria.   If the
patient survives  the  convalescent  period few  permanent
evidences  of  the  affection may  persist.   Occasionally
sclerotic or scar-like  areas betray the preexisting disease.
Arteriosclerosis  is  accompanied by  sclerotic changes  of
the  heart  muscle which diminish  the contractile power
of the organ.  In the obese the heart is frequently bur-
dened  by heavy  deposits of fat, while in wasting disease
and severe  anemias the muscle itself may  undergo fatty
degeneration.  The symptoms of  myocarditis are very
variable and  indefinite; there may  be repeated  attacks
of  cardiac  insufficiency as already described;  in  other
cases there may  be anginal symptoms; or  there  may  be
simple arrhythmia with slight dyspnea, precordial distress,
or dyspeptic symptoms.   In fatty heart sudden death is
not uncommon.

             VALVULAR HEART DISEASE.
  Acute Endocarditis.—Simple  endocarditis  begins acutely
but insidiously, usually in the course of acute  articular
rheumatism of which it forms an integral part rather
than a complication.  At this period  it is often over-
looked, as there  may be no symptoms other  than those
of the joint infection itself.  Sometimes there may be a
slight chill, an access of fever,  or nocturnal delirium, but
the  diagnosis will depend  upon careful routine examina-
tions of the heart for altered sounds or murmurs.  Sub- 
102
DISEASES OF  THE HEART
sequently,  enlargement  of  the  heart  will  confirm  the
diagnosis.  If rest  at this period is prolonged,  perfect
compensation may  be secured and no  further symptoms
will be  observed.   Aery  often,  however,  the  patient
  Fig. 20.—Diagram modified from Page to show the relation of the
various valves.  The tricuspid valves lie between the right auricle and
right ventricle; the pulmonic, between the right ventricle and the pul-
monary artery; the mitral, between the left auricle and left ventricle;
the aortic,  between the left ventricle and  aorta,  If the valves do not
close accurately, leakage occurs (valvular  insufficiency); if the  orifices
are narrowed (stenosed)  the blood flow is  obstructed.   The valves are
never all open at the same time (as depicted).  When the mitral and
tricuspid valves are open the aortic and pulmonary are closed  or vice
versa.  (Hare.)


gets up too soon, hypertrophy is  insufficient, and symp-
toms become manifest, e. g., dyspnea  and  slight edema.
Cases of simple endocarditis are very prone to subsequent
attacks with  increased damage to the valves  and with
general febrile symptoms.   Repeated failures of compen- 
VALVULAR HEART DISEASE         103
sation are also  common,  with or without fresh  endo-
carditis.   The symptoms of loss of compensation are those
of cardiac insufficiency.
  At  the opposite extreme is the so-called  malignant
endocarditis.  This is due to more virulent microorganisms
and is accompanied by  very irregular temperature  of the
septic  type,  severe chills,  and drenching  sweats.  The
temperature may range in a single day from 97° to 105°
or 106°.  The pulse and respiration are extremely rapid.
Dec.
DAY			3			i			5 1					t>				7 1	
HOUR				l	4 7-10	1.4 7-	LO 1-4	7-10	1-4 7-10		1-4	7-10		1-1 7-10		1-4 7-10(1-4 7-10			
106° 105° 104 -103 |l02 iioi <100° 1 99 "98 97° 96° 95°							>										j		
																	|		
									J			I							
							1					f[							
									I			I				] " , ~~			
					1				1										
				\													1		
								1/											
																			
	\	,	f									1		T				__	—
		\J					\					1							
							\												
																			
Fig. 21.—Malignant endocarditis (Episcopal Hospital).
There  may be distinct  murmurs,  but  sometimes  the
action of the heart is so tumultuous, or the respiration so
noisy, that nothing can be discovered by physical exami-
nation.  Examination of the blood reveals a leukocytosis
and cultures from the same fluid will often discover the
causative  organism  (gonococcus, streptococcus,  etc.).
These cases after a stormy course of a few weeks terminate
fatally.  Intermediate varieties  are much  more common
than the latter extreme.  If an autopsy is performed on
a case of simple endocarditis little wart-like vegetations 
104
DISEASES OF THE HEART
are found on the affected valves, while  in the malignant
variety the  vegetations are larger  and are accompanied
by ulceration, hence the contrasting terms, warty (verru-
cose)  and ulcerative endocarditis.
  Chronic Endocarditis.—The  mode  of  onset  of  chronic
rheumatic endocarditis has  already been sketched.   The
varieties due to syphilis, arteriosclerosis,  etc., are chronic
from the beginning and are first revealed when the shrink-
ing and distortion of  the  valves  have  interfered with
the action of the heart, and have  brought on symptoms
of cardiac distress (pain and  dyspnea)  or cardiac insuf-
ficiency. Patients suffering from chronic endocarditis im-
prove  on rest and treatment,  but  grow  worse when the
heart is subjected to strain beyond its capabilities.  "We
frequently see convalescents who are perfectly comfortable
as long as they remain in the hospital wards, but relapse
as soon  as they are subjected to home  conditions, with
hard  work,  stair  climbing, and improper diet.  Others
have so narrow a margin that they  are only well, to speak
paradoxically, as long  as they are sick in bed.
  The Individual  Valve Lesions.—Disease of the heart
valves interferes with  their function, either  by  causing
them  to become  roughened  or narrowed,  so that  an
obstruction  is placed in the course of the blood  current
("roughening,"  "obstruction," "stenosis"), or by  pre-
venting their closure,  thus  permitting the blood  to leak
backward or regurgitate  ("insufficiency").  (Fig, 20.)
  Lesions of the pulmonary valve are almost always  of
congenital origin.  I have,  however,  seen cases in pneu-
monia and  syphilis.   Congenital  heart  disease  is char-
acterized by dyspnea, chronic  cyanosis,  and clubbing  of
the fingers.  The tricuspid valve is frequently insufficient
in extreme cases of  cardiac failure, but this is  due not
to endocarditis  but  to excessive dilatation of the  right
ventricle. The  valves  are not large  enough to close the
widely stretched opening between the auricle and ven-
tricle.   It is therefore  spoken of as relative insufficiency.
In myocarditis with loss of compensation there  is  also 
VALVULAR HEART DISEASE          105
relative insufficiency  of  the tricuspid valve and of the
mitral valve.
  The mitral valves are frequently involved, particularly
in rheumatic  disease.   There may  be  insufficiency or
stenosis; in the latter case the leaflets of the valve are
sometimes glued together  leaving only a buttonhole-like
opening.  Stenosis  and  insufficiency may be  combined,
but  usually one lesion  or the other predominates.  In
mitral insufficiency the heart  is  enlarged  transversely
(both ventricles), and dyspnea and edema are the first
signs that appear when the heart weakens.  With loss of
compensation  the  whole  sequence of symptoms char-
acteristic  of insufficiency of the heart makes its appear-
ance.  Under  suitable conditions of life  patients with a
healthy heart muscle may live for many years  in com-
parative comfort.  Sudden  death  is  exceptional.  In
mitral stenosis the  pulse is often irregular.  The heart is
enlarged to the right and a thrill is felt near the apex, just
before the impulse of the heart.  This and the correspond-
ing presystolic murmur is characteristic of the disease.
With beginning cardiac embarrassment the patients suffer
from nosebleed,  orthopnea, precordial pain, and  palpi-
tation.  Later  on,  the ordinary symptoms of cardiac in-
sufficiency develop.  Embolism,  although it occurs in all
forms of heart disease is unusually frequent in mitral steno-
sis.  The  emboli lodge most often in  the kidney, spleen,
or brain.  In the latter instance  hemiplegia develops.
  True aortic stenosis is much less common than aortic
insufficiency.  Roughening, which  is often mistaken for
narrowing of the valve, is  very common.   In stenosis, in
addition to the murmur, there is a small, "slow" pulse.
The face  is sometimes pallid and attacks of syncope or
evidences of mental  impairment occur.   Aortic insuffi-
ciency, on the other hand, is accompanied by very char-
acteristic  signs and  symptoms.  The heart  is  greatly
enlarged downward and to the  left.  The pulse is full,
soft, and collapsing (Corrigan pulse).  The capillary pulse
is present as well as  other characteristic  signs (murmurs 
106
DISEASES OF THE HEART
in the heart and  arteries, e. g.) which can only be appre-
ciated by  the  use of the stethoscope.  As long  as  the
valvular lesion is  fairly well compensated,  the  ordinary
symptoms  of cardiac  insufficiency are absent, but  the
patients may  suffer  acutely  from  nocturnal  anginoid
pains and  cardiac "asthma."  Sudden death is frequent
in aortic insufficiency.
  Multiple lesions,  aortic insufficiency, or stenosis, with
mitral insufficiency or stenosis in all possible combinations,
are not at  all unusual.  I once performed an autopsy on
a patient who had been under the care  of two physicians,
a father and son, for over sixty years.  She had  almost
 Fig. 22.—Warty endocarditis of aortic valve.  (Adami and McCrae.)

complete obstruction at both the mitral and aortic valves.
Another similar case seen  about the  same time lasted
for more than thirty years.  The prognosis of rheumatic
valvular disease, if the heart muscle  is good,  and the
patient  well  cared  for,  may  therefore  be  excellent.
Syphilitic lesions being usually progressive are less hopeful.
  Treatment of Acute Endo- and Myocarditis.—Prophyl-
actic Treatment.—The development of endocarditis may
doubtless be prevented  in many cases by the removal  of
large tonsils, and by proper treatment  of gonorrhea and
other local infections which may give rise to this disease.
Rheumatism should be treated from the beginning with
efficient doses of salicylates to prevent the extension of the 
VALVULAR HEART DISEASE          107
process to the endocardium.   Similarly, myocarditis may
be prevented  from working serious  harm, if prolonged
rest  is instituted in those infections, such as diphtheria
and  influenza, in which it is liable to give rise to serious
consequences.   In diphtheria it may be sufficient to avoid
exertion for a  month or six weeks.   In  severe influenza
the symptoms of cardiac weakness may persist for months.
Acute  myocardial degeneration  will usually require  no
medicinal treatment  beyond  strychnin  and  tonics.  In
acute endocarditis, if the heart is rapid and irritable, the
ice-bag may be  employed as in pericarditis.  Morphin
and bromides may also be used for the purpose of quieting
the heart action.  Rest in bed, if not already prescribed
for the primary disease, should be made absolute.   Only
in cases  of  severe  dyspnea should  a partially  elevated
position  be  adopted.   Rest includes  the use of the bed-
pan  and urinlal, as well as feeding the patient by hand.
Visitors,  except those closest to the patient,  should  be
barred.  Acute heart failure, if  it should unfortunately
occur,  would  require the  hypodermic administration of
strychnin, camphorated oil, etc.  If the case develops the
symptoms of cardiac insufficiency, the treatment described
below will apply.
   The Treatment of Cardiac Insufficiency.—The  treat-
ment of cardiac insufficiency, whether due to loss of com-
pensation in valvular disease  or to simple  dilatation and
hypertrophy, is about the same.  The patient should be
placed in a bed with a firm mattress and if orthopneic,
should be propped up in a comfortable position.  Properly
arranged bed-rests are better than pillows, as they give a
firmer  support and the patient is less likely to slip down.
As he becomes less dyspneic, the rest should be gradually
lowered,  as the strain on the heart  is much less in the
horizontal position.   On  account of the edema, chafing
and  irritation  are particularly liable to occur,  but can
be minimized  by careful nursing.   If the dropsy is not
promptly dispelled  by medicinal means  the physician
may  take measures to  withdraw  the fluid  from the 
10S
DISEASES OF THE HEART
chest (see  page 13.")) by  aspiration,  from the  abdomen
by the trocar and cannula (see page  192), and  less often
from the subcutaneous tissues by  incision, or by  means
of Southey's tubes.  The latter are  fine silver cannulas
which  are  thrust into the subcutaneous tissues  of  the
lower extremities, and attached to  small rubber drainage
tubes.  Scrupulous  cleanliness  both before and  after this
treatment  is necessary to avoid infection.  Sweating by
the hot-air bath or vapor bath, as  a  method of removing
dropsy is contra-indicated in severe cardiac failure.   If pul-
monary congestion  is pronounced, cupping  is a  useful
measure.  A half-dozen or more  cups, or as many as the
surface  will  accommodate,  should  be  applied  simul-
taneously.
Fig. 23.—Venesection.  (Heath.)
  If the patient is unusually cyanotic, free  venesection
is  a life-saving  measure.  This little operation may be
briefly described at this point, although its usefulness is
not limited to cardiac disease.  Venesection is frequently
employed in uremia,  particularly  if there is  high  blood-
pressure, in apoplexy, and  in the early stages of pneu-
monia (in the robust).  After the  skin at the  bend of the
elbow has been  disinfected  in the  usual  manner a few
turns of bandage are placed about  the upper arm and
tightened until  the superficial  veins are  distended.  If
the congestion is still insufficient the patient may be asked
to grasp  a  stick.  An  incision is then made obliquely
through  the  vein with  a sharp  scalpel or lancet.   After 
VALVULAR HEART DISEASE          109
eight ounces or more of blood have been obtained  the
bandage is  loosened  and a sterile gauze  pad is secured
over the vein by a few turns of the bandage.   Venesection
may also  be performed by opening the vein after it  has
been dissected  out as for intravenous infusion, or a large
hollow needle may be thrust directly into the vein without
preliminary incision of the skin.  It is difficult by this
last  method,  however,  to withdraw more  than  a  few
ounces  of blood.
  Medicinal  Treatment.—The  remedy  par  excellence in
cardiac insufficiency with dropsy is digitalis.  Of this there
are numberless preparations, none of which is more effica-
cious, though some may be less nauseating, than the leaves
themselves.  The dose of the leaves is 1  grain [0.07 gram],
administered in pill or capsule.  It is a common practice
to precede  the administration  by a  large dose of mer-
cury, 3-10 grains [0.2 to  0.6 gram], or to combine it with
a smaller one, the purpose being to relieve if possible the
congestion of the gastro-intestinal tract by free catharsis.
Digitalis is administered in moderately large doses for a
day or two, to obtain the full effect, and then the dose
is reduced to avoid the danger of poisoning. The pulse
should  be recorded and  the  quantity of urine carefully
measured, both before and after the administration of the
drug, as a favorable effect will be indicated by a full, slow
pulse and a profuse excretion of  urine (diuresis).  The
effect of digitalis is ordinarily most happy, though a large
part of the benefit, sometimes attributed  to this or other
drugs,  may often  be obtained  by  rest alone.   Other
preparations of digitalis universally used are the infusion,
the tincture, and the essential principles  (digitalin, etc.),
but  the last mentioned are not very reliable.  Strophan-
thin, the  essential  principle of  strophanthus, a  drug
closely  related to digitalis, is much more effectual in an
emergency.  The dose is very minute and should be  in-
jected intravenously.  Squills and caffein are often used
with digitalis  to  supplement  its action.   Theobromin
and the phyllin  are employed to promote  diuresis  and 
110
DISEASES OF THE HEART
relieve dropsy.  They are  not heart stimulants.  With
treatment such as that described, the majority of patients,
at least in their earlier attacks, recover a greater or less
degree of compensation, and many are able to return to
their usual occupations.
  After  the  dyspnea  and  edema have disappeared, or
in cases in which  these  symptoms  have never  been a
marked feature, there may  still be distress  on slight
exertion.  This  means that the patient's reserve  is very
small.  Under these circumstances it is the object of the
physician to strengthen gradually the heart muscle and to
accustom the organ to an increased  amount of work by
means of baths, methodical exercises, etc.   In Germany
these methods have been systematized, but have perhaps
been overdone.  In this country the  opposite holds true.
The best-known hydrotherapeutic method is that which
originated  at Nauheim.  This consists essentially  in the
administration of daily saline baths, which contain variable
amounts of carbonic-acid gas, and are of gradually increas-
ing concentration and  duration, and of diminishing tem-
perature.   The effect of the cold water is to raise the blood-
pressure and to retard the  pulse while the carbonic-acid
gas stimulates the skin and obviates the sensation of cold.
Used with judgment  they  improve  the  circulation  and
increase  the strength  and tone of  the  heart muscle.
Another method of strengthening the heart muscle is by
graduated  exercises.  In one  system  resi.-tance exercises
are employed.  The patient executes a series of movements
against a passive resistance given by the operator, or is
exercised  by machines (Zander apparatus). Another
system  is  by  ordinary gymnastic   exercises  especially
adapted to the patient's needs.  Finally, the best and sim-
plest method, at any rate for the less advanced cases, is
by  graduated walks, hill climbing, and similar exercises.
In patients with heart disease, who have good compen-
sation, it  is well to encourage  regular but mild exercise,
stopping short of weariness.  For this perhaps nothing is
better suited  or more capable of nice adaptation than the
game of golf. 
             VALVULAR HEART DISEASE          111

  The treatment of many distressing  symptoms which
arise  in  the course of heart disease has already  been
alluded to in the appropriate sections, e. g., anginoid pains,
under  Angina.   Digestive disturbances  resulting  from
passive congestion in the stomach are a frequent cause of
complaint  and have not  been sufficiently  emphasized.
They are principally manifest as belching, distention, and
precordial  distress.  The meals should not be  too  large
and may be supplemented by lunches.  Articles likely to
give rise to flatulence, such as beans, cabbage, and coarse
root vegetables,  should be excluded from  the dietary.
The quantity of fluid may often be restricted with advan-
tage.   Creosote in small dose , cardamom, spirit of chloro-
form, aromatic spirit of ammonia, soda mint, and similar
remedies are the remedies most likely to prove beneficial. 
 
PART IV.
DISEASES  OF  THE  UPPER AIR
   PASSAGES,  LUNGS, PLEURA.
General Considerations.
  Respiratory Movements.
  Dyspnea.
  Aphonia.
  Cough.
  Sputum.
  Epistaxis.
  Physical  Signs of  Respiratory
   Disease.
Diseases of the Upper Air Pas-
   sages.
  Rhinitis.
Hay-fever.
Pharyngitis,
  Adenoids.
Tonsillitis,   and
  Acute Laryngitis.
  Spasmodic Croup.
  Bronchitis.
Diseases of the Lungs.
  Bronchopneumonia.
  Hypostatic Pneumonia.
  Pulmonary Edema, Infarcts, etc.
  Asthma.
  Emphysema.
  Tumor, etc.
Diseases of the Pleura.
  Pleurisy.
  Empyema.
  Pneumothorax
  Hydrothorax.
GENERAL CONSIDERATIONS.
  Respiratory  Movements.—Respiration may be costal,
abdominal, or costo-abdominal.  These  terms  show the
direction in which expansion chiefly takes place and indi-
cate whether the intercostal muscles or the diaphragm are
principally brought into play.  In women the costal type
prevails,  while in men the abdominal or  costo-abdominal
is usual.   The type of respiration may be altered in dis-
ease; in ordinary pleurisy the chest may be almost motion-
less while in painful abdominal affections diaphragmatic
breathing is limited.  In severe dyspnea the  accessory
muscles of respiration chiefly of  the neck and abdomen
are visibly contracted, e.  g.}  the  sternomastoids and 
114    DISEASES OF THE  UPPER AIR PASSAGES

trapezii.   In adults under  normal conditions there are
sixteen to twrenty-four respiratory movements a minute.
The relation to  the pulse is roughly one to three or four.
In infants or young children the respiratory rate is almost
double the adult rate.  Inspiration and expiration require
about the same length of time, but the inspiratory murmur
(heard on auscultation)* is four or five times as long as the
expiratory.
  Dyspnea.—In dyspnea inspiration or expiration may
be labored,  or respiration may be merely  exaggerated in
depth  or  increased in frequency.  Dyspnea if  severe is
often associated with blueness  (cyanosis).  Inspiratory
dyspnea is most often due  to spasm or obstruction and
is accompanied by stridor.  It may be seen, for example,
in spasmodic croup, edema of the glottis, and external
pressure  by aneurysm.  Expiratory dyspnea is seen  in
asthma, chronic  bronchitis, and emphysema.  Inspiration
in asthma is comparatively easy but expiration is pain-
fully prolonged and wheezing.   A special type of dyspnea
("air hunger"), which is  peculiar in that both inspiration
and  expiration are unusually full and deep, is seen  in
diabetic  coma.  Cheyne-Stokes  respiration,  alluded  to
under Myocarditis and Uremia, is remarkable on account
of its rhythm.   The respirations, at first  almost  imper-
ceptible, increase in depth in a step-like fashion until they
reach a noisy acme and then  as gradually fade away
and may cease altogether for  a brief space. The  whole
cycle occupies about a minute.
  Aphonia.—Hoarseness or aphonia is a common symptom
of laryngitis and other affections of the larynx—tubercu-
losis, tumors, etc.  A nasal quality in the voice is usually
due to  obstruction in the nose or nasopharynx (adenoids);
it may be caused by deficiencies of the palate, congenital
or acquired  (cleft palate, syphilitic ulceration).
  Cough.—Cough  is usually described  as either  "dry"
or "loose;"  in the former variety the sputum is  scanty
and tough or altogether  absent, in the latter, abundant
and more or less fluid.  Free secretion and a loose cough 
              GENERAL CONSIDERATIONS          115

 may exist without expectoration, particularly in children
 (sputum swallowed).  A dry cough usually has a ringing
 or  barking quality.  A hacki-g cough is often due  to
 nothing more serious than irritation of the pharynx.   In
 pertussis  a series  of  paroxysmal  coughs ends  with a
 sharp, inspiratory whoop.  The inspiratory crow of laryn-
 gismus is independent of cough.  Hawking is a voluntary
 expiratory movement employed to  "clear  the  throat;"
 it is not identical with cough.
   The Sputum.—The sputum varies  greatly in consistency,
 from the frothy, serous sputum of edema  of the lungs to
 the tough, tenacious variety seen in pneumonia.  Serum
 and mucus in varying proportions constitute the greater
 part of most sputa.  Pus  or blood may be present  in
 quantity  or in  traces,  hence the prevalent terms muco-
 purulent,  bloody, rusty, etc.   Coal dust (in miners)  lends
 a  black color  to  sputum;  jaundice,  a greenish-yellow
 tinge.   In certain grave cases of pneumonia the sputum
 resembles  prune juice.   In  tuberculosis firm, greenish-
 yellow  masses are seen  floating in a thinner material;
 these have been fancifully compared to coins, hence the
 term "nummular."   In gangrene of the lung, dilatation
 of  the  bronchi, and  tuberculosis  with  cavitation, the
 sputum acquires a horrible  fetid stench or a sweet, sick-
 ening odor hardly  less diagreeable.  Microscopic exami-
 nation  of the sputum is of great  value,  particularly  in
 the  diagnosis  of  tuberculosis  and  pneumonia.  The
 sputum is collected and  suspicious particles picked out
 and stained.  For the tubercle bacilli the carbol-fuchsin
 stain is usually  employed.   This stains the  organism a
 deep red and the remainder of the slide blue.  Pneumo-
 cocci, streptococci, influenza bacilli, etc.,  are frequently
 demonstrated by appropriate stains
  Epistaxis.—Epistaxis or nosebleed may be due to local
or general causes.   As examples of the latter  may  be
instanced  high blood-pressure and  typhoid fever; of the
 former, ulceration and  inflammation.  It  is usually not
serious and ceases either of itself, or after the use of simple 
116    DISEASES OF THE  UPPER AIR PASSAGES
measures, such as sprays, the application of cold, adren-
alin, etc.  In severe cases (e. g., in bleeders")  packing of
the anterior or posterior nares is required.  To pack the
posterior nares a  special instrument (Bellocq's cannula)
is  convenient, but the following  method will suffice in
an emergency.  A long,  stout  silk ligature  is threaded
through the eye of a soft-rubber catheter.  The catheter
is  passed through the  nares  into  the throat until its
point is seen back of the soft palate.  One end of the silk
Fig. 24.—Packing the posterior nares.  (Ferguson.)
ligature is then seized by a pair of forceps and drawn out
of the mouth while  the  other end  is withdrawn through
the nose by  the  aid of  a catheter.  A pledget of gauze
of sufficient size to fill the nasopharynx is attached to the
middle of the ligature and is guided into position by its
aid.   The  anterior nares are then packed  from behind
forward.
  Physical Signs  of  Respiratory Disease.—The diagnosis
of respiratory diseases  depends   in  large  measure on
physical  signs, but  as these signs  cannot as a rule be 
      DISEASES OF THE UPPER AIR PASSAGES    117

utilized by the nurse they will receive only brief notice.
An increase  of secretion in the bronchial tubes causes
bubbling sounds,  known as rales, which can be heard by
the ear applied to  the chest.  If the secretion is scanty
and tough the rales have a whistling or snoring character
("dry rales"),  if free  and  liquid,  a bubbling character
("moist  rales").   When  the fluid  is abundant  in  the
trachea or bronchi,  as in advanced edema of the lungs,
the bubbling sounds ("death rattle") are easily heard at
a distance.   Consolidation  of the lung is  indicated by a
"dull" sound on percussion over the area affected, by
changes  in  the normal respiratory murmur (bronchial
breathing), by increased transmission of the voice sounds
through the chest wall, and by special rales.  Fluid in the
chest is indicated by restriction of the movements of the
chest, a  "dull" or "flat" sound on percussion,  and by
distant breath and voice  sounds.   Sometimes the fluid
changes its  level with change  of position or  pushes  the
heart to one side or the other.  Roughening of the pleura
(dry pleurisy) is indicated by rubbing sounds ("friction")
heard by the ausculting ear.

      DISEASES OF THE UPPER AIR PASSAGES.

  Acute  and  Chronic  Rhinitis.—Acute  rhinitis, coryza,
or cold in the head,  is an acute infection which may
apparently be evoked by  a number of  microorganisms.
Similar symptoms  may  also be  brought about by con-
stitutional conditions,  congestion, and various irritants.
Many persons with all the  symptoms of acute cold in
the head will be immediately relieved by local treatment,
followed by a laxative and a salicylate.  Nose and throat
specialists usually attribute  these cases  to the  so-called
" gouty diathesis."  The action of certain irritating vapors
(bromin, boiling sulphuric acid, etc.) will  also call forth
transient  symptoms of similar  character.
  The ordinary infectious variety begins with sensations
of chilliness,  sneezing,  and stuffiness in the nose.  There 
118    DISEASES OF THE UPPER AIR PASSAGES

may be slight fever and malaise.  These are succeeded by
a stage of profuse watery secretion, and this in turn by a
stage of decline with mucopurulent or purulent discharge.
In many  cases  there is more or less  pain  above or at
the inner side of one or both eyes.  This is due to conges-
tion of the frontal  sinuses which connect  with  the nose.
In the more severe cases the pain will  be intense  and
paroxysmal,  and will be associated with marked tender-
ness and  sometimes with redness, swelling, and edema.
Other sinuses  connected with  the  nose may  also  be
involved.   If the inflammation of a sinus  becomes puru-
lent, it is sometimes necessary to  open, curette, and drain.
Acute rhinitis  is prone  to involve the pharynx, larynx,
and  bronchi  secondarily, but  if uncomplicated  clears up
in a week or ten days.   It seems to  be more contagious
at one time than another, probably depending upon the
exciting organism or upon its virulence.   On account of
the frequency of the disease, it is not  practicable to carry
out  isolation,  but  frail and  susceptible persons should
be protected from  infection  so far  as possible, by pre-
venting close contact with those  who are infected.
  Treatment.—The  curative treatment of acute rhinitis is
not  satisfactory  although most persons have  some fav-
orite plan which they find more or  less efficacious.   In
the early stages elimination by the skin, bowels, kidneys,
and  the diminution of internal congestion are the special
objects of treatment.  For these purposes Rochelle  salt
with  sodium bicarbonate, Dover's  powder, Turkish or
cabinet baths,  potassium citrate, and  tincture of aconite
are used separately or in combination.  Later belladonna
(atropin)  is employed to check excessive secretion and to
promote drainage from  the  sinuses.   Quinin,  strychnin,
ammonium chloride, and camphor probably act as gen-
eral or local  stimulants.  Oily sprays and ointments are
used in the early stages and  mild alkaline and antiseptic
sprays and douches in the later stages.
  The  prophylactic treatment is of  greater  value  and
importance.  The most important  prophylactic factors 
      DISEASES OF THE UPPER AIR PASSAGES    119

are cool,  well-ventilated  living rooms  (winter), cool or
cold morning baths, daily exercise in the fresh air, regu-
lation of the bowels, moderation in food and drink,  and
attention  to local disorders of the nose and throat.
  Chronic rhinitis  is of several  varieties, two  of which
may be mentioned.  In hypertrophic rhinitis, there are
chronic congestion  and thickening of the mucous mem-
branes, increased secretion,  and more or less obstruction.
Rhinitis of this  type is  aggravated by repeated  acute
attacks, by cold, humid climates, and  by constitutional
conditions.  It is often susceptible of great improvement
and cure by local treatment, change of climate, or correc-
tion of general medical conditions.  Atrophic rhinitis, on
the other hand, is  characterized  by pallor and  smooth-
ness (atrophy) of the mucous membranes, diminution of
secretion, crusting,  and an  extremely  foul  odor to the
breath  (ozena).  The nasal passages are free.  As  this
condition is dependent on atrophy,  complete cure is not
to be expected.   The patients may secure relief from the
distressing odor, which is, however, not apparent to them,
by  appropriate douches (potassium  permanganate, etc.).
Tertiary syphilis with  ulceration and  bone  destruction
may produce a similar foul discharge.
  Hay-fever.—Hay-fever  is  a disease which is  induced
in the nasal  and conjuctival mucous membranes by the
pollen of certain plants, particularly of the rose, ragweed,
and grasses.   These irritants do not affect ordinary per-
sons but  only those who are predisposed.  Hay-fever  is
therefore sometimes considered to be a neurosis, but there
is  more evidence to connect it with  certain so-called
anaphylactic  conditions.   The  typical  example of  the
!atter is seen in those persons who develop hives, rashes,
etc., after a small dose of horse serum  (diphtheria  anti-
toxin).  Rose-cold develops in the spring when roses are
in bloom.  It is not, however, so common as the ordinary
hay-fever, which develops in August and September,  and
which is attributed to ragweed and the grasses.  Attacks
of  hay-fever  usually begin  on a definite date  and are 
120    DISEASES OF  THE UPPER AIR PASSAGES

characterized  by sudden, intense congestion of the nose,
profuse discharge,  redness of  the  eyes, lachrymation,
and  sneezing.  This is easily  relieved by a sea  voyage
or removal  to certain mountain  districts  where  the
irritants which cause  the disease  do  not  exist.  The
attacks may last for a number of weeks and recur each
succeeding  year.  Patients may  subsequently  develop
asthma.  Ordinary nose  and throat  treatment gives  a
certain amount of relief but is not curative.  In the last
few  years   prophylactic  substances  such  as Dunbar's
Pollantin have been used with considerable success.  The
latter is instilled into the eyes and nostrils by means of a
pipette.
  Pharyngitis, Tonsillitis, and Adenoids.—Diseases of the
pharynx and  nasopharynx,  although  often discussed
under  the digestive system, are more  naturally included
with the respiratory tract. Acute and  chronic pharyn-
gitis are commonly associated with the similar conditions
in the nose which have already been described.  The use
of the voice and the  abuse of  alcohol and  tobacco are
causes which may lead to a special involvement of the
pharynx (see  Chronic  Laryngitis).
  The most important diseases of this  region are those
affecting the adenoid tissue.  This tissue occurs in three
principal situations.  In  the  roof of the  nasopharynx
there are folds of lymphatic  tissue which  are usually
spoken of as "adenoids."  There are also large collections
of adenoid  tissue on each side of the throat between the
pillars of the  fauces.  These almond-shaped masses are
commonly known as the tonsils.  Another mass of ade-
noid tissue which sometimes becomes engorged and leads
to a distressing, tickling cough is found at  the base  of
the  tongue and  is  known as the lingual  tonsil.  The
adenoid tissue  of the nasopharynx and  of the tonsils is
very prone to chronic hypertrophy or  overgrowth.  This
is especially deleterious in the case of the former because
it leads to more or less  complete blocking of nasal breath-
ing.  Enlargement of the tonsils causes a lesser degree of 
DISEASES OF THE UPPER AIR PASSAGES   121
obstruction and sometimes induces  irritating cough or
stridor.  These enlarged masses  of lymphoid tissue are
also liable to harbor infection and thus give rise to recur-
ring inflammatory attacks in the upper air passages or to
chronic enlargement of the glands of the neck.
  Adenoids proper have a special symptomatology which
is  often characteristic.   Newborn infants  rarely  suffer,
  Fig. 25.—Anteroposterior section of the head of an adult, showing
the situation and gross structure of hypertrophy of the lymphoid tissue
of the nasopharynx.  (Zuckerkandl.)
though symptoms may  occasionally begin  in the first
year, and the  obstruction may  be sufficient to interfere
with nursing.   The more aggravated cases are seen in and
after the  second year, and  are  characterized  by mouth
breathing, snoring at night,  liability to acute respiratory
infections, mental dulness, and certain  physical changes,
such  as narrow, pinched   nostrils,  high  palatal  arch, 
122    DISEASES OF  THE UPPER AIR PASSAGES

irregularities of  the teeth, and in the rachitic deformities
of the chest. Adenoid  vegetations usually disappear spon-
taneously before adult life.
Fig. 26.—Examination for adenoids.  (Koplik.)
  Treatment.—Medical  treatment of adenoids is  of little
avail; if there is any considerable obstruction, they should
be removed as soon as the child is  able to undergo the
operation with impunity, usually after the second year.
Enlarged tonsils should be removed if they are of  unusual 
      DISEASES OF THE  UPPER AIR PASSAGES   123

size  or badly  infected.  A  focus  of infection in  these
glands may be the cause of  repeated attacks of rheuma-
tism or endocarditis. In adults treatment by cautery, etc.,
is  sometimes  sufficient.  Acute infections of the tonsils
are described in the chapter on Infectious Diseases.
  Acute Laryngitis.—Acute catarrhal laryngitis is a very
common infection, particularly in cold, raw climates or
in the cold seasons of the year.   It  is more common in
those who  overstrain  their  voices,  for  example singers,
hucksters,  and clergymen.  It is usually  a trivial affection
accompanied  by slight  fever, hoarseness,  aphonia, and
dry cough.  At night the cough is often more severe and
there may be inspiratory dyspnea with  stridor. It may
last from  a few days  to  two weeks and is frequently
associated  with rhinitis,  pharyngitis,  or bronchitis.
  Spasmodic  Croup.—In young children there  is a mild
form of catarrhal laryngitis  associated with  recurring
nocturnal attacks of severe spasmodic croup.  The attack
is  characterized  by a croupy cough and  by severe and
often  alarming inspiratory  dyspnea which wears  away
after several hours, but may recur on successive nights.
In certain  families  there seems to be a special liability to
spasmodic  croup (in adult members, to asthma).  This is
the  affection  which  is  responsible  for  the inclusion of
syrup of ipecac in the pharmacopoeia of the nursery.
  Laryngismus  stridulus is  a nervous  affection seen in
ill-nourished, rachitic infants. It is characterized by noc-
turnal attacks of "holding the breath" with blueness and
threatened  asphyxia, which  terminate  in a peculiar
"crowing"  inspiration.   In these cases there is no catarrh
of the larynx.  Membranous croup  is  an old-fashioned
name for diphtheria of the larynx.
  Chronic  laryngitis is due to a continuation of the same
causes which occasion acute laryngitis and is accompanied
by  thickening and  other changes  in  the vocal cords.  It
is largely an occupational disorder.
  Acute  laryngitis  is  treated  by  inhalations  of steJam,
plain or medicated, by ipecac, tartar-emetic, rest of the 
 124    DISEASES OF THE  UPPER AIR PASSAGES

 voice, etc.  The general measures advised in acute rhinitis
 are also useful.  In spasmodic laryngitis ipecac should be
 given in emetic doses.   Sedatives such as  bromides are
 also useful.  Chronic  laryngitis requires rest and  local
 treatment of the vocal cords.  For those who can afford
 it, change of climate is valuable.
  Other  important diseases  of the larynx, all of which
 may  cause  hoarseness  or  aphonia,  are  tuberculosis,
 syphilis,  cancer, benign tumors (polyps), and edema of
 the glottis.   Most of these  have been described under
 the appropriate headings, and in most  cases will depend
 for their diagnosis  on laryngoscopic  examination.   The
 prognosis in tuberculosis or  cancer is  extremely bad.   In
 benign tumors the voice may be restored by removal of
 the tumor either  by operation or the  z-rays.  Hysterical
 aphonia  offers a  favorable prognosis.  Edema  of  the
 glottis may accompany generalized edema, as in Bright's
 disease, or may result from acute inflammation.  As a
 rule it begins suddenly  with increasing dyspnea (both
 inspiratory  and  expiratory) due  either to swelling  of
 the epiglottis or  to  infiltration of the  surrounding, soft
 tissues.   The course is usually very rapid,  and requires
 scarification of the epiglottis or immediate tracheotomy.
  Bronchitis.—Bronchitis is  a term which  is commonly
 applied  to inflammation of  the trachea (tracheitis)  and
 of the large  and medium-sized bronchial  tubes.   The
 same process, if it  extends  to the finest bronchioles, is
 called capillary bronchitis.   This is seldom distinguish-
 able from  bronchopneumonia in which the  pulmonary
 vesicles  are  also inflamed.  Ordinary  acute bronchitis
 involves the trachea and large bronchial tubes and often
 presents  no characteristic physical signs.  It is  accom-
 panied by the usual symptoms of a mild fever, by soreness
 beneath the sternum, and by cough, which is at first dry
 and racking, with little or no sputum.   After a  day or
two, the  cough becomes looser and the  sputum which is
at first mucoid and scanty,  becomes profuse and muco-
purulent.  The fever rarely lasts more than a few days, 
DISEASES OF THE UPPER AIR PASSAGES   125
and with it the aching and other constitutional symptoms
disappear.  After persisting for two or three weeks  the
cough gradually clears up.
  In the young and the aged, less often in healthy adults,
symptoms may be much more severe  with involvement
of the  smaller bronchi.  When the ear is laid upon  the
the patient's  chest, bubbling, whistling,  snoring,  and
crackling sounds are  heard.  The first are known as
moist rales and the others as dry rales.  In children  the
bronchial secretion may produce  considerable obstruc-
tion and induce  attacks of suffocation with cyanosis  and
collapse  which require the prompt use  of emetics, mus-
tard baths, and other counter-irritants.  In the young,
the aged, and  the debilitated, bronchopneumonia is  a
common complication.  Bronchitis frequently occurs as
a secondary condition in congestion due to heart disease,
in inflammatory diseases of the lung, in infectious diseases
(such as typhoid fever, influenza, measles, and whooping-
cough),  in  constitutional disorders (such  as  gout  and
Bright's disease), and finally in asthma and emphysema.
When it is complicated with asthma and emphysema there
is usually severe dyspnea with wheezing.
   Chronic bronchitis is a term used to designate cases in
which  there is more or less continuous cough with brief
intervals of freedom.  Frequent attacks of acute  bron-
chitis  predispose to its  development.   In  the  so-called
"winter cough" the patient is usually free from symptoms
in the summer months, but with return of cold weather
the cough recurs and persists until the following spring.
The patient's general health may be comparatively little
affected, but in  severe and prolonged cases, emphysema,
dilatation of the bronchi, and embarrassment of the heart
may finally ensue.  Asthma is commonly associated with
chronic  bronchitis.
   Treatment.—The prophylactic treatment of  bronchitis
depends on the removal of the cause when this is possible.
The disease is- more prevalent in damp, cold, changeable
climates, so that much may be gained by removal to a 
126    DISEASES OF THE  UPPER  AIR PASSAGES

dry, warm atmosphere, or even to a dry, cold one.  Acute
cases  are  benefited by  a change of climate of even less
radical nature, as from the city to the seashore, or from
the shore to the mountains.  Some cases are  occasioned
by exposure to dust or gases incident to certain occupa-
tions, and may be relieved by  the  use of  ventilators  or
Fig. 27.—The croup kettle.  (Hare.)
respirators.   In a similar way, the treatment of under-
lying gastric,  cardiac, renal, or other disease may cure
an otherwise intractable cough.   For analogous reasons
stimulants,  tonics, and alteratives  (strychnin,  arsenic,
iodide of iron, and cod-liver oil) are  useful.
  In  the early stages of acute bronchitis a  simple fever
mixture is usually employed, containing potassium citrate, 
DISEASES OF THE LUNGS
127
spirit of  nitrous ether, etc.   At the same period "seda-
tive  expectorants," such as wine of antimony, syrup of
ipecac, and  apomorphin  hydrochloride are used to relax
the cough.  As the case progresses  "stimulant expecto-
rants" which increase  secretion and aid in  its expulsion
come into use.  Examples are ammonium chloride, senega
(syrup), terebene, terpin  hydrate, tar, and creosote.   The
latter class of remedies is also useful in chronic bronchitis.
If the cough is excessive, demulcents, such as licorice and
flaxseed,  or  sedatives, such as bromides, spirit of chloro-
form,  hydrocyanic acid, codein,  Dover's powder,  and
other  opium  preparations   are  required.  In  children
opium in all forms should be  used  with  great care and
expectorants are best employed in the form of inhalation.
Compound tincture of benzoin, creosote, and many other
substapces may be given in this way, although the bene-
ficial results are largely due to the relaxing effects of the
steam.  In  the same class of patients as well as in the
aged, counter-irritants are employed, dry cups, mustard
paste,  camphorated  oil, etc.   In  the early  stages of
ordinary bronchitis,  rest in bed in a well-ventilated but
fairly warm (65° to 70°) room, undoubtedly shortens the
attack.  In  the more severe varieties, such as  accom-
pany or follow measles or influenza, absolute rest in bed
is imperative on account of  the danger of bronchopneu-
monia.   In  the later  stages fresh  air  in abundance or
actual open-air  treatment has its  place.

             DISEASES  OF THE  LUNGS.

   Bronchopneumonia (Catarrhal Pneumonia).—Broncho-
pneumonia or lobular pneumonia involves, as these appel-
lations imply, small lobules  or  groups  of vesicles which
open into a single  minute  bronchus  (bronchiole).  In
severe cases innumerable small foci may coalesce  causing
nearly complete consolidation of a whole lobe or lung. It
may be caused by a great variety of organisms.  It differs
from the specific infectious  disease "pneumonia" (see 
128    DISEASES OF THE UPPER AIR PASSAGES

Infectious Diseases)  in that the latter involves a whole
lobe almost from the beginning and is always due to the
pneumococcus.   It  runs an  irregular  course  and  is
commonly preceded and accompanied by bronchitis.  The
fever  is not high,  as a rule,  but  respiration  is  usually
rapid  and  cyanosis  marked.  Bronchopneumonia  is  a
common cause of death in measles, whooping-cough, and
other  diseases of infancy and early childhood and again in
the infirm  and  aged.  During the epidemic of measles
and influenza in 1917 and 1918 very fatal forms of bron-
chopneumonia were rife.   Healthy young adults, includ-
ing many pregnant women, were  particularly  attacked.
The causative organisms varied but seem to have  most
commonly  been types of pneumococci or  streptococci,
sometimes associated with influenza bacilli.  The treat-
ment  is partly  that of bronchitis and partly  of pneu-
monia  (q.  v.).  Stimulation  and  careful  feeding  are
important.   Fresh air is  valuable,  but opinions differ as
to the propriety of cold which is so beneficial in the lobar
variety.
  Hypostatic Pneumonia.—Hypostatic  pneumonia is  a
condition that succeeds congestion of the dependent parts
of the lungs in cardiac cases and in weak and bed-ridden
patients.  It is frequently the "last straw" which finally
turns the balance, but is to be regarded as a contributing
rather than a principal cause of death.   Aspiration pneu-
monia is a somewhat similar condition due to sucking of
food or other  foreign particles into the bronchi and air
vesicles with subsequent infection.   The natural defences
(cough, etc.) suffice  to prevent this in the  normal indi-
vidual,  but  these may be overcome by destructive dis-
ease of the larynx, perforation of the esophagus or aorta
into the bronchus, and a variety of other causes as well
as  by extreme  debility, stupor,  anesthesia, etc.  This,
again, is a very fatal form of pneumonia.  Chronic inter-
stitial pneumonia  is a fibroid  induration  of  the  lung
resulting, as a rule, from chronic irritation by coal dust,
marble  dust, and other mechanical irritants peculiar to 
DISEASES OF THE LUNGS           129
various trades.  Such a  condition  is sometimes called
pneumokoniosis  and,  as a rule, is complicated by tuber-
culosis  (chronic fibroid  phthisis).  The  symptoms are
chronic cough and emaciation.  It bears no resemblance
to the conditions described above except in name.
  Pulmonary  Edema, Infarcts,  etc.—The same  causes
which lead to hypostatic pneumonia may also induce
edema of the lungs.   In this condition fluid accumulates
in the vesicles and bronchi giving rise to bubbling sounds.
Edema of the lungs is found in a large proportion of all
cases at autopsy, but is in itself not necessarily a fatal
condition.   Infarcts  have been mentioned in Part  III,
Chapter I;  they result from the lodgment of emboli in
the small arteries.  In this condition cone-shaped areas
of consolidation, usually red in color and with the base
outward,  are  found  at the  surface  of  the  lung.  The
physical signs are those of pneumonia but the symptoms
may  be suggestive  or diagnostic. The most important
are sudden pain in the chest  and the expectoration of
deeply  blood-tinged sputum or pure blood.   If  the clot
or embolus  which causes the infarct  is infected (pyemia,
malignant endocarditis), gangrene or abscess of the lung
may develop.  Gangrene and abscess  may also occur after
pneumonia  or from the aspiration of infective material.
Under  these conditions  the patient runs an  irregular
hectic fever, often with sweats and chills, and expectorates
either pus  in the one case, or fetid gangrenous material
in the other.
  Asthma.—Asthma,  or bronchial asthma, is a spasmodic
affection which  is frequently associated with bronchitis.
It occurs in paroxysms, commonly at night, and compels
the patient  to sit up in bed or to go to the window to
catch his breath.  Inspiration is  only slightly impeded
but  expiration is  prolonged and wheezing;  the patient
cannot get  the air out.  The face is cyanotic, the muscles
of the neck  prominent and contracted.  When the attack
has passed relaxation occurs and sleep is again possible.
Asthma is sometimes  a sequel of hay-fever and like that
      9 
130    DISEASES OF THE UPPER AIR PASSAGES

disease  is  supposed  to  be more  common  in neurotic
people.   The prognosis for the attack is good, for perma-
nent cure,  bad.   The  attacks tend to recur at frequent
intervals for years.  In children—in whom it is fortunately
not very common—it  may lead to chest deformities; in
the elderly it predisposes to emphysema.
  Treatment.—Occasionally the treatment  of some nasal
condition or of a gastric anomaly  may bring about cure.
Potassium  iodide has  a  favorable effect on  the disease.
The attack itself is relieved by atropin or a tropin and mor-
phin administered hypodermically, or  by the inhalation
of the fumes of burning saltpeter usually mixed with bella-
donna, or stramonium leaves in varied combination. These
are the principal constituents  of  the ordinary "asthma
pastilles" and "asthma cures."
  Emphysema. — Emphysema is  a disease characterized
by  an  increased volume  of the lungs, due to permanent
distention  and loss of elasticity.  The  lung completely
fills the chest and does  not retract as it  should  during
expiration.  The chest is round or barrel-shaped and moves
very slightly  with  respiration  which is almost entirely
diaphragmatic.  The accessory muscles  of respiration are
brought  actively into play.  The patient has  trouble
in  emptying  his  lungs,  and  is  sometimes somewhat
cyanotic.   In protracted  cases hypertrophy and  dilata-
tion of the  heart commonly develop.   Emphysema  of
moderate degree is normal in extreme old age, but severe
cases  usually result from prolonged cough,  hard work,
and, it is  generally believed,  from such occupations  as
glass-blowing and the use of wind  instruments.  Emphy-
sema is an  incurable disease which may be aggravated by
hard work or by repeated attacks of asthma and bronchitis.
Treatment is concerned largely with the prophylaxis and
treatment of these intercurrent diseases or of cardiac com-
plications.   i\side from the ordinary form of emphysema,
there is a temporary  distention or hypertrophic emphy-
sema of the healthy lung in pneumonia, pleural effusion,
etc., which compensates  for its  crippled  fellow.   This 
DISEASES OF THE PLEURA          131
condition disappears with convalescence from the primary
disease.
   Tumors etc.—Tumors of the  lung and  pleura  may
occur, but they are rare.  Syphilis occasionally affects the
lung; tuberculosis  very commonly.  Both are described
under their appropriate headings.

             DISEASES OF THE PLEURA.

   Pleurisy.—The pleura is the serous membrane which
invests  the  lungs (visceral  pleura), the inner  surface of
the chest (parietal pleura), and the diaphragm  (diaphrag-
matic pleura).   Inflammation of the pleura  is known as
pleurisy;  sometimes it  is localized in  one portion of the
membrane,  e. g.,  diaphragmatic pleurisy.  Pleurisy is a
common accompaniment of diseases of the lungs, partic-
ularly of tuberculosis and  pneumonia.  In these condi-
tions there is usually a dry pleurisy which results in the
formation of more or less extensive adhesions.  Simple or
primary pleurisy may  be either dry (plastic)  or serous.
It may  be due to a variety of microorganisms, most com-
monly to the tubercle bacillus and the pneumococcus.   In
many cases no organism can be found in the pleural fluid.
Simple  pleurisy  generally begins with a chill or rigor,
slight fever, malaise, and sharp,  stabbing pain in  one side
of the chest.  Sometimes in diaphragmatic pleurisy pain
is felt in the  abdomen alone, so  that the disease has been
mistaken for appendicitis or gall-bladder  trouble.  The
patient  restricts  the movements of the chest so far as
possible and  favors breathing on the sound side by lying
on the  affected  one, although  this is  by  no  means  an
invariable rule.   Early  in  the  disease the physician is
usually  able to detect a to-and-fro scratching sound due
to the rubbing of  the  inflamed pleural surfaces against
each other.   Sometimes the disease proceeds no further
and  recovery takes place with the formation of slight
adhesions. These probably cause the "stitch in the side,"
of which patients complain from time to time for years. 
132    DISEASES OF THE UPPER AIR  PASSAGES

Ordinarily dry  pleurisy is  followed  by an effusion  of
clear fluid.
  Often  patients  in  whom  the early  symptoms have'
passed unnoticed come into hospitals with large effusions.
The fluid fills the chest more or less completely, causing
partial or complete collapse of the lung and relief of pain,
if this has been  present,  by separation  of the  inflamed
pleural surfaces.   On account of the diminution of the
breathing space, shortness of  breath and blueness develop
on exertion.  The affected side is nearly  motionless while
the other  side  shows  an exaggerated  movement. On
examination  the  physician finds signs of fluid, flatness,
disappearance of the breath  sounds, movable dulness on
change of position, etc.  The  fluid may disappear of itself,
or as  a result of  the use of diuretics, etc., but  if it does
not, tapping  is required.  Sometimes operation  has to be
repeated  several  times before recovery occurs.   Uncom-
plicated  pleurisy  is  seldom  fatal.  Even when  due to
tuberculosis recovery  is the  rule unless it is preceded or
followed  by pulmonary involvement.
  Empyema  (Purulent Pleurisy).—Empyema does not
usually follow a simple pleurisy,  but is common after
pneumonia.  It is to be suspected after the  subidence of
the primary  disease if an irregular temperature with or
without chills and sweats develop.   Examination of the
blood generally shows an  increase of leukocytes.   Physi-
cal  examination  is usually decisive, but sometimes the
signs  of  the  preceding  disease  complicate the  examina-
tion.  In other cases the pus is  between  the lobes of the
lungs  and cannot be detected except by the needle. The
diagnosis  is confirmed by exploratory puncture  and by
the withdrawal of pus.
  Pneumothorax.—Pneumothorax almost invariably re-
sults from the perforation of  a tubercular cavity through
the pleura, and is usually announced by sudden pain,
shortness of breath, and the signs of free  air  in the chest.
On  examination the  affected half of the chest  is found
to  be increased  in size, with a  hyperresonant  or drum- 
DISEASES OF THE PLEURA
133
like  note throughout.  The breath  sounds are masked
and, if the patient is violently shaken, a loud splashing
sound  is heard, due to free fluid in the  air-containing
space.   If the fluid  is serous (watery), it is called hydro-
pneumothorax, while if it is purulent, as  is usually the
case, it is known as pyopneumothorax.
Fig. 28.—Removing fluid from the chest by aspiration.  (After Hoppe-
                        Seyler.)
  Hydrothorax.—In heart disease, Bright's disease, ane-
mia, etc., there may be  a passive transudation of fluid
into the pleural cavity (hydrothorax) as well as into the
peritoneum  (ascites), etc.  This is extremely common in
chronic heart disease with loss of compensation.  The fluid
is usually much more abundant on the right side.  Some- 
134    DISEASES OF  THE UPPER AIR PASSAGES

times the fluid disappears with rest in bed and treatment
of the cardiac condition, but it may require aspiration.
  Treatment of Pleurisy.—In  acute pleurisy the  patient
should be put to bed and  treated as a mild febrile case,
Fig. 29.—Removing fluid from the chest by syphonage.  (After
                  Hoppe-Seyler.)
by rest, diet, fever mixtures, etc.  A laxative, for example
calomel and salts, should be administered.   The pain in
the chest may  be relieved by an ice-bag,  by mustard
paste or poultices, by cupping, strapping,  or the  hypo- 
DISEASES OF THE PLEURA
135
dermic  injection ' of  morphin.  Strapping  is probably
the simplest  and most effectual method, but when  the
signs of the disease are in doubt it is often avoided, as it
interferes with a  careful examination.  After the pain
disappears the patient's bowels should be kept open and
diuretics administered to  limit if possible the effusion of
fluid.  Usually aspiration will be required.   For this pur-
pose Potain's aspirator or a similar apparatus is usually
employed.  (Fig. 28.)  It is very necessary that the appa-
ratus should be tested before the operation is undertaken,
as the tubes or valves  are likely to be obstructed or leaky
or the pump  out of order.  In some cases trouble may be
 Fig. 30.—Apparatus for expanding the lung after empyema.  (Hare.)

due to blood clots or thick pus, but usually the fault lies
in neglect to test the  apparatus in advance.  After the
apparatus has been assembled and the bottle exhausted
it should be tested with sterile water to make sure that a
vacuum is present. It would be quite possible to attach
the pump wrongly and inject air into the chest instead of
withdrawing fluid, with  possibly serious consequences.
Some physicians prefer to remove fluid from the chest by
simple syphonage.  For this purpose a much simpler outfit
and one not liable to get out of order is required.  (Fig. 29.)
The fluid should be drawn off gradually and if the  amount
is large, too much should not be removed at one  time. 
136    DISEASES OF THE UPPER AIR PASSAGES

Otherwise the  patient  may  develop an alarming acute
edema of the lungs, characterized by the expectoration of
large  quantities of serous fluid.  If this accident should
occur a timely hypodermic of atropin and morphin will
avert danger.   If the fluid is loculated, i. e., divided into
small pockets, there may be  considerable  difficulty in
locating it.  In empyema a large needle is necessary for
aspiration, as the  small ones  become clogged with  pus.
In this variety of pleurisy tapping is usually employed
merely  for diagnosis.  However, in some  of the acute
empyemas, with thin sero-pus,  which were seen in the
"camps"  following measles and influenza, repeated  tap-
pings were successful in saving life and occasionally in avoid-
ing radical operation.  For the cure of the condition free
drainage by incision, resection of a rib, and the insertion
of a rubber tube is ordinarily required.  Recently,  con-
tinuous  or  intermittent  irrigation with Dakin's  solu-
tion (by  means of tubes) has been  found to improve
the results of operation.  In  pyopneumothorax tapping
or draining is of little  or no benefit, and is not  usually
recommended.  In the  convalescence from  pleurisy the
treatment should consist of rest, fresh air, tonics,  and an
abundance of food.   This is important on account of the
danger of the development of  tuberculosis.   After empy-
ema the lung is collapsed and often  adherent.  It may
usually be reexpanded  by respiratory exercises, e. g., by
blowing fluid from one bottle  into another by means of a
special arrangement of tubes.   (Fig. 30.) 
PART V.
DISEASES OF THE DIGESTIVE TRACT
            AND  PERITONEUM.
                   CHAPTER I.

DISEASES  OF THE MOUTH  AND  ESOPHAGUS.

General Considerations.       |  Rectal Feeding.
  Anorexia.                    Miscellaneous.
  Dysphagia.                Diseases of the Mouth, Tongue,
Heartburn.
Belching.
Fulness and Distress.
Pain and Colic.
Vomiting.
Constipation and Diarrhea.
Lavage.
Test-meals.
Enteroclysis.
   and Salivary Glands.
  Stomatitis.
  Pyorrhea Alveolaris.
  Teething.
  Parotitis.
Diseases of the Esophagus.
  Stricture and Tumor.
  Hemorrhage.
  Anorexia.—Anorexia is a term used to designate complete
loss of appetite.   This symptom occurs in many diseases
of the digestive  tract as well as in  fevers and chronic
diseases.   Increased appetite  is less common  and when
present is suggestive of  diabetes rather than  of gastro-
intestinal  disease, especially when it is associated with
great  thirst.  It  is also noted in the convalescence from
fevers and particularly in typhoid. There are rare nervous
conditions  in  which  patients  without organic disease
suffer from absolute anorexia  or from polyphagia (exces-
sive appetite);  children and occasionally adults may have
perverted  appetites, eating clay and  other indigestible
substances. 
13S     DISEASES OF THE DIGESTIVE TRACT

  Dysphagia.—Dysphagia (difficulty in swallowing) occurs
in inflammation of the throat  and gullet, in intrathoracic
(mediastinal)  tumors  (aneurysm), and  in the  various
forms of esophageal obstruction.
  Heartburn.—The eructation of fluid, bitter or acid, into
the throat is known as waterbrash.  The nearly synony-
mous terms, pyrosis and heartburn,  emphasize the dis-
tressing burning sensation at the pit of the stomach and
beneath the sternum which accompanies this phenomenon.
  Belching.—In belching, swallowed  air,  or  less  often
malodorous  gas produced by  fermentation, is eructated,
sometimes with much noisy  rumbling.  This may be a
purely nervous  habit  analogous  to  the  "cribbing" of
horses.  In  this case the air is unconsciously drawn into
the  esophagus or  stomach and  immediately expelled.
I have seen persons who have belched  continuously for
days, cured by the passage of a stomach tube or by a
stern command.  If the stomach and  particularly the
intestines are distended with gas, the  condition is known
as tympanites (from the word meaning a drum).  Frequent
passage of gas by the bowel  is spoken of as flatulence.
These conditions may be due to  fermentation, but are
nore frequently due to disturbances of motility.  Normally
the gas is absorbed or expelled unconsciously.
  Fulness and Distress.—Fulness and  distress are  sensa-
tions of discomfort which fall short of actual pain, and
are usually felt in the epigastrium or pit of the stomach.
This symptom is common in nervous dyspepsia, heart
disease, gall-bladder disease, etc.
  Pain and Colic.—Gastric pain if very severe and paroxys-
mal is spoken of as gastralgia.  This may be met with as
an independent affection  similar to neuralgia, but is more
often due to ulcer and other organic conditions.  A  rare
but severe form occurs  in tabes  (gastric crisis).  Colic
is a severe, cramp-like pain which is usually accompanied
by nausea.  In gall-stone colic, the pain radiates around
the right side  of the chest and to the "right shoulder."
In renal colic it radiates  from  the loin downward toward 
   DISEASES OF THE  MOUTH AND ESOPHAGUS   139

the bladder.   In intestinal colic  and lead poisoning  the
pain is referred to the center of the abdomen.  In ulcer,
less often in  cancer, there may be localized soreness and
tenderness, while in  gastritis the pain  is diffuse.   The
areas of tenderness due to ulcer, on either the gastric or
intestinal side of the pylorus,  and that due to gall-bladder
disease are close together and  sometimes indistinguishable.
In ulcer there may be tenderness in the  back  on the  left
side, in gall-stones on the right.
  Vomiting.—Vomiting is usually preceded or accompanied
by nausea.   The vomiting of brain tumor is explosive in
character  and without nausea.  Fecal  vomiting is an
indication  of  intestinal  obstruction.   Hematemesis  or
vomiting  of  blood  occurs most commonly  in ulcer and
cancer of the stomach,  and in  cirrhosis of the liver.  In
cancer the blood is usually old and dark.  It is compared
to "coffee"grounds."
  Constipation and  Diarrhea.—Constipation and  diarrhea
are relative  terms which refer to the frequency and con-
sistency  of  the movements.  What would be  diarrhea
in an adult  is normal in an  infant, and similar but  less
marked differences exist between normal adults.  Com-
plete constipation or obstipation  is one of the symptoms
of intestinal  obstruction.
  Lavage.-—For the performance of lavage a stomach tube
of moderately large size (32 F.) with a glass or rubber
funnel is  best suited.  The tube should be long enough
to permit of easy syphoning and should have few or no
joints, as these are likely  to leak sooner or later.   If  a
bulb is required it can be attached to the outer end after
removing the funnel.  A bulb  is often useful  to free the
tube  of  mucus or  large particles of food  or  to start
syphoning by aspiration.   After being used the stomach
tube  should  always be washed in  cold  water and then
boiled.
  When the  tube is to be inserted it should be dipped in
warm water  (no  other lubricant  is required) and passed
back to the pharynx exactly  in the  middle  line.   The 
140      DISEASES OF  THE DIGESTIVE TRACT
patient is then asked to close his lips and swallow,  the
physician meanwhile continuing to push the tube onward.
  Fig. 31.—The stomach tube having been passed, the funnel is filled
from a pitcher and moderately elevated to force the water into  the
stomach.  While in this position a measured amount of water may be
added (a pint in all for example).  Just as the last portion of water is
almost to disappear down the tube, the funnel is lowered and the con-
tents of the stomach are syphoned out.  (Hare.) 
   DISEASES OF THE MOUTH AND ESOPHAGUS   141

If the patient has any respiratory distress he is asked to
take a few long breaths, and then to swallow again.   In
a very few seconds the tube reaches the stomach.  While
the tube  is being passed  the head should be  inclined
slightly forward.   The funnel is now lowered and  the
contents of the stomach syphoned off.  If the stomach is
empty the funnel is raised and  a measured quantity of
plain or medicated water poured into the stomach.  This
is now withdrawn by syphoning and the  operation  re-
peated until  the stomach  is clean.   If there is difficulty
in syphonage the tube should be inserted  or withdrawn
a short distance.  Lavage  is employed to detect retention
of the stomach contents and more largely for treatment.
  Test-meals.—Test-meals are administered to determine
the power of the  stomach to secrete the digestive juices
and to empty itself  within  a normal time.  There  are
many forms of test-meals, but that in most common  use
is known as the Ewald-Boas test breakfast.  This consists
of a large  cup of tea without milk or sugar, and a breakfast
roll  without  butter.  Similar quantities of water  and
bread or toast may be substituted.   The breakfast should
be  taken  in  the morning,  fasting;  if there is  retention
preliminary lavage is essential.  At the  end of an hour a
stomach  tube is  inserted,  and the  patient expels  the
contents  of  the stomach through  the  tube by bearing
down  or  pressing gently  on the upper  abdomen; occa-
sionally the physician will need to exert suction by means
of a rubber bulb.  Normally, the contents are of a puree-
like consistency without  admixture of  mucus  or  blood.
On  examination  free hydrochloric acid is found to be
present, and a total acidity within  definite normal limits
is determined by quantitative estimation.  The quantity
of  stomach  contents normally  obtained varies  from 50
 to 150 c.c. (H to 5 ounces).
   Under  abnormal  conditions the  bread may be poorly
 digested,  there may be an excess  of mucus suggesting a
 gastritis,  or  traces of blood pointing to ulceration.   The
 free hydrochloric acid may be in excess or  absent, and in 
 142     DISEASES OF THE DIGESTIVE TRACT

 like manner the total acidity may be increased, diminished,
 or absent.  In cancer, lactic acid may be found.  An excess
 of fluid or remnants of  food remaining from  previous
 meals  show that the stomach is not emptying itself  as
 promptly as it should.
  In some cases a more  satisfactory idea  of  the  course
 of gastric  secretion is obtained  if—after  a test  break-
 fast—samples of the  stomach contents (2  to  3 c.c.) are
 removed every fifteen minutes until the stomach is empty.
 This "fractional" method has been popularized by Reh-
 fuss and has been made possible by the use of the duodenal
 tube (Einhorn), a slender tube with a perforated metal
 capsule at the  tip.  This can be  tolerated indefinitely
 by the patient.  The author uses a fine tube weighted
 at the tip by a perforated  shot.   The duodenal tube
 was used primarily to obtain  the contents  of the upper
 intestine for examination; recently it has been employed
 to introduce  food and water directly into the intestine  in
 cases of gastric ulcer.
  There are a  large  number of  other  test-meals  and
 modified  methods  of  examination which we  cannot
 attempt to describe.  The stomach tube is also used to
 distend the stomach with air for the purpose  of discovering
 its size and position.  At the present time, if the facilities
 are at  hand, this object may be  better accomplished by
 ar-ray  examination  (fluoroscope).
  Enteroclysis.—In many cases physiological salt solution
 or other medicated fluids  may be given by rectum when
 other  routes are inconvenient or impossible.  Formerly
 the whole quantity desired was rapidly introduced, but
 at the  present day a very gradual, continuous enteroclysis
 (Murphy drop method)  is usually preferred.  For this
 purpose  a  reservoir which can be  maintained at body
heat and a cut-off by which  the rapidity of flow can
be exactly  regulated are required.  (Fig. 32.)   Such an
apparatus may be  improvised from a  hot-water bag,  a
fountain syringe, a  catheter, a hemostat, a  piece of glass
tubing, and a straight pipette. 
DISEASES OF THE MOUTH AND ESOPHAGUS  143
  Rectal  Feeding.—Rectal  feeding is at the  best, a pre-
carious method of nourishing a patient but is nevertheless
of great temporary  service in ulcer of the stomach, per-
GLASS "U" TUBE
Fig.  32.—Apparatus for proctoclysis (enteroclysis).  In this case the
       solution is heated as it flows through the tube.   (Hare.) 
144     DISEASES OF THE DIGESTIVE TRACT

nicious vomiting, etc.  As a rule not over three feedings
of six to eight ounces each should be given in the twenty-
four hours.  At  least one simple cleansing enema should
be given daily (not just before a feeding).  The "feeding"
should be warmed to body temperature and introduced
very  slowly so  as not to provoke  rectal contractions.
During  the  administration of the nutritive  enema the
patient should lie on  the left side.  He should also remain
quiet for a long  time after the enema has been given to
favor retention.   The following substances are commonly
employed for rectal feeding: eggs, peptonized milk, milk-
sugar, peptone solutions, etc.
  Miscellaneous. — The interior of  the  esophagus  and
stomach may be viewed directly through special  tubes
known as esophagoscopes and gastroscopes.  The technic
of these examinations is too  diffiult  and the discomfort
to the patient too great to make them generally applicable.
This is not true  of the  somewhat similar but far  easier
methods of examining the rectum and sigmoid.  By the
aid of rectal specula, strictures, tumors, ulcers, and hemor-
rhoids may be seen.  The rectum is sometimes washed out
to obtain samples for examination:  more commonly the
stools are  examined, with or without a previous special
diet  for the  detection  of  gall-stones, abnormalities in
digestion, or the presence of mucus or blood.   The color
and consistency  of the stools should  be observed by the
nurse and, if unusual, reported to the physician.  Sticky
black stools (tarry)  suggest hemorrhage high up, white
or clay-colored   stools, with jaundice, indicate obstruc-
tion of the bile duct.  Mucus and pus in large quantities
are also of diagnostic  importance.  Blood may be detected
chemically  when it  cannot be seen (occult blood);  its
presence  may confirm the dignosis  of  ulcer or cancer.
Examination of the stools for the intestinal parasites  and
their eggs is also very important. 
     DISEASES OF MOUTH, SALIVARY GLANDS    145

 DISEASES OF THE MOUTH, TONGUE, AND SALIVARY
                       GLANDS.

   Stomatitis.—Stomatitis  (inflammation of the mouth)  is
 of common occurrence, particularly in children, and may
 result from hot or highly spiced food, local  injuries, erupt-
 ting teeth, local and general infections, and drugs.  Simple
 stomatitis is characterized by pain, redness of the mucous
 membrane, salivation, and  fetor of the breath.  These
 symptoms are  well marked and persistent  in mercurial
 stomatitis.   In this form the  teeth frequently become
 loose.  It is seen in susceptible persons who are taking
 the so-called Xiemeyer's  pill (digitalis, squills, and  blue
 mass) for cardiac or renal dropsy, and syphilitics under
 intensive treatment by  mercury.  The  severe degrees
 with ulceration are seldom  seen  at the present  day.
 In babies stomatitis is frequently accompanied by small
 blisters which leave shallow ulcers: this variety is known
 as aphthous stomatitis.
   Ulcerative stomatitis is  another variety; there may be
 a solitary ulcer on the gums, which heals rapidly under
 treatment and is not accompanied by much inflammation,
 or in debilitated individuals and in those  suffering from
 severe illness, there may be extensive intractable ulcera-
 tion with intense inflammation.
   A horrible and fortunately  rare, variety  is gangrenous
 stomatitis ("noma").  This occurs in debilitated children
 after measles and other infections and may lead to  per-
 foration and destruction of the cheek. It is almost always
 fatal.
   A severe stomatitis, frequently accompanied by ulcera-
tion, is associated with Vincent's angina.   This form of
infection was very common  in the "trenches."   In typical
cases the  mucous membrane of the mouth,  tonsils,  and
pharynx shows a soft  grayish deposit which  may easily
be  mistaken for diphtheria.  Constitutional  symptoms
are slight  or absent.
  Thrush  is a  parasitic disorder due to fungus and is
     10 
146     DISEASES OF THE DIGESTIVE TRACT

characterized by white,  milk-like patches  in  the mouth
with very little inflammation; it is  seen  principally in
nurslings.
  Leukoplakia  is a condition of  localized  thickening of
the mucous  membrane of the tongue, not unlike a callus
and white ("leuko") in color.  It is common  in smokers
and may be due to irritation, although usually attributed
to syphilis.
  "Mucous patches" are seen in the mouth  and throat
as well as on other mucous membranes, and are distinctive
of secondary syphilis.  They appear as oval, bluish-white,
or semitranslucent areas.  Tertiary syphilitic ulcers are
common on the tongue, palate,  and throat,  and in the
latter situation lead to considerable destruction  of tissue.
Cancerous  ulceration and  infiltration  of the  tongue are
also common.  Tuberculous ulcers are  less often seen.
Many of the scars seen on the tongue are  due to injury
(biting), and are suggestive of epilepsy.
  Formerly great stress was  laid on  the  appearance of
the tongue, but the modern view approaches that of Oliver
Wendell Holmes, who when consulted by a lady in regard
to a coated tongue, advised her  to procure a small hoe
and scrape the  fur off.  Defective teeth, insufficient chew-
ing, soft or  liquid food, dryness from mouth-breathing or
fever,  all tend to impair the normal attrition  and des-
quamation  of  the  epithelium  which  result  from  the
thorough mastication of hard food.  In chronic dyspeptics
with low acidity a large, pale, flabby, tooth-marked tongue
is supposed to be characteristic.   In acid  dyspepsias,
diabetes, etc., the tongue is raw and beefy.  Sometimes
the tongue  is denuded and  atrophic.  Other suggestive
appearances of the tongue,  such as  those  which are
observed in scarlatina and typhoid fever,  are mentioned
in the appropriate sections.
   Pyorrhea Alveolaris.—An indistinct blue or black line
near the free edge of the gums is seen in lead poisoning.
Spongy  and bleeding  gums occur in leukemia,  scurvy,
purpura, and  other  conditions.   The  most  important 
    DISEASES OF MOUTH, SALIVARY GLANDS     147

disease of the gums from a medical point of view is pyor-
rhea alveolaris, which in the  early stage is characterized
by retraction of the gums, and later by the formation of
pockets of pus1 about  the neck and roots of the  teeth.
The latter loosen and finally drop out, although they may
not be  at all decayed. Similar ulcerative and infective
conditions occur about carious teeth and  roots  in  the
neighborhood  of "bridge-work"  and  beneath  plates.
These  minute foci  of  infection are  believed  by  many
physicians to be important  as causes  of  anemia, joint
irritation, and even neurasthenia, and there is little ques-
tion but that they  are responsible for  some  at least of
these supposedly toxic states.
  Transverse ridges on the teeth are usually signs of some
severe illness which  has occurred during early childhood.
Irregular  teeth, and  particularly peg-like incisors  of  the
second  dentition, are  suggestive of congenital syphilis.
The role of caries in causing neuralgia has been referred
to elsewhere.  Extensive defects in the teeth are a prolific
cause of dyspepsia (imperfect mastication).
  Teething.—The influence of teething in the  production
of febrile  and other  disorders of infancy has been grossly
exaggerated  in the past.  This  has been harmful because
it has been accepted as a sufficient explanation for severe
diarrheas, etc., which a careful examination would have
shown to have been due to remedial causes.  On the other
hand, it cannot be denied that  irritability and even mod-
erate fever may be due to erupting teeth.
  Parotitis.—The parotid glands are those most subject
to disease. Acute epidemic parotitis (mumps) is described
under  Infections. Inflammation of  the parotid, usually
suppurative,  occurs  as  a complication or sequel of acute
infectious diseases  and of various  abdominal disorders,
such as typhoid, pneumonia, and colitis.  Chronic enlarge-
ments of the parotid occur but  are more rare.  The other

  1 Recently minute organisms, known as ameba?, have been found in
the pyorrhea pockets. 
148     DISEASES OF THE DIGESTIVE TRACT

salivary glands may likewise be involved simultaneously
with, or independently of, the parotids.
  Treatments.—Treatment  of all  these  oral  conditions,
aside from those due  to syphilis or cancer, consists pri-
marily in the proper  hygiene  of  the  mouth  and  teeth.
All patients  who are confined to bed, particularly those
with  fever,  should have the mouth and  teeth cleaned
after every feeding.  For this purpose some simple anti-
septic  solution  such   as  liquor  antisepticus   (diluted),
carbolic solution (1 to 200 or weaker), or boric acid solu-
tion should be applied with the aid of absorbent cotton
and an orange  stick.   If  there is  dryness,  glycerin  is
useful in  the form of  boroglyceride, glycerin and lemon-
juice, etc.  In pyorrhea the teeth should  be  freed from
tartar by a dentist and the pus pockets frequently swabbed
out with  peroxide  or  tincture of iodin,  or injected with
emetin.
  In  stomatitis  similar antiseptic  solutions  are  useful
and in the mercurial variety chlorate  of potash solution
(2  per cent.) is  very effective both for prevention  and
cure.  Ulcers should be touched with the solid stick of
nitrate  of silver; this  often has  a magical  effect.   In
Vincent's angina, ipecac1, iodine, and salvarsan solutions,8
powdered  copper  sulphate,  etc.,  have  been  employed
successfully.  The affection is obstinate.
  Lead poisoning, syphilis,  noma,  and cancer require
special treatment,  in many instances operative.

           DISEASES  OF THE ESOPHAGUS.

  Stricture and Tumor.—Inflammation of  the esophagus
or gullet does not usually give  rise to any  definite  symp-
toms,  or  at the most  to  a little soreness beneath the
sternum or to pain on swallowing.   It is  most common in
alcoholic  gastritis.   Corrosive  poisons, as  a  cause of
inflammation, will be  mentioned  below.  Dysphagia  is

  1 Wine of ipecac, 5 mils.;  glycerin,  7.5  mils.; solution of hydrogen
dioxide, 50 mils.; water to make 100 mils.  Local application. 
DISEASES OF THE ESOPHAGUS        149
the most common symptom referable to the esophagus.
This may be due to the pressure of a growth outside the
gullet, for example aneurysm. Occasionally an aneurysm
ruptures into the esophagus with resulting hemorrhage
and  death.  Sometimes  small  pockets, or  diverticula
opening out  of the esophagus, become filled with liquid
or semisolid food  and cause  obstruction  by pressure.
These diverticula are difficult to deal with, as they are
not readily accessible to operation.  Fortunately patients
are usually able to empty them by pressing on the neck
and are then able to swallow.
  Stricture from narrowing of the  esophagus itself is
almost always due to one of four causes:  (1) It may be
due  to  spasm  in nervous persons  in whom  it may be
induced by excessive acidity of the stomach contents, etc.
In these persons a  stomach tube is frequently checked
at the opening of the stomach but if patience is used and
the tube kept  in place,  the spasm after a time relaxes
and permits  the tube to enter the organ.  These patients
are frequently improved by the regular passage of sounds
or tubes and by general medicinal and hygienic treatment.
(2) So-called simple strictures of the  esophagus are due
to contracting scar  tissue,  resulting from inflammation.
Strictures  are  commonly found at the  narrower  parts
of the esophagus opposite the larynx and at the entrance
into the stomach.  They result  from the swallowing of
corrosive liquids such as  caustic soda or sulphuric acid,
or from injuries inflicted by bones and other hard objects
which  have  been swallowed.  When  caustic fluids have
been swallowed the inflammation may be  so  violent as
to lead to perforation,  edema  of  the lungs,  and even
death  before  stricture  develops.   Simple  stricture is
treated  by dilatation, by sounds  or special forms of appa-
ratus, or occasionally by operation.  (3) Stricture due to
syphilitic ulceration is also a common variety. Much more
rare are simple, tubercular, and typhoid ulcers.  The diag-
nosis is  made by the history and associated symptoms, or
by the  Wassermann  reaction.   Mercury and  potassium 
150     DISEASES OF THE DIGESTIVE TRACT

iodide are of great use in this variety.  (4) Cancer of the
esophagus occurs either high  or near the entrance of the
gullet into the stomach. There is usually a varying degree
of spasmodic obstruction in addition to the actual obstruc-
tion due to the tumor.  This accounts for the improvement
which is often seen from time to time in these patients.  The
malignant growths cannot often be successfully removed,
but the patient may survive for a surprisingly long  time
without great discomfort.  When the obstruction becomes
considerable  and emaciation  is marked, an opening  may
be made through the abdomen directly into the  stomach
and a tube sewed in, through which the patient may be
nourished.  This operation is known as gastrostomy.
   Treatment. — The  general treatment  of  esophageal
obstruction  consists  in the administration of a concen-
trated,  bland,  and finely  divided diet, including   such
articles as milk, purees made from milk, gruels, raw eggs,
etc.  Olive oil given prior to meals sometimes seems to act
both as a demulcent to allay irritation and as a concen-
trated nutriment.
  Hemorrhage.—Hemorrhage from the  esophagus, when
it occurs, is  commonly very profuse, being due, as a  rule,
either to rupture of an aneurysm or to esophageal " piles."
The latter occur in  cirrhosis of  the liver and will be
referred to under that head.  During life it is not always
possible  to   say  whether  the blood  comes  from  the
esophagus or stomach. 
CHAPTER  II.
DISEASES OF THE STOMACH.
Organic Diseases of the Stomach.
  Acute Gastritis and Gastra-en-
    teritis.
  Chronic Gastritis.
  Ulcer of the Stomach and of the
    Duodenum.
  Cancer of the Stomach.
  Pyloric Stenosis, Atony, and Dila-
   tation of the Stomach.
  Gastroptosis.
Functional  Disorders of the
   Stomach.
  Nervous Dyspepsia.
  Diseases of the stomach may be organic or functional.
In organic diseases there are distinct pathological altera-
tions, such as inflammation,  ulceration, malignant change,
etc., which are the primary cause of the disturbed function.
In the functional disorders  as the result of nervous dis-
turbances of various kinds,  a great variety of  symptoms
develops without any corresponding organic basis.  As
the result of prolonged functional disturbances secondary
organic changes may finally occur.  In many cases dys-
peptic symptoms are the expression of  disease in distant
organs—the  lungs, heart,  kidneys, etc.   There is  also a
close  interdependence  between diseases of the  stomach
and  diseases of other parts of the  digestive canal—the
intestines,  liver, and pancreas.
       ORGANIC DISEASES OF THE STOMACH.

  Acute Gastritis and Gastro-enteritis.—Acute  gastritis
and  gastro-enteritis  are  caused  by  overindulgence  in
food  or drink  (alcoholic beverages), by unsuitable  or
decomposed food, by infections, etc.  A very intense and
frequently fatal form of gastritis is due  to corrosive and
other poisons.  The symptoms of gastritis are: loss  of 
 152     DISEASES OF THE  DIGESTIVE TRACT

 appetite, nausea, vomiting of food and mucus, pain and
 tenderness in the pit of the stomach, and, if the intestines
 are also  involved,  general abdominal  tenderness,  colic,
 and  diarrhea.   In ordinary  cases  if  food is withheld
 for a day and afterward  a light diet is  given, recovery is
 rapid.  In the severer cases there may be excessive vomit-
 ing and purging, with fever and prostration.  Symptoms
 of this character are frequent  accompaniments of so-called
 "ptomaine"  or  food poisoning  and  may  occasionally
 prove fatal.   Ordinary acute  gastritis in adults is almost
 always  mild, but repeated attacks may lead to chronic
 gastritis.  In children in whom the symptoms are usually
 due to  unsuitable food, diarrhea is frequently  present.
  Treatment.—The  treatment, as  already  indicated,  is
 largely  dietetic.  Temporary starvation is often not amiss.
 In  infants the food may be restricted to albumen or barley
 water; in older children and adults to gruel, broth, softened
 toast, skim  milk, milk toast, rusks, arrow-root biscuits,
 and the like.  In some cases,  when the stomach is over-
 loaded, an  emetic may be administered, or better  still,
 gastric  lavage may be practised.   In children it is usual
 to  administer a  laxative  and, if necessary, to wash out
 the bowel.  Bismuth and other local sedatives  are useful
 to allay irritation in the stomach and to relieve diarrhea.
 In  the more severe cases  stimulation may be required.
  Chronic Catarrh (Chronic Gastric Catarrh).—The term
 chronic gastritis (gaster—stomach)  should be  restricted
 to  those  cases in  which  evidences  of  inflammation  or
 catarrhal change in the  stomach are  demonstrable; it
 should not be used as a synonym for chronic dyspepsia of
 all  varieties.  The  majority of chronic dyspepsias are of
 nervous  or  reflex origin  and  true gastritis is  relatively
 infrequent, a fact quite at variance with the common view.
 An  amusing popular etymology derives gastritis from "gas"
 and makes it equivalent to flatulent dyspepsia.  Chronic
 gastritis may occur as an  independent or primary disease
 or  it  may be  secondary  to other 'diseases, particularly
chronic  heart, liver, and kidney disease.   In these diseases 
        ORGANIC DISEASES OF THE STOMACH    153

chronic passive congestion of the mucous membrane  of
the stomach is an important factor in causing the catarrhal
condition.  The most important causes of ordinary chronic
gastritis are  alcohol, improper food,  and  bad  dietetic
habits.   Whisky,  particularly when taken undiluted on
an  empty stomach,  is the  leading cause.  Hot breads,
pastry,  fried foods, sweets, etc., doubly bad  if unskilfully
prepared, are  doubtless  important in  the  causation  of
gastritis.  Ice-water, iced drinks,  and ice-cream cannot
be exculpated, though if taken with discretion they may
not be  as harmful as they have been painted.  Irregular
meals,  hasty eating,  and insufficient chewing seem  to
me to be of more importance than the character of the
food.  Certain drugs (copaiba, e. g.) and  poisons of a
locally irritating  character are less usual causes.  Ulcera-
tion and  cancer  of the stomach itself,  as well as many
of the functional  states,  may ultimately be complicated
by  a greater or less degree of gastritis.
  The characteristics of gastritis are an increased secretion
of mucus and a diminished secretion of hydrochloric acid
and eventually of pepsin.   At first there may be an irrita-
tive and  excessive secretion of hydrochloric acid,  while
in advanced cases there  is  an  absence  of all secretions,
even  mucus, due  to atrophy of the mucous membrane.
The symptoms are loss of appetite, flabby tongue, belch-
ing,  slight  pain  and general epigastric tenderness after
meals, and constipation.  In the severe cases nausea and
vomiting  of mucus, particularly in the morning,  are the
rule.  Frequently the stomach  loses  tone and  becomes
moderately  enlarged  (atony).  The course of the disease
is chronic and the symptoms continuous though  aggra-
vated from time to time following indiscretions in food or
drink.
  Treatment.—The treatment consists of a careful restric-
tion of diet  and regularity in meals.  The following food
list, modified  from one prepared by Dr.  C. B". Worden
for  dispensary use, illustrates  the general  character of
the  diet for  a mild case. 
154     DISEASES OF THE DIGESTIVE TRACT

  Soups:  consomme,  bouillon,  beef, chicken, mutton,
oyster and clam broths, tomato, asparagus, pea and celery
purees.
  Meats:  chicken, turkey, squab, broiled  steak, roast
beef, lamb,  fish,  oysters, sweetbreads.
  Eggs: lightly  boiled, poached,  raw.
  Vegetables :  baked or mashed white potatoes, spinach,
asparagus tips, cauliflower,  green  peas,  lettuce,  young
lima beans, young string beans, stewed carrots,  celery.
  Cereals:  rice,  macaroni, oatmeal,  hominy,  wheat
preparations.
  Breads:  stale  wheat bread,  toast, zwieback,  pulled
bread, rusks, crackers.
  Fats: butter,  cream, grilled bacon, olive oil.
  Beverages: milk,  buttermilk,  weak  tea or  coffee
once a day, cocoa,  water moderately at meals and freely
between meals.
  If the teeth are carious they should  be  repaired  or
artificial ones substituted.   Lavage  is often  useful when
there is much mucus.  It should be given in  the morning
before breakfast and a teaspoonful of sodium bicarbonate
should  be added  to each pint of warm water (105° F.)
to facilitate the removal of the  mucus.  In other cases
lavage  with  nitrate of silver  solution (1 to  10,000  or
stronger) may be used.  Many patients get  along nicely
with hot water and alkaline powders taken before break-
fast.  The medicinal treatment  consists  of  nux vomica
and other bitters to promote appetite and secretions, dilute
hydrochloric  acid  to  supplement secretion,  or alkalies
(magnesia, chalk,  and sodium bicarbonate) to neutralize
excessive  acidity,  and bismuth  or  nitrate  of  silver  to
diminish irritation. Pepsin and other ferments are not of
much use, in spite of the popular prejudice in their favor.
  Ulcer of the Stomach  and of  the Duodenum.—Ulcers
of  the  stomach  and  of the duodenum  are considered
together, because  in  many  cases  it  is  impossible  to
determine  clinically on  which  side of the  pylorus  an
ulcer may be situated.  Formerly ulcer of  the stomach 
       ORGANIC DISEASES OF THE STOMACH    155

was considered to be much more frequent than ulcer  of
the duodenum, which was looked upon  as more or less
of a curiosity, but  the experience of abdominal  surgeons
has apparently demonstrated that ulcer of the duodenum
is more  common  than ulcer of the stomach.  Ulcer  is
common in middle-aged persons, but the symptoms are
usually most clearly manifested in young persons.
  Fig. 33.—Duodenal ulcer showing erosion of an artery in the base,
from  which fatal hemorrhage occurred:  S, stomach; D, duodenum;
A, artery; R, point of rupture.  (Lockwood.)
  Symptoms.—The cardinal symptoms of ulcer are pain,
localized tenderness, hyperacidity of  the  gastric juice,
and  vomiting of  blood.   The  time  at which the pain
develops depends  largely on  the situation of the ulcer.
If the ulcer is in  the body of  the stomach or near the
cardiac end, that is, near the opening of the gullet, pain
may develop very shortly after eating and may disappear
when the stomach is empty.  A sharply localized area  of
tenderness will be  felt in the middle of the epigastrium  or
slightly to the  left,  and there may  also be  tenderness 
 156     DISEASES OF  THE DIGESTIVE TRACT

 at the left of the lower  spine (tenth dorsal).   If the ulcer
 is near the pylorus,  pain will develop later in the course
 of digestion as the stomach is emptying itself.  In ulcer
 of the duodenum a gnawing pain (" hunger pain") becomes
 manifest  two,  three, or more hours after meals and is
 relieved by food.  In many cases of duodenal ulcer there
 may  be no distinct  pain and the condition  will only be
 recognized on the development of some threatening com-
 plication.  When careful routine examinations are  made,
 localized tenderness may be elicited, causing the diagnosis
 to be suspected.
   Both in ulcer of the  stomach and in  ulcer of the duo-
 denum, there  is usually  a  decided hyperacidity;  it  is
 possible indeed that the excessive acidity of the stomach
 may precede the ulceration and be a factor  in its causa-
 tion.
   Complications.—In typical cases of ulcer there is usually
 free  hemorrhage or hematemesis,  sometimes a pint or
 more.   The vomited fluid  is dark  red, usually clotted,
 and sometimes mixed with gastric contents.  The writer
 once  saw  a  pint  or more of clotted blood withdrawn
 through a stomach tube after a test-meal.  Fortunately
 this led to an  immediate  diagnosis of a hitherto unsus-
 pected  ulcer, and consequently to an operation  (gastro-
 enterostomy), and  the  permanent cure  of  the  patient.
 Hemorrhage, due to cirrhosis of liver, is in itself indistin-
 guishable from that  due to ulcer.   In pulmonary hemor-
 rhage the blood is bright red and  frothy.  In spite of its
 severity the hemorrhage in ulcer is seldom fatal, but is very
 liable to recur.  If the ulcer is situated near the pylorus
 or in the duodenum no blood may be vomited, but black,
 tarry  stools will be  a feature of the case (melena).   In
 many cases blood in the feces may be detected by delicate
 chemical tests ("occult" blood tests).
  Perforation  is particularly common in duodenal ulcer
 and it may occur in ulcer of the stomach.  The symptoms
 of this accident are frequently the  first evidences of
digestive disturbance of which the patient is conscious. 
ORGANIC DISEASES OF THE STOMACH     157
It is accompanied by intense pain, rigidity, and symptoms
of collapse and requires immediate laparotomy.   Many
ulcers heal with the production of scar tissue.  If this is
in the body of the stomach it may do no harm unless very
extensive.  Rarely a constriction may be produced form-
ing the so-called "hour-glass"  stomach.  If the scar is
at the pylorus  or in the duodenum, stenosis results, with
subsequent dilatation of the stomach.  A  case  of  this
sort is referred to in the discussion on  stenosis and dilata-
tion.
  Treatment.—The treatment of ulcer is either medical
or surgical.  Medical treatment consists  in absolute rest
in bed and relative starvation.  The patient is  nourished
(?)  for a number of days by nutritive enemata (e. g., six
ounces of peptonized milk and an egg every eight hours)
and nothing is given by the mouth  except, possibly, a
little  cracked ice.  An ice-bag or warm compresses may
be applied to the epigastrium.  When  the hemorrhage  has
ceased or  subjective  pain  no longer occurs, a very light
diet is gradually begun, at first consisting merely of milk,
gruels, and beef preparations; later, eggs and other semi-
solid  articles are added. After a few weeks the patient
may take a diet such as has been recommended for chronic
gastritis.   He is allowed to sit up only  when this no longer
causes gastric distress.
  Sometimes instead of adopting this routine the physi-
cian puts the patient on teaspoonful doses of iced milk or
beaten white of egg administered at fifteen-minute inter-
vals from  the  very beginning.  The quantity of the food
is gradually increased and the intervals of administration
lengthened.   This plan has the  advantage of causing
less anemia  and  loss  of strength,  and  of  avoiding  the
unpleasant rectal  feeding.  Convalescent  ulcer  cases
usually require iron  and other tonics.  Milder cases  are
treated by the ambulant method with a light diet, (prin-
cipally milk,  gruel, and eggs),  bismuth  subcarbonate in
large doses,  or nitrate  of  silver.  Severe hemorrhage is
treated by absolute rest, by the application of an ice-bag 
158     DISEASES OF THE DIGESTIVE TRACT

to the  epigastrium, by the  administering  of  morphin
hypodermically as well as  by adrenalin, and astringents
internally.   If  bleeding  recurs  constantly, operation is
indicated.  Gastro-enterostomy  with or without excision
of the  ulcer  is  usually  practised.  Operation is  also
demanded  in cases of  perforation  and  stenosis with
secondary dilatation of the stomach.
  Cancer of the Stomach.—Carcinoma is the only common
form  of tumor in  the  stomach, although sarcoma and
benign tumors may occur.   In a rather extensive experi-
ence I have seen only  one case  of each.   Commonly  the
cancer is of the hard or scirrhous variety, but soft cauli-
flower-like  growths are not rare. Sooner or later ulcera-
tion takes place in almost all cancers of the stomach with
oozing of blood and discharge of pus.  Free hemorrhage,
so frequent in ulcer is rare,  and  blood  when  vomited
has a dark appearance  resembling coffee grounds.  In
the stools blood is present in minute  amounts—"occult
blood."  The symptoms of the disease  depend in part
on the situation of the growth.  A tumor at or  near  the
esophageal opening sooner or later prevents the  entrance
of food into  the stomach and  gives rise  to esophageal
obstruction and  starvation.   A tumor  at or near  the
pylorus ultimately causes  obstruction at  that orifice,
retention and lactic-acid fermentation of the food, hyper-
trophy  and  dilatation  of  the  stomach (visible gastric
peristalsis), and vomiting.  The visible peristaltic con-
tractions represent an effort on the part of the musculature
to overcome  the resistance at  the pylorus.  They always
pass  from  left to  right and  are  seen even in normal
stomachs by the ar-rays.   A tumor of the body  of  the
stomach produces neither cardiac nor pyloric obstruction
and proves fatal  by the progress of the  disease,  by its
extension beyond the confines of the stomach, etc.  The
general symptoms of cancer of the stomach  are progres-
sive wasting, loss of strength, and  anemia ("cachexia"),
with  pain, tenderness,  hemorrhage, and  vomiting.   To
these  may be  added symptoms of metastasis  (that is, 
        ORGANIC  DISEASES OF THE STOMACH     159

the transfer  of the disease through  the  blood)  to  other
organs, and  particularly to the liver, and  the signs of
perforative peritonitis.
  The disease attacks persons in middle or advanced life,
and, as a rule, there is no history of preceding dyspepsia,
except in those cases which follow ulcer.  In the  latter
there is a history of recurring attacks of painful indigestion,
often with hemorrhage, varied by long  periods of well-
being.  Heredity seems  to be an important factor.  Men
are more frequently attacked than women.  The disease
is usually fatal within  two years.   The varieties which
obstruct the orifices  are the most rapidly fatal.
  Examination  of the  stomach contents in most cases
(except  those preceded  by ulcer) shows diminished or
absent hydrochloric  acid; in the pyloric cases there are
retention and lactic-acid fermentation.  The  white cells
of the blood are increased in carcinoma (leukocytosis).
  Treatment.—If the tumor is at the  cardiac end, obstruc-
tion finally gives the  patient no choice between starvation
and gastrostomy,  i. e.,  the formation  of a new entrance
into the stomach  from  the epigastrium.  This operation
is performed solely for the  purpose of feeding  the patient
and serves only to prolong life for a brief period. At each
feeding the  rubber tube which has been fastened in the
abdominal wall is connected to a funnel through  which
food is introduced.  This must be finely divided.  Some-
times the patient prepares his  own food by chewing it
and spitting it out.  This is supposed to satisfy his hunger
and to encourage the secretions of the stomach.  In the
pyloric cases, gastro-enterostomy, or the formation of an
opening between the stomach and intestine, may palliate
the patient's condition in a similar manner.  In early cases
excision of part of the stomach  may  result in  recovery.
Aside from  operation,  treatment consists in  a carefully
selected diet similar to that used for  chronic gastritis—
lavage,  bitters and  tonics, hydrochloric acid,  etc.   If
there is obstruction the diet will need to be finely divided
or  semifluid, or nutritive enemata will be required, e. g., 
160     DISEASES OF THE DIGESTIVE TRACT

6 to S ounces of peptonized milk every eight hours.  Salt
solution by the bowel (Murphy method) is of great value
in cases of obstruction and vomiting, to supply fluid to the
tissues.  In bed-ridden cases care of the mouth and teeth
and  general attention to the skin  will be of importance.
Hemorrhage rarely requires special  treatment.  Perfora-
tion, heralded  by  sudden pain,  rigidity,  and collapse,
will  require immediate medical attention  and  probably
laparotomy.
  Pyloric Stenosis, Atony, and Dilatation of the Stomach.
—These three conditions are more or less interdependent;
they may  constitute distinct  affections  in  themselves,
but  are  usually secondary  to  other conditions.   The
stomach is essentially a muscular  bag, with  great differ-
ences in  capacity according  to  demands made upon  it.
In hearty eaters and beer drinkers it may become greatly
enlarged  without losing its  tone;  this may  be called
hypertrophy of the stomach.  In atony the stomach walls
are relaxed so that the food is  not discharged as rapidly
as it should be.   Air and other gases which are normally
absorbed or rapidly passed on to the intestine or upward
into the  esophagus (normal eructation), collect  in the
stomach and cause distress and distention.  Occasionally
the gas may be  derived from  fermentation, but  this is
undoubtedly less  common than popularly supposed.  The
carminatives  probably act  by stimulating  the  muscle  of
the stomach to reject the superfluous air.   Simple atony
may occur as an independent affection and is also an
accompaniment  of gastroptosis and of  many forms  of
dyspepsia, particularly of the nervous variety.
  If there is moderate obstruction at the pylorus there
will be increase  in  muscular power to compensate for it
and  overcome it, and as  a  consequence the peristaltic
movements will become distinctly visible.  With increas-
ing obstruction   or stenosis  the  stomach  will dilate  to
accommodate the retained food.  Relief  from excessive
dilatation is obtained by periodic  vomiting.  The writer
recently had a  man  under his care who had vomited 
        ORGANIC DISEASES OF THE STOMACH    161

almost daily for years.  In this patient the stomach reached
the  symphysis  pubis and enormous  peristaltic  waves
could be  seen passing slowly from left to right,  like a
heavy "ground  swell."   In this case at  operation  an
obstruction due to the scar of an old ulcer was found.
  The principal  causes  of  stenosis may be enumerated
as follows: cancer of the pylorus, ulcer in  the neighbor-
hood of the pylorus with spasm  or cicatricial contraction,
adhesions due to gall-bladder disease, kinking due to dis-
placement of the stomach  (gastroptosis),  and congenital
hypertrophic  stenosis.  The  latter is a rare  affection seen
in infants and due to thickening of the circular muscle
at the pylorus. The principal symptoms are vomiting and
rapid and usually fatal  inanition.  The causes of hyper-
trophy or dilatation  of  the stomach  include the causes
enumerated  above, and  in addition,  simple  atony  and
enlargement due to overfilling.
  Treatment.—The treatment of stenosis is usually opera-
tive.  In the congenital form prompt operation is impera-
tive.   In  the cases in which spasm of the pylorus occurs
on  account of irritation by acid contents  or because of
the presence of adjacent ulcers, or as a reflex from gall-
stones or chronic appendicitis, relief may be obtained by
treatment of the primary disorder, operative or otherwise.
In  dilatation, in  so far as this is due to stenosis, the same
remarks hold true to a large extent, nevertheless palliative
treatment will often  give a certain degree of relief and
improve the chances  of a subsequent operation.  This
treatment consists in lavage, practised daily or oftener,
and in the  administration of finely divided and easily
digested foods.  Water may be administered by the bowel
(continuous  enteroclysis),  as the  amount that reaches
the intestine by the normal route in these conditions is
often small.   In some  cases rectal feeding is necessary,
though this is never more than a temporary resource.  In
simple  atony an effort  may  be made to  stimulate the
musculature of the stomach by large doses of nux vomica
or  strychnin, by the use  of electricity and by douches
      11 
162     DISEASES OF THE DIGESTIVE TRACT
against the  spine and the epigastrium, or even into the
stomach itself.   In hyperacidity, alkalies, such as chalk,
                    magnesia  and soda, may relieve a
                    spasmodic contraction of the pylorus.
                      Gastroptosis.—Splanchnoptosis  is
                    a term applied to downward displace-
                    ment of the abdominal organs.  Gas-
                    troptosis  refers particularly  to the
                    stomach, but in most cases it is asso-
                    ciated with "falling" of the kidneys,
                    of the colon, and even  of the  liver.
                    With these  displacements there  is
                    usually  associated a peculiar forma-
                    tion of  the  thorax, drooping shoul-
                    ders, wing-like shoulder-blades, flat
                    chest,  and  acute   epigastric   angle
                    (habitus enteroptoticus).  The con-
                    ditions  are thought by some to be
                    congenital and by others to  be the
                    result of poor nutrition (rickets) in
                    early childhood. Splanchnoptosis is
                    not a disease in itself,  but persons
                    in whom  it  is found lack resistance
                    and are prone to tuberculosis, neu-
                    rasthenia, and digestive disturbances.
                    Downward displacement of the stom-
                    ach or of other organs may occur in
                    persons  of normal build, and particu-
                    larly in women who have worked
                    hard and borne many children in
                    rapid succession.
                      In a case of gastroptosis, the ab-
                    domen is prominent below the umbil-
                    icus (Fig.  34), the walls are thin, and
                    the muscles poorly developed.  The
                    stomach  instead  of occupying the
normal area well above the umbilicus, assumes a more ver-
tical position and extends to or below the umbilicus, some-
Fig. 34.—Habitus  en-
  teroptoticus (p. 164).
  (Aaron.) 
ORGANIC DISEASES.OF THE STOMACH     163
times even to  the symphysis  pubis.  To  diagnose the
position of the stomach, water is sometimes  given and
the lower border of the stomach marked out by means of
  Fig. 35.—Position of stomach in ptosis as shown by the z-rays. Left,
patient standing; right, patient reclining.  In the vertical position the
normal stomach occupies a position nearly identical with that shown
on right.   (Hertz.)


the  splash.  More commonly the stomach  is dilated by
pumping air in  through a stomach tube, or by distending
with carbonic-acid gas (evolved in  the organ after the

           r—----------------------------.--------------------------------------
n    \     /''    m
Fig. 36.—Rose's belt.  (Lockwood.)
administration  of successive  doses of tartaric acid  and
sodium bicarbonate).   Under these conditions its position
is  evident to inspection or easily mapped out by percus-
sion.  The ar-rays  are the most satisfactory means of diag- 
164
DISEASES OF THE DIGESTIVE TRACT
nosis; they are also valuable for locating the colon which
is usually displaced in common with the stomach.  Patients
         Fig. 37.—Rose's belt as applied.  (Lockwood.)

with gastroptosis may suffer no ill effects, but with loss of
weight and lowered tone they frequently develop symp-
toms of atonic dyspepsia and complain of vague sensation 
   FUNCTIONAL DISORDERS OF THE STOMACH   165

of dragging, bearing down, etc.  They are relieved when
lying down.
  Treatment.—The  treatment of ptosis, per se, consists in
improvement of the nutrition (S. Weir Mitchell rest cure),
exercises to  develop the  abdominal muscles,  specially
fitted belts and corsets, and operations designed  to sus-
pend the stomach.  The most satisfactory support for tem-
porary use is the "Rose" adhesive-plaster belt, either in
its  original form  or variously modified.   Such  a belt,
renewed every three to six weeks according to the condition
of the skin, may be worn for many months.  A piece of
zinc oxide plaster, preferably spread on moleskin, approxi-
mately one yard long  and  seven inches  wide, is cut as
shown in Fig. 36.  The apex of the large piece (/)  is fixed
to the skin just above the pubis (shaved)  while the ends
are  carried  upward  and  backward around the  body.
During this maneuver  the abdomen is firmly supported
in the desired position by the physician's  hand placed
over the plaster.  The  remaining strips (27 and III) are
reversed before being applied and serve to keep the soft
parts from bulging  at the sides.  (Fig. 37.)  The associated
symptoms are treated as described elsewhere.

    FUNCTIONAL DISORDERS OF  THE STOMACH.

  Functional  disorders are usually  traceable to  general
nervous  disturbances  (neurasthenia), local irritation, or
reflex causes.  In sensory neuroses the stomach is unusually
responsive to painful  sensations; heavy food or  normal
degrees of acidity will produce sensations of weight, burn-
ing,  and distress (hyperesthesia), or intense paroxysmal
pain may develop  (gastralgia).  Gastralgia may  be  a
purely sensory phenomenon  (rare) or it may be a mani-
festation of local irritation, as in ulcer, or of reflex dys-
pepsia, as  in disease of the  gall-bladder  and appendix,
or of disease  in  distant  organs, as  in locomotor  ataxia
(gastric crises).
  The motor neuroses include excessive relaxation of the 
166     DISEASES OF THE DIGESTIVE TRACT

gastric musculature (atony)  and undue muscular irrita-
bility.   The  former causes  delayed expulsion of  the
ingesta (retention).  The latter is exemplified by nervous
vomiting,  nervous  belching,  and  hvpermotility.    In
nervous  belching  constant eructations  occur  quite in-
dependently of fermentation or atony.  In hypermotility
the food  is hurried on into the intestines very  soon after
it is ingested. This may set up diarrhea, etc.
  Secretory disturbances  are the  most frequent of all
and  include  hyperacidity  (hyperchlorhydria)  in which
an excess of  hydrochloric acid is secreted, subacidity in
which the secretion is diminished,  and achylia in which
the  gastric  juice  is  entirely  deficient without  obvious
or adequate  cause.   Hyperacidity  is usually  associated
with constipation and presents symptoms such as heart-
burn and acid eructation, one-half  to two or more hours
after meals, often only at night.  The patients are relieved
temporarily by  taking food, sodium bicarbonate,  etc.
In achylia with careful diet there may be no symptoms,
but  examination by  the stomach  tube  shows that the
stomach  empties  itself rapidly into  the intestine.   If
coarse, or even slightly decomposed food is taken, abdomi-
nal distention and diarrhea readily  occur  because the
food has not been broken up by digestion, nor the growth
of  harmful microorganisms prevented by the  antiseptic
action of  hydrochloric acid.
  Nervous Dyspepsia.—In  nervous  dyspepsia there  is
usually more or less derangement of  all the functions of
the stomach combined with the symptoms characteristic
of  mild neurasthenia.  The symptoms are manifold  and
are described in great detail by the patients.   The com-
monest gastric symptoms are belching, flatulence, nausea,
heart-burn,  fulness  and distress   (not severe  pain or
localized tenderness), and constipation.
  Reflex  or symptomatic dyspepsia  is most frequently
due to gall-stones, appendicitis, constipation, pulmonary
tuberculosis,  heart disease, Bright's  disease,  and preg-
nancy. Unless the physician is continually on his guard, 
   FUNCTIONAL DISORDERS OF THE STOMACH   167

he is liable to  treat  some grave  organic disease  as a
trivial dyspepsia. Persons who treat themselves, including
nurses,  are far more liable to fall into  this serious and
sometimes fatal error.  Indigestion is often the first and
only evident manifestation of nephritis and tuberculosis.
  The treatment of motor neuroses has been discussed
under Atony,  etc.   Sensory neuroses may  be treated
locally by sedatives, such as nitrate of silver and bismuth,
and   generally by bromides, tonics, massage, baths, etc.
Hyperacidity is treated by a bland diet free from coarse,
acid, spicy, or even "tasty"  foods.  Excess of starch is
to be avoided.  Atropin is used to check secretion, and
alkalies (sodium bicarbonate, powdered chalk, magnesia,
and  bismuth subcarbonate)  to  neutralize acidity.   Sub-
acidity and  achylia  are treated by dilute hydrochloric
acid, which in the former case stimulates acid secretion
and in the latter to some extent replaces it. 
CHAPTER III.
DISEASES OF THE INTESTINES.
Diarrhea and Enteritis.
  Infantile Diarrhea.
  Diarrhea in Adults.
Chronic Constipation.
Intestinal Obstruction.
  Hernia, Volvulus, and Intussus-
   ception.
Intestinal Tumors.
Stricture of the Rectum.
Hemorrhoids,   Fissures,
  Fistulas.
Appendicitis.
Diverticulitis.
  Diarrhea and Enteritis.—Diarrhea is one of the com-
monest symptoms of intestinal  derangement; it may be
functional or dependent on organic changes in the intes-
tines.  Anxiety or other emotion, the stimulus of a heavy
meal, or a sudden change  in the weather may, any  one
of them, be the occasion of a mild diarrheal attack.  The
effect of cold,  in the form of  an ether spray directed
against the  abdomen, is sometimes utilized to relieve
constipation, while  the  use of  the woolen  abdominal
band for the prevention of diarrhea in babies  and sus-
ceptible  adults is familiar to  all.   Functional  diarrhea
may be due  to toxemia.   Typical  examples are seen in
uremia and in certain infectious diseases.  The commonest
cause of functional diarrhea is the ingestion of indigestible
food.  Prompt removal of the offending material by purga-
tives and enemas affords relief.  An analogous form of
diarrhea,  sometimes acute and sometimes chronic, is
dependent  on  gastric disease with  absence  of  secretion
and consequent  imperfect preparation  of the  food for
intestinal digestion.
  Enteritis is  a  prolific cause  of  diarrhea; it  may  be
catarrhal or ulcerative.  The specific forms of ulceration,
due to dysentery, typhoid, and tuberculosis are considered 
DISEASES OF THE INTESTINES        169
elsewhere.   Ulceration  is  a  manifestation  of  severe
enteritis and colitis  in infancy and childhood; ulceration
of the colon is also  a common terminal condition in the
aged  or  in the subjects of  chronic disease.   Enteritis is
usually bacterial in  origin but chemical (including toxic)
agents may occasionally play a part.   Passive congestion
as seen in heart and  lung  disease is an important pre-
disposing cause.
  Enteritis is classified  according to the  portion of the
bowel primarily involved; thus there may be duodenitis,
enteritis,  colitis, enterocolitis,  proctitis,  etc.  Enteritis
is used in a general  sense and also specifically with refer-
ence  to  the  small  intestine.  Duodenitis (inflammation
of the duodenum) is supposed to be  one of the causes  of
catarrhal jaundice (q. v.). In this form of enteritis as well
as in  inflammation of the small bowel generally, diarrhea
may be absent.  The terms colitis and proctitis are applied
to inflammation of the colon and  rectum  respectively.
Involvement  of  this portion of  the intestinal tract  is
characterized  by the  passage of  mucus and  blood  and
sometimes by rectal tenesmus.  Very frequently  there is
more or less  general involvement of the whole gastro-
intestinal tract (gastro-enteritis).
  Infantile Diarrhea.—Diarrheal  disturbances are much
more frequent and serious in infants and children than in
adults. In artificially fed infants the  mortality from intes-
tinal  disturbances is extremely high, particularly during
the summer months.  In them the disease tends to recur
and  become   subacute  or chronic.   The  most  frequent
types of diarrhea in infants are: (1) acute dyspeptic diar-
rhea, (2) fermentative diarrhea and, (3) catarrhal or infec-
tious enteritis, and enterocolitis. Acute dyspeptic diarrhea
is caused by the ingestion of  coarse or otherwise unsuitable
food (unripe fruit), and usually yields to enemas, purgation,
lavage of the colon, or other measures, directed to the re-
moval of the  offending material.  Fermentative diarrhea
is brought about by bacterial decomposition of sugars,
either on account of the ingestion of excessive amounts 
170     DISEASES OF THE DIGESTIVE TRACT

or because of impaired digestive capacity  (congenital or
acquired).   The resulting acids act as laxatives  (irrita-
tion of the mucous membrane) and may lead to acidosis.
In mild  cases there is slight  fever, colic,  and  diarrhea.
The stools are thin and  often green, and may contain
undigested milk.  They  often cause  excoriation  of  the
buttocks.  In  the severer  cases  the movements  are
very  frequent  and the fever high.  Ultimately,  if  the
condition is unrelieved,  the  child becomes  prostrated
(subnormal   temperature),   apathetic,  and   shrunken
(excessive loss  of  water).  In this type of diarrhea  the
albumen milk  of  Finkelstein and buttermilk  mixtures
are especially'indicated.  The various types of infectious
enteritis  are commonly due to the dysentery bacillus.
They are most apt to  occur in the hot weather of early
and mid-summer.  The stools  are often offensive (decom-
position of protein) and in the aggravated cases contain
mucus, blood, and even pus.   The severe and neglected
forms may become subacute or chronic, and are accom-
panied by emaciation and prostration.  These cases  are
extremely difficult to feed, and relapse with the slightest
change in the diet.  The prognosis, except under the best
hygienic  conditions, is very dubious.  Cholera infantum,
fortunately a comparatively rare type of acute enteritis, is
characterized by fever, vomiting,  the passage of watery
stools, rapid wasting, and early collapse.
  Diarrhea in Adults.-—In adults  acute enteritis  is less
common,  and  is  comparatively  mild  as  a rule.  The
ordinary  symptoms are colicky pains, abdominal soreness,
and  the  frequent  passage of  semisolid or  liquid stools.
The discharge may contain mucus,  but seldom any  blood.
Uncomplicated  cases usually clear up in a few days.  The
severe fulminant form with vomiting, rice-water stools,
excessive thirst, rapid emaciation,  weak pulse, and sub-
normal temperature corresponds to cholera  infantum and
is known as cholera morbus.
  Chronic diarrhea in adults is not uncommon.  It may
be due to specific infections, such as dysentery and  tuber- 
DISEASES OF THE INTESTINES        171
culosis,  to toxemias such as uremia,  to  chronic inflam-
mation  and ulceration, to secretory disturbances in the
stomach, to nervous influences, etc.  Most of these causes
are alluded to  elsewhere.  The symptoms in enteritis
are not, as a rule,  characteristic of the several  under-
lying causes.  The latter must  be  sought out by pains-
taking clinical and laboratory studies.   In most varieties
the stools are of  a  thin  puree-like consistency and are
passed  without pain.  In  chronic dysentery there is
tenesmus (painful straining) and the passage of mucus
and blood.  In  mucous colitis there is an alternation of
constipation and diarrhea (see Constipation). Emaciation
and anemia are  features of most severe chronic diarrheas
but are particularly marked in tuberculous enteritis.
   Treatment of Diarrhea.—The  treatment of diarrhea in
adults consists in  the removal of the  cause when this is
possible, in temporary abstinence, or in restriction of diet
(see Gastro-enteritis),  and  in  initial  purgation.  These
measures are followed by antiseptics, astringents,  local
and general sedatives,  etc.   As examples of  such drugs
in common use  may be mentioned salol, beta-naphthol,
tannin, catechu,  kino, chalk,  bismuth,  paregoric, and
Dover's powder.
   In infants similar drugs are of value, but opium must
be used with caution or not at all.  Intestinal lavage is
often effective and is given by  means of a catheter and
a  small funnel.  The child should  be  placed on its  back
with the buttocks  brought to the edge of the bed or table.
The  latter should  be protected by  a  mackintosh,  so
arranged  as to lead the fluid into  a pail.  The catheter
should be introduced and then the  flow of water started,
after which it may be pushed in for eight to  ten inches.
The funnel should  not be  more than one or two feet
above the level  of the body, and a pint or more of fluid
may be introduced at a time.   As  portions are expelled,
usually with considerable force, washing is repeated, until
the fluid returns clear.  A variety  of fluids may be used
for the  purpose, such as isotonic salt solution, boric-acid 
172     DISEASES OF THE DIGESTIVE TRACT

solution, or a weak solution of nitrate of silver.  In patients
with symptoms indicative of acidosis or of great  loss of
water, physiological salt solution or sodium bicarbonate
solution may  be given subcutaneously or intravenously
(the latter usually intravenously).  In addition to these
measures fresh,  cool air and cleanly surroundings are of
great importance in the treatment  of intestinal disorder.
The removal of an infant  to the country or seashore may
cure diarrhea  which has persisted in the city in spite of
the most careful attention.
  The diet demands  the greatest care.  In  breast-fed
infants, water may sometimes be given before nursing to
dilute the milk, and abnormalities  of this secretion may
be corrected, if practicable, by attention to the diet and
exercise of the  mother.   Diarrhea in  breast-fed infants
usually presents no serious difficulties.   In artificially fed
infants  the dietetic treatment  will depend entirely  on
what  the  child has been  getting.   Usually, milk  should
be withdrawn at least temporarily, and albumen water,
sugar water, or gruel substituted. Subsequently albumen
(casein) milk,1 buttermilk, skimmed milk, whey, or simply
pure milk, properly diluted or modified, may be employed.
  The possible  variations of diet  are  too  numerous  to
allow of description, but stress should be laid on the
importance for prophylaxis as well  as for cure of a pure
milk supply.   In most of our large cities the local medical
societies  "certify" milk which  meets their requirements
as to purity  and  uniform  composition.  Such  milk is
relatively free from bacteria (not over  ten thousand per
cubic centimeter)  and except  in very hot weather  does
not need to be heated.   Ordinary market  milk, on the
other hand, if untreated, is frequently rich in  organisms
(as many  as  one  million per  cubic  centimeter).  The
number of bacteria is most important  as an index of the
care with which the milk has been handled.  Certified milk
is unfortunately too expensive for  general consumption,
1 See Malnutrition, p. 203. 
DISEASES OF THE INTESTINES        173
although the poor may afford it temporarily in case  of
illness.  An effort is being made to improve the general
milk supply, so that it may approximate this high stan-
dard.  Meanwhile commercial  pasteurization is being
demanded  for all  milk that  does not meet  the  highest
requirement.  This process,  if carefully performed,  is
usually effectual  in destroying harmful  bacteria, but  it
cannot be expected to purify milk which is already badly
contaminated, or to preserve it unless it is subsequently
iced.   The term "pasteurization" is applied to milk which
has been heated sufficiently to destroy pathogenic bacteria,
for example to 150° F. (range 150° to  167°) for twenty
minutes.  When the milk supply is dubious or the temper-
ature  of the  air  high, domestic pasteurization  can be
practised with advantage.   Complete sterilization necessi-
tates heating the milk to the boiling-point  for one-half
hour on three successive days.  Nearly sterile  milk may
be obtained by a single heating.
   Chronic  Constipation.—The average  healthy  person
has  a regular, formed evacuation of the bowels daily.
Perfectly normal persons may,  however, have two or per-
haps more regular movements a day,  or only  one every
two or three days.  In constipation,  on the  other hand,
movements occur at irregular  intervals; the  evacuations
are usually increased in consistency; sometimes  there is
an alternation of constipation and diarrhea. Stools in con-
stipation may assume  peculiar forms, ofttimes appearing
as small  balls  like sheep dung.  Band or  ribbon-like
movements may  occur in spasmodic constipation, but
may also be suggestive of  actual stricture, as from cancer.
In mucous colitis constipation alternates with diarrhea,
but the former is the dominant condition.  A  character-
istic feature  is the passage of  large masses  of mucus  or
cast-like formations with accompanying colic.
   Under simply constipation we  include only those cases
which are seemingly independent  of organic disease.  Two
forms are  usually described—the atonic and the spas-
modic. In one case the  constipation is due to undue 
174     DISEASES OF THE DIGESTIVE TRACT

relaxation  of the colon and  lack of irritability of the
rectum;  in the other there is excessive irritability and
spasm, delaying the  progress of the intestinal contents.
The latter type occurs particularly  in  neurotic persons
and is influenced by general treatment of the neurosis and
by certain drugs which relax the spasm of the intestinal
muscle, such as belladonna and hyoscyamus.  These cases
do not respond satisfactorily to the usual dietetic treat-
ment, as the coarse food may actually irritate the bowel.
   The causes of atonic constipation are very numerous
and only the most important can be mentioned.  As the
result of modern "improved"  methods of manufacture,
man}- of our  foodstuffs are offered in  such a  digestible
form and so free from waste material, that there is little
residue remaining to give  bulk to the feces and to stimu-
late the  peristaltic movements.   It is believed that this
lack of  pabulum checks the  growth  of useful  micro-
organisms,  which normally constitute  a  very consider-
able bulk of the feces and secrete substances which stim-
ulate  peristalsis.  For this reason  Graham  bread, rye
bread, oatmeal, shredded wheat,  green vegetables, root
vegetables, and fruits are often of value,  since they furnish
an excess  of  indigestible  cellulose.  Sometimes  bran,
variously prepared,  agar-agar  (or  vegetable gelatin),
liquid  petrolatum, and  other  unabsorbable  substances
are administered with the same idea in view.   The last-
named substance differs from  the rest in that it does not
favor  the  growth of microorganisms.   Aside from the
foods  which furnish "ballast," there are certain articles
which are  natural laxatives, in which  may be included
fats (including olive  oil,  butter, cream,  etc.), the  salts
and acids of fruits and vegetables, spices, and condiments.
  Another  factor of  even greater  importance is habit.
The mechanism of defecation is peculiarly susceptible to
training, and  is easily deranged by the slightest  irregu-
larity.   Women  are more apt to  be negligent in this
particular  for  trivial and insufficient  causes  than  are
men.  The arrangement of the modern "closet" does not 
           DISEASES OF THE INTESTINES        175

favor the most  efficient use of the abdominal  muscles.
In defecation the  normal  crouching  position  is much
more effectual, as it makes the line of force more direct
and  favors the  use  of accessory muscles.  Dr.  Howard
Kelly and others have suggested the use of a foot-stool
to overcome partially this objection, as there is no likeli-
hood of  a return to primitive habits.   This  topic bears
directly on the next cause of constipation, that is, impair-
ment of muscular  power,  from maldevelopment  (as in
gastroptosis),  from lack of exercise, from undue relaxa-
tion of the abdominal  muscles following multiple preg-
nancies,  and from injury to the rectal and perineal muscles
in childbirth.  Most of these causes are especially opera-
tive in women in whom constipation is so common as to
be almost the rule.   Here again there is much chance for
improvement  by exercises,  particularly walking, rowing,
and  special  abdominal movements,  by the fattening
or supportive treatment of ptosis,  and by the repair of
birth injuries.  Not to multiply causes we may finally
allude to  the  abuse  of  laxatives.   The homeopathic
physicians perhaps go too far  in their distrust of purga-
tives, but there  is no doubt that there would be  less con-
stipation if people paid more attention to diet and regu-
larity, and did not resort immediately to drugs to secure
relief from the  fancied dangers of constipation.  Many
persons  permit  their minds to dwell upon  the alleged
harmful  effects of  constipation  and  do not allow the
natural  forces a chance to assert themselves.  If the
bowel is completely emptied by a laxative,  there is no
oncoming column of feces to excite  the contraction of the
rectum on the following day and one  cannot expect the
normal rhythm to be reestablished.
   Treatment.—The curative treatment of constipation has
been largely covered in the discussion of the causation.
Simple  enemas  (soap  and water)   and suppositories
(glycerin, gluten, or the  home-made  "soap stick") are
harmless methods of inducing an evacuation of the bowel
if not too long continued.  They should be used  with the 
176     DISEASES OF THE DIGESTIVE  TRACT

idea of establishing a regular habit (infants).  In mucous
colitis  enemas consisting  of olive or cottonseed oil are
valuable.  One pint (more or less) of oil, warmed to blood
heat, should be slowly injected by means of a rectal  tube
and a funnel, the patient meanwhile lying on the left  side.
If possible the oil should be retained for several hours or
overnight.  Drugs properly play little or  no part except
perhaps to tide the patient along until proper habits  have
been established.  For this purpose cascara in some  form
is probably least objectionable.  The palliative treatment
includes a long list of laxatives too well known to enumer-
ate in detail.  The salines are particularly useful when it
is the aim to withdraw fluid and to reduce local congestion
as in heart disease, gall-bladder disease, and pelvic disease.
Podophyllin and rhubarb are  supposed to act especially
well on the  upper  bowel and aloes on the lower.  Senna
(compound licorice powder) is particularly useful in  piles
as it makes the movements soft but not loose.  The  more
drastic purgatives such as compound cathartic pills and
the like are  only suitable  in aggravated cases.
  Intestinal  Obstruction.—Obstruction  of  the  bowels
is a very serious  and often fatal condition which  may
at  times  be mistaken for obstinate constipation.  The
distinction is very important,  since purgatives  which are
indicated  in constipation, may be  extremely  dangerous
in obstruction.  In obstruction the lumen of the bowel is
shut off, from one cause or another, so that the contents
cannot pass; in acute obstruction, there is usually in addi-
tion strangulation, i.  e., cutting off  of the blood supply.
Chronic obstruction develops  insidiously, and  is usually
due to  tumors,  benign strictures (following ulceration),
and peritoneal  adhesions.  Acute  obstruction may  be
due to these  causes, but more frequently results  from
strangulated hernia, volvulus, or intussusception.
  Hernia,  Volvulus, and Intussusception.—Hernia may be
either external  or  internal.  A portion of the bowel is
caught either  in one of the external "rings" or in one of
the many normal or abnormal pockets or slits in the peri- 
DISEASES OF THE INTESTINES        177
toneum which invite such an accident.  At the point of
stricture the circulation is usually interfered with, so that
the loops of bowel which  have  been  caught,  become
swollen, congested, inflamed, or gangrenous.   Hernia may
occur at any age.  Another  cause of  intestinal obstruc-
tion is volvulus.  This  signifies a  twisting or rotation of
the intestines, with consequent obstruction to its lumen
or blood supply.  I have recently seen  a case in which
the greater part of the small intestine was tied in a com-
plicated knot, causing obstruction, gangrene, and death.
Volvulus occurs chiefly in the aged.  In infants and young
Fig. 38.—Intussusception.  (Park.)
children the  most  important  cause  of obstruction is
intussusception.  In this condition, which is probably the
result  of spasmodic contraction, one part of the bowel
above  becomes telescoped  into  the  part below, like  a
glove finger which  has been partially turned inside out.
This produces a " sausage-like" tumor.  Intussusception is
most common where the ileum joins the  ascending colon.
  Symptoms.—The  symptoms of obstruction are  those of
severe  prostration  or  collapse with vomitings constipa-
tion, paroxysmal pain, rigidity, distention,  and visible
peristalsis.   If the obstruction is high up the vomiting is
frequently  fecal.  The  constipation is usually complete,
     12 
178     DISEASES OF THE DIGESTIVE TRACT

but there may  be small movements or discharges of
blood and  mucus.   The  position and  direction of the
peristaltic movements sometimes indicate  the site of
obstruction.  The rapidity of development and severity
of the symptoms depend on the situation and complete-
ness of obstruction.  Obstruction high up is more rapidly
fatal than that low down.
  In rare instances the symptoms of obstruction may be
due to a functional spasm—dynamic obstruction.   Such
cases may be promptly relieved by a large dose of atropin
administered hypodermically.  In  obstruction  due  to
external  hernia or to a low-lying intussusception,  if the
patient is seen early in the disease, the bowel may some-
times be reduced by  manipulation.  In the majority of
cases  obstruction "spells" immediate operation.  If the
strangulation has existed for a short time only it may be
sufficient to relieve the obstruction, but  if the vitality
of the tissues has been impaired, a portion of the intestine
may have to be resected.  The  medical treatment, pre-
liminary to operation,  consists  in  the use  of  enemas,
lavage of the stomach, and other measures designed to
relieve distress or to clarify the diagnosis.
  In this connection,  we may mention another compara-
tively rare  condition which presents similar symptoms—
embolism or thrombosis  of one  of the larger abdominal
arteries  or veins.  The blocking  of one of the mesenteric
vessels causes intense,  agonizing pain, distention,  and
other symptoms suggestive  of obstruction.  As a result
of interference with the circulation a large section of the
bowel may become gangrenous.
  Intestinal Tumors.—Many forms of tumor occur in the
intestines, but we shall limit  our attention to the  com-
monest, which is cancer.   This generally leads to chronic
intestinal obstruction and its accompanying  symptoms,
In addition there are the usual  symptoms of cancerous
invasion—loss of weight and strength, progressive anemia,
and pain of varying degree depending on the part affected.
Any portion of the intestines may  be attacked by car-
cinoma, but the usual sites are the ascending colon, the 
           DISEASES OF  THE INTESTINES        179

 sigmoid, and the rectum.  In the latter situation  the
 obstruction may be felt on rectal examination.  In cancer
 of  the  colon and  sigmoid  a distinct tumor is usually
 palpable; the gut  above the tumor is  often thickened
 and spastic  and  peristaltic waves  may  be seen passing
 in the direction of the obstruction.  This hypertrophy is
 compensatory and is "designed" to force the fecal material
 through the  strictured intestine.  The stools are some-
 times  ribbon- or  pencil-shaped, but  this  appearance
 may  be produced  by  simple  spasmodic constipation.
 Other symptoms  are the passage of mucus, pus, or blood.
 If the tumor is low down, these may often be detected in
 the stools  by the naked eyes, otherwise  only by micro-
 scopic examination.
   Treatment.—The  treatment of cancer,  when  an early
 diagnosis has been made, is  operative—excision  of the
 growth.  In  advanced cases palliative measures are alone
 indicated.  These may include operations, e. g., the forma-
 tion of an artificial anus.  Sometimes it is possible to
 short-circuit  the  bowel and avoid the obstruction, with
 or without removal of the growth.  The medical treatment
 consists merely in ordering  food that will leave as little
 residue  as possible and in attending to the comfort of the
 invalid.
   Stricture of the  Rectum.—Syphilitic stricture of the
 rectum is relatively common, and produces  local symptoms
 not altogether unlike those of carcinoma.  The general
 cachexia is, however, lacking and the history and symp-
 toms of syphilis distinguish the affection.  The  Wasser-
 mann reaction affords an almost certain indication of the
 character of the disease, when it is otherwise in doubt.
  Hemorrhoids, Fissures, and Fistulas.—Hemorrhoids or
 piles are produced by the enlargement of the small veins
 in the rectal walls just above or below the sphincter.  In
 the latter case they are known as external hemorrhoids,
 in the former as internal hemorrhoids.  They are really
the same as  varicose veins and are produced  by causes
which promote local congestion;  constipation,  chronic
 liver disease,  and chronic heart disease.  In internal hem- 
 ISO     DISEASES OF THE DIGESTIVE TRACT

 orrhoids the  most prominent symptom  is  hemorrhage
 which may be  persistent  and lead to intense  anemia.
 Occasionally the piles may  be caught in the sphincter and
 strangulated,  with the production of great pain.   Exter-
 nal hemorrhoids appear as irregular  tags or ears about
 the  anal  opening.  From time  to time  they  become
 inflamed and painful.   Not infrequently these tags become
 distended with  large  blood clots.   They then appear  as
 red, rounded,  and extremely tender lumps,  like cherries.
 If an attempt is made to  reduce them into the  rectum,
 on the mistaken supposition  that they are prolapsed
 internal hemorrhoids,  the pain is aggravated.
   Hemorrhoids  are  treated  by  soothing  or astringent
 ointments or  suppositories, by attention to the bowels
 to prevent constipation or diarrhea, and by local applica-
 tions of cold.  Cleanliness is of great importance.  When
 hemorrhoids do  not yield to palliative measures, opera-
 tion is demanded.  For external hemorrhoids it may suf-
 fice to incise or turn out clots,  but the usual  treatment  of
 hemorrhoids consists in removal by ligation, cauterization,
 or excision.
  Fissures are narrow, linear ulcers in the region of the
 rectal sphincter  which either complicate hemorrhoids  or
 arise independently.   They cause  intense pain and slight
 bleeding with  every movement of the bowels. They are
 usually cured  by stretching of the sphincter muscle to
 prevent spasm or by touching with lunar caustic.
  Fistulas are deep sinuses at the side of  the  rectum
 which result from abscesses in this region (ischiorectal).
 They usually require operation, which consists in slitting
 up the sinus and packing with gauze.  They are common
 in tuberculous subjects.
  Appendicitis.—Inflammation of the appendix presents
 very distinctive  symptoms  which call  for separate con-
 sideration.   The appendix  is situated  at the tip of the
cecum, and  in certain lower  animals  (herbivora) is of
considerable size and of much importance in digestion.
In man it is  apparently a relic and  like other  unused
organs, particularly liable to disease.  The appendix con- 
DISEASES OF THE INTESTINES        181
tains a large proportion of  lymphoid tissue, similar  to
that of the  tonsils, and like  that  of  low vitality and
peculiarly liable to infection.   The blood supply is vari-
able and sometimes inadequate.  The lumen of the organ
is often narrowed or obliterated by adhesions, by  kink-
ing, by repeated attacks of inflammation, or by the lodg-
ment of foreign bodies.   If, as is usual, the obstruction is
near the cecum this interferes with drainage and in case
of inflammation  impedes  or prevents  the  discharge  of
inflammatory products.   These and other conditions favor
the frequent development of bacterial infections.   The
colon bacillus and the streptococcus are the common infect-
ing organisms, the latter being the more dangerous.
  Inflammation of the appendix may be acute or chronic.
The acute forms are the catarrhal, suppurative, gangren-
ous, and  perforative.   The  chronic  varieties  are the
catarrhal  and the obliterative.  Catarrhal appendicitis
tends to recovery and subsequent relapse.  Suppurative
appendicitis frequently  involves the peritoneal covering
and  leads to  local adhesions,  abscess, or general  peri-
tonitis. In the gangrenous form the appendix often per-
forates or sloughs off and sets up general peritonitis before
limiting adhesions have  had time to form.
  Symptoms.—The chief symptoms of acute appendicitis
are pain, tenderness, and rigidity.  The pain may at first
be general over the whole abdomen, but later will become
localized in the right side of  the lower abdomen.  Occa-
sionally it may be referred to the back or other situations.
The tenderness is usually sharply localized at McBurney's
point, below and to the right of the navel.  The muscles
of the affected side are rigid, and if an abscess has formed,
a mass may be felt.  There is moderate fever, the pulse is
rapid,  and the white blood cells,  if counted, are found
to be  increased.   The  bowels  are  usually  constipated
rather  than loose.   An  acute attack  of appendicitis may
subside in a  few  days,  but there is  usually some slight
tenderness remaining over the appendix, and attacks tend
to recur at irregular intervals.  At  other times instead
of clearing up, perforation and abscess  formation occur, 
182     DISEASES OF THE DIGESTIVE TRACT

and if the patient is "unoperated," death will follow from
peritonitis.  In  chronic  appendicitis there  is  usually
persistent, though slight, tenderness over the appendix,
and the thick and hardened organ  can  at times  be felt
through the abdominal wall.  Chronic appendicits is less
likely than acute to give rise to abdominal complications,
but is a common cause of chronic functional dyspepsia.
  Treatment.—The treatment of appendicitis is usually
by  operation.   Mild cases  frequently  recover  without
resort to  this measure, but recurrences are so likely to
take place and may be so dangerous to life, that operation
is almost always  called for.  The  operation in uncom-
plicated cases consists  in the  removal  of  the appendix
(appendectomy).  If an abscess has formed  it must be
drained, while if  general peritonitis has developed  free
drainage of the peritoneal cavity is necessary.  In chronic
appendicitis  the necessity  of operation  will be  largely
determined  by the severity of the dyspeptic symptoms.
The medical treatment of  acute appendicitis is usually
confined to rest in  bed, fasting, or strict limitation of diet,
cold local applications,  low enemata,  and enteroclysis.
Purgatives are contra-indicated.
  Diverticulitis.—Diverticulitis is  a name  applied  to  a
somewhat rare  inflammatory process, involving certain
pouch-like appendages  of the  small or large intestine.
Near  the end  of  the ileum  a finger-like diverticulum
(Meckel's) is occasionally found which bears some resem-
blance to the appendix, but is considerably larger.   This
is due to the abnormal persistence of a structure, normal
in prenatal  life.   Other  thimble-shaped protrusions are
found in the course of the large intestine, most frequently
on  the  left side.   The  symptoms  of diverticulitis  are
similar  to those of  appendicitis, but the pain,  etc., is
often  on  the left  side.   I recently  performed autopsies
on two  cases illustrating these  types, occurring within a
few weeks of each other and in the  same hospital.  The
treatment of the affection is surgical. 
CHAPTER IV.
DISEASES OF THE PANCREAS, LIVER,  BILE
       PASSAGES, AND PERITONEUM.
Diseases of the Pancreas.
  Pancreatitis.
Diseases of the Liver and Bile
   Passages.
  Jaundice.
  Gall-stone Disease.
  Cirrhosis of the Liver.
  Abscess of the Liver.
  Cancer of the Liver and Gall-
   bladder.
  Congestion of the Liver.
Diseases of the Peritoneum.
  Ascites.
  Peritonitis.
  Tumors.
            DISEASES OF THE PANCREAS.

  Pancreatitis.—Diseases of the  pancreas are  difficult
of recognition  because of their  rarity,  the deep-seated
situation of the organ, and the similarity of the symptoms
to those produced by disease of neighboring structures in
the upper abdomen.  They bear a close relation to gall-
bladder disease because the bile and the pancreatic juice
empty into the bowel by a common opening.   Obstruc-
tion of this  duct  by tumor  or  gall-stones may  cause
chronic pancreatitis, a condition often recognized by sur-
geons at the  operating table.  The presence of chronic
pancreatitis is suggested by an excess of fat and undi-
gested meat  in the stools, due to the exclusion of the
pancreatic  juice from the intestines.  Bile or infectious
material  may also gain  access to the pancreas, particu-
larly in cases with obstruction, and thus initiate an acute
hemorrhagic,  suppurative,  or gangrenous pancreatitis.
Acute pancreatitis is characterized by sudden agonizing
pain in the pit of the stomach,  vomiting, and collapse.
Death may occur in a few hours, or a few days.  In less
acute cases there is a coincident peritonitis.  Obstruction 
1S4   DISEASES OF THE LIVER AND BILE PASSAGES

of the bowel or perforation of a gastric or duodenal ulcer
is usually suspected.  At operation or autopsy, extensive
hemorrhage into the pancreas is found, with fat-necrosis
(destruction) throughout the abdomen, due to the escape
of the powerful digestive (fat-splitting)  secretion of the
pancreas.  In other cases  there  is gangrene  or  abscess
formation. Occasionally cases are saved by early opera-
tion.  Cancers, cysts, and other tumors, as well as  stone
may occur in the pancreas.

   DISEASES OF THE LIVER AND BILE PASSAGES.

  Jaundice.—Jaundice is a symptom  common to many
disturbances and diseases of the liver, such as congestion,
cirrhosis, cancer,  and gall-stone disease.  In jaundice the
skin, the whites of the eyes, the roof  of the mouth, etc.,
take on a yellowish color which may vary from a scarcely
perceptible lemon tinge to a deep olive hue.   Even the
serum  of the blood  is bile-stained.  In  negroes,  and to
a less extent in "whites" care must be taken not to mis-
take brownish-yellow deposits  of fat in the sclera for
jaundice.  The brown "liver spots" (chloasma), so com-
monly seen on the face, are quite distinct from jaundice,
though it is possible that in some  cases they may be
due to defective action of the liver.  Jaundice is frequently
accompanied by  severe  itching.   The pulse  is  usually
slow and there is  an unusual liability to hemorrhage
(tendency  to  bruising  and  purpura).   In pronounced
cases nervous symptoms not  unlike uremia may develop
(cholemia).  In obstructive jaundice, the bile cannot reach
the intestines and the stools are  of a white, clay color.
The urine, on the other hand, is deeply pigmented (orange-
yellow).  In non-obstructive or toxic jaundice, the stools
may be of normal color or deeply bile-stained.
  Causes.—Jaundice  is  common  in  the newborn  and
usually is not of serious significance; occasionally it may
be a manifestation of septic infection.  Septic or infectious
jaundice of adults (Weil's Disease) has recently been found 
DISEASES OF THE LIVER AND BILE PASSAGES   185

to be due to a spirochete.  It is characterized by fever,
vomiting, jaundice, and hemorrhages from the nose, bowel,
etc.  A small epidemic occurred in the British army in
Flanders; prior to  the war it was a  rare affection.  Jaun-
dice is not an uncommon complication of pneumonia and
in some  epidemics a large proportion of the patients are
thus affected. Catarrhal jaundice is a common affection
in young people.  It is commonly  associated with acute
duodenal catarrh,  or occasionally with a general gastro-
enteritis (vomiting, diarrhea, etc.).  The congestion and
swelling of the mucous membrane of the duodenum prob-
ably accounts for  the temporary closure of the orifice of
the bile duct in these cases.  In the beginning there may be
slight fever, malaise, coated tongue, epigastric distress, but
by the time the jaundice is fully developed the patient
may feel perfectly well. Clay-colored stools and  other evi-
dences of obstruction are  present.  The jaundice usually
lasts for several weeks or even months, but in  the latter
case some  more  serious  disease should  be  suspected.
Acute  yellow atrophy is a rare and rapidly fatal disease
characterized by increasing jaundice, vomiting, delirium,
and other  toxic symptoms.  Accompanying it  there are
hemorrhages into the skin and from all the mucous mem-
branes.  Fever is slight or absent.  At autopsy the liver
is small and fatty.
   Gall-stone Disease.—Gall-stone disease (cholelithiasis)
is an extremely common condition in middle-aged persons
and in those inclined to obesity  ("fat and forty").  It is
more common in  women than in  men.  It is probably
favored by  lack of exercise (sedentary habits)  and may
frequently follow  infection, particularly typhoid fever.
Gall-stones  are  usually accompanied or  preceded by
inflammation of  the gall-bladder  (cholecystitis).   The
stones themselves consist of an accumulation of bile salts
about some central nucleus, but may occasionally be cov-
ered with a rough whitish deposit of lime salts.  They are
more frequently of an olive or brown color, and may be
solitary or multiple (from two or three to several hundred). 
ISO   DISEASES OF THE LIVER AND BILE PASSAGES

In the latter case they are often nicely faceted, so that
they fit  closely together  and frequently completely fill
the gall-bladder.  If  they  remain  undisturbed  in the
gall-bladder there may be no symptoms, or merely slight
dyspeptic disturbances.  Reflex  gastric symptoms, how-
ever, may be severe, particularly  when there are large,
rough stones which cannot escape.  These excite inflam-
mation, local adhesions, or reflex  spasm of the pylorus.
The symptoms are those  of hyperacidity and retention.
Several hours  after  food (at  night)  intense  distress,
heart-burn,  and  water-brash supervene.   The  patient
gains relief by vomiting or by taking sodium bicarbonate.
With  these symptoms  there is  usually tenderness over
the gall-bladder and in the  back  (at the right of tenth
or eleventh vertebral  spine).  Smaller stones are prone
to escape from the gall-bladder through  the ducts  into
the intestines, exciting in their passage intense paroxysmal
or colicky pains.  These pains are referred to the gall-
bladder region and pass around  the  chest and up to the
right shoulder.   The stone is usually delayed more or less
in the  common duct and may be permanently impacted,
leading to slight temporary, or severe permanent jaundice
with the usual associated symptoms.  Sometimes a stone
acts like a ball-valve and causes intermittent jaundice. In
other cases suppurative conditions  of the bile passages or
fistulous openings into neighboring organs occur.   These
complications are often accompanied by fever,  sweats,
and chills.
  Treatment.—Gall-stone dyspepsia may be treated on the
same  principles  as gastric hyperacidity (q.  v.)  with the
addition  of special measures, such as the administration
of sodium phosphate or Carlsbad salt.  If the symptoms
are at all severe and persistent, operation affords the best
prospect of permanent relief.  Gall-stone colic is treated
by the hypodermic administration of morphin and atro-
pin, by local hot applications, etc.   If the stone becomes
impacted, early operation is advisable to prevent compli-
cations.  In cases with recurrent gall-stone  colic, opera- 
DISEASES OF THE LIVER AND BILE PASSAGES   187
tion is also indicated.  Opening of the gall-bladder (with
drainage) is  known as cholecystotomy; its removal as
cholecystectomy.  In choledochotomy  the common  bile
duct is opened  for the purpose of drainage or for the
removal  of stones.
  Cirrhosis of the Liver.—Atrophic cirrhosis is described
in popular parlance as "hardening of the liver."  This is
Fig. 39.—Liver, advanced cirrhosis; typical hob-nailed organ.
             A, gall-bladder.  (Hare.)
a more apt designation than the accepted medical term
since the liver is not always either small or distinctly
yellow (cirrhosis means  yellow)  in this disease.   "Gin-
drinker's liver" is also a good old term that is still appli-
cable if gin is understood to mean whisky.  There are
many forms of cirrhosis, but only two or three are of com-
mon occurrence,  to wit:  the alcoholic  (portal) type and 
INS   DISEASES OF THE LIVER AND BILE PASSAGES

its varieties, and the syphilitic type.  The former type
includes  fatty cirrhosis in which the liver  is large  and
fatty as well as rough and hard.  This is seen in immod-
erate beer drinkers  (Munich liver) and occasionally in
clironic tubercular patients.  Much more common is the
so-called atrophic type which is seen in those who indulge
in spirits to excess.  In this  type the liver is either large
(early) or  small  (in the  advanced stage),  yellowish in
color, and  very  hard and firm.  The surface is covered
with small granules or " hob-nails."  (Fig. 39). The spleen
is usually enlarged, and, owing to the interference with
the circulation through the liver (portal  vein and  its
branches), the abdominal veins are distended with blood.
This causes hemorrhoids, esophageal  piles,  enlargement
of the collateral veins on the  surface of the abdomen,  and
as a consequence of  these conditions, rectal hemorrhage,
vomiting of blood, ascites, etc.   In syphilitic cirrhosis the
liver is even more distorted  and irregular,  but  the chief
distinction is  in  the etiology.   True hypertrophic  cir-
rhosis is a comparatively rare disease.  It is accompanied
by severe jaundice and cannot usually be traced either to
alcohol or syphilis.  The description which follows applies
only to the common portal or alcoholic cirrhosis.
  Symptoms.—The symptoms of cirrhosis develop so grad-
ually that  the diagnosis can at first  be suspected only
from the habits of the patient.   The onset of this disease
is usually preceded by  a more or less prolonged history
of chronic  gastritis with  its typical symptoms—vomit-
ing of  mucus in the morning, anorexia, diffuse epigastric
distress,  and bowel disturbances.   Frequently there  will
be a history  of  intercurrent attacks  of acute gastro-
enteritis  with vomiting, diarrhea,  and sometimes jaun-
dice.   At this stage  the liver may be easily felt and is
somewhat tender.  The diagnosis  of the disease is  not
usually certain, however, until  the typical association of
anemia, ascites, and hemorrhages from the stomach (rup-
tured esophageal piles) settles  the nature of the case.
There  may be slight jaundice  revealed by the muddy 
DISEASES OF THE LIVER AND BILE PASSAGES   189

tinge  of the conjunctiva.   More  often the whites of the
eyes are unusually white and shiny.  With radical change
of habits the disease may be checked in the early stages,
and even after the development of ascites marked improve-
ment  is possible, but usually the  course is steadily down-
ward.  In the later  stages of the disease the  liver may
become so small that it is no longer palpable, but this is
by no means invariable.   After  tapping for ascites has
been  instituted, it must usually  be repeated at frequent
intervals.  In the  majority of cases the patient does not
long survive,  but occasionally, after a large number of
tappings, the ascites may disappear and the patient may
recover a moderate degree of health.  This favorable out-
come always suggests  that the disease may be largely  a
chronic peritonitis, but in some cases  improvement is due
to vascular adhesions,  with the development of adequate
collateral branches which relieve the circulation through
the diseased organ.
   Prognosis.-—The prognosis of cirrhosis of the  liver after
typical symptoms have once developed  is not hopeful.
Life is rarely prolonged more than two or three years.
At the present time  certain functional  tests  are  being
tried  out which may make an earlier diagnosis, hence  a
more favorable prognosis,  possible.  One of these tests is
concerned with the  ability of the liver to take care of
(metabolize) certain sugars, another is similar in principle
to the phenolsulphonephthalein test in kidney disease.
   Treatment.—Syphilitic cases should be treated in accord-
ance  with the  principles  laid down elsewhere.  In  ordi-
nary  alcoholic cirrhosis, alcohol should be forbidden, and
a bland  diet suitable for  chronic  gastritis  should be
ordered.  Purgatives and diuretics may be  prescribed to
prevent  or remove  accumulation of  fluid.  If there is
much fluid in the abdomen, it should be removed by tap-
ping  with a trocar  (see Ascites).  Operative  treatment
(Talma's operation, etc.) consists in opening the abdomen,
removing the fluid, and afterward attempting to estab-
lish a collateral circulation between the omentum or liver 
190  DISEASES OF THE LIVER AND BILE  PASSAGES
and  the abdominal wall,  with the purpose of relieving
the local congestion and consequent ascites.  This method
is occasionally successful.
  Abscess of the Liver.—Multiple abscesses of the liver
and bile passages (suppurative cholangitis) may occur in
neglected gall-stone disease  with obstruction and  infec-
tion, in suppurative appendicitis,  and in other abdomi-
Fig. 40.—Case of enormous ascites due to atrophic hepatic cirrhosis.
                       (Hare.)
nal inflammations.   The  condition  is  accompanied by
fever, sweats, and  chills, and  manifestations of pyemia,
and is almost invariably fatal.  Solitary abscess  of the
liver is usually a sequence of dysentery, and will be referred
to again in the consideration of the latter disease.  These
abscesses may be of considerable size, and are frequently
cured by incision and drainage. 
          DISEASES OF THE PERITONEUM       191

  Cancer of the Liver and Gall-bladder.—Cancer of the
liver may be primary, but is usually a sequence of cancer
in other localities, most frequently in the  stomach  or
colon.   The site  of the primary  disease is frequently
obscure during life.  The chief symptoms are persistent
and increasing jaundice, an irregular tender liver, ascites,
and cachexia  (anemia, emaciation,  and weakness).  The
disease is progressive and is not amenable to treatment.
Exploratory operation is at times  justifiable to  exclude
even the remote possibility of gall-stone disease, since the
latter can  usually be  relieved by operative measures.
Cancer may also begin in the gall-bladder and later extend
to the liver.  This variety is frequent in those who have
suffered from neglected gall-stone disease.
  Congestion  of the Liver.—Passive congestion of the
liver is due to failure of the circulation and the damming
back of the  blood into that organ.   This is a symptom  of
heart disease, with  loss of compensation.  The  liver  is
enlarged and  pulsating.   It is felt, however, to be  per-
fectly smooth, and returns to  approximately normal size
with the relief of the causal condition.   Acute congestion
with slight swelling and tenderness may occur in so-called
bilious attacks, catarrhal jaundice, etc.  This condition is
usually relieved by correction of the diet and laxatives.

          DISEASES OF THE PERITONEUM.

  Ascites.—Ascites is a term  applied to  an effusion  of
fluid into the peritoneal cavity.  If the amount of the fluid
is  at  all large the abdomen bulges in  the flanks, while
the intestines  are  floated forward.  On examination the
physician will  find dulness which is movable with change
of position, and a wave or fluctuation which is transmitted
through the fluid  from  one side of the abdomen  to the
other.   When the physician  is attempting to elicit the
latter symptom, he will usually ask the nurse to rest the
ulnar side of her hand on the middle line of the abdomen.
This is to prevent the transmission of a deceptive wave 
192   DISEASES  OF THE LIVER AXD BILE PASSAGES

through the abdominal wall itself.  Ascites is a symptom,
not a disease in itself.  It occurs in cirrhosis of the liver,
chronic heart disease, Bright's disease, etc.  Local causes
of ascites are simple, acute, and chronic peritonitis, tuber-
cular peritonitis,  peritoneal cancer, ovarian tumors,  etc.
The character  of the fluid  varies with the cause of the
ascites.  In diseases of the heart and liver, where it is
due  to simple  transudation or  leakage,  it is thin  and
watery; in peritonitis it is more or less syrupy or purulent;
in cancer it is bloody.  Rupture of one of the solid organs
(liver, spleen, kidney, or adrenal) or of an extra-uterine
pregnane}'' may cause massive effusion of blood into the
peritoneum.
  Treatment.—The  treatment of  the  last-named  cases is
essentially surgical, but they often appear to arise spon-
taneously and thus come under the eye of the physician
in the first instance.   Other effusions, whatever their
causes, frequently require removal by paracentesis.
  For tapping  the abdomen it  is customary to use a
simple trocar and cannula of moderately large size.  The
patient sits  on the side of  the bed or on  a chair.   An
area midway between the  umbilicus  and the symphysis
pubis, which  has  been  previously "prepared"  in  the
usual manner,  is made  anesthetic by infiltration with
cocain solution  or by freezing.  A short preliminary inci-
sion is made with a scalpel  and the trocar inserted by a
sudden twisting thrust.  As soon as the stilet is with-
drawn the fluid  spurts out freely and is received in  kidney-
shaped basins which are emptied from time to time into
a large container.  As the  force of the flow diminishes it
may be encouraged by the application and  tightening of
a many-tailed binder.  After the  operation  the puncture
is dressed with  a sterile gauze dressing and a firm binder
applied to prevent, so far  as possible, undue accumula-
tion of gas in the  intestines.  If leakage occurs from the
puncture it  is usually regarded as an advantage, rather
than  a fault of technic.  If the  patient  is unable to sit
up the fluid may be withdrawn  by syphoning,  using a 
DISEASES OF THE PERITONEUM       193
trocar  (Billroth's) provided with a side opening for the
attachment of the rubber tube and a stop-cock to prevent
the entrance of air when the stilet is removed.
  Peritonitis.—Peritonitis may  be  general  or localized,
acute or chronic,  primary or secondary, etc.  Acute,  gen-
eral, purulent peritonitis is usually  due to perforation  of
some one of the hollow  abdominal organs.  The most
frequent causes are perforative appendicitis, inflammatory
conditions  of the tubes and ovaries, and perforated  gas-
tric or duodenal  ulcers.  The principal symptoms of the
condition  are  vomiting,  pain,  and  tenderness in  the
abdomen, with rigidity and distention, effusion of fluid,
and  the absence of flatus.   The expression is  pinched,
the temperature moderately elevated, and the pulse small
and  hard  (wiry).  Leukocytosis  is usual.  The condition
is  extremely serious, but recovery may ensue, following
prompt operative treatment of the primary focus and free
drainage.   Acute localized peritonitis  may occur under
the same or similar conditions.  If suppurative it usually
terminates in a walled-off abscess which can be drained
with comparative safety.  When the inflammation is  of
less  severity the exudate becomes  organized with the
production of adhesions.
  Chronic  peritonitis may be due to tuberculosis  (q. v.),
to miscellaneous infections, or to unknown causes.  There
may be general  or local  thickening of the peritoneum,
adhesions,  etc.  Occasionally we see cases with involve-
ment of the peritoneum, pleura, and pericardium, which
seem to constitute  a special  disease (multiple serositis).
In tubercular peritonitis  brilliant results are frequently
obtained by  incision into the peritoneum and drainage.
Operation should be combined with the usual rest, fresh
air, and liberal feeding.
  Tumors.—Cancer, which usually  spreads from some
other tissue or organ, frequently  involves the peritoneum.
There are innumerable  small or large  nodules, scattered
over the peritoneum, omentum,  and mesentery, with an
extensive effusion which  may be syrupy or bloody.  T
     13 
194  DISEASES OF  THE LIVER AND BILE PASSAGES

have seen cases in which it was very difficult during life
to distinguish cancer from  cirrhosis with  ascites.  Sar-
comatous tumors may originate behind the peritoneum
and push forward into the abdomen.  They often attain
a great size and are spoken of as retroperitoneal growths.
Unlike cancer they may occur in young adults and  even
children. In a case recently under observation the patient,
a young man of twenty-seven, complained of nocturnal
attacks  of intense pain in the epigastrium which were of
recent onset.  The other findings—abdominal tenderness,
hyperacidity, and blood  in  the stools—suggested  the
possibility of duodenal ulcer.   At operation a sarcoma
was found at the right of the  spinal column.  This had
undoubtedly involved some of the spinal nerves and had
given rise to the deceptive pains. 
              PART VI.

DISEASES OF METABOLISM.
General Considerations.	Diabetes Insipidus
Principles of Metabolism.	Gout.
Food Values.	Rickets.
Diseases of Metabolism.	Scurvy.
Obesity.	Osteomalacia.
Inanition and Malnutrition.	Beriberi.
Diabetes Mellitus.	Pellagra.
  General  Considerations.—Principles of Metabolism.—
Metabolism ("change")  is the name applied to all those
complicated physical  and chemical processes occurring
within the living body,  by means of  which heat and
energy are liberated and nutriment  is assimilated and
built up into living structures, or on the other hand, effete
tissues and waste products are broken down and excreted
from the body.  The term is not applicable to changes in
the food which occur in the stomach and intestine before
absorption, or to alterations in the secretions and excre-
tions after they have escaped from the glands of the skin,
kidney, and gastro-intestinal tract, or from the alveolar
epithelium of the lung.
  The principal substances with which we have to do in
the study of metabolism are the proteins, the hydro-
carbons or fats, the  carbohydrates (sugars and starches),
water, salts, and oxygen.  In addition substances known
as vitamins, which seem to be essential to health or even
to life, are  found in minute amounts in a normal diet.
The absence of certain specific vitamins is the cause of
beriberi and possibly of  scurvy, pellagra, and other dis- 
196
DISEASES OF METABOLISM
eases.  With the exception  of oxygen which we absorb
from the air through the lungs,  all these  substances are
found in the food.  Protein is ingested in the form of
meat, the casein of milk and cheese, the gluten  of wheat,
etc.  Protein compounds  are  characterized by the  fact
that they all contain nitrogen.  They are an essential con-
stituent of  all the  organs and tissues.   An excess of pro-
tein in the food beyond that required for the repair of the
tissues is used  for the  production of heat and  energy.
The daily requirement of protein  may be illustrated by
an example.  A man of seventy kilos, or one hundred and
fifty pounds, at ordinary work, will  require from sixty
to one hundred and fifty grams  (two  to five ounces) per
day.  Ordinarily one hundred grams (three and  one-third
ounces) give a safe margin.
  The fats  are  either stored up  in  the  body (adipose
tissue) as  a reserve  or oxidized  (in familiar  language,
"burnt  up") with the production of  heat and  muscular
energy.   A man of the weight previously  mentioned will
require fifty to one hundred  and fifty grams of fat, ninety
grams (three ounces) being an average amount.
  The carbohydrates, which include  the  closely related
sugars and starches, under ordinary conditions furnish
the greater proportion of the heat and energy required
by  the organism.   A plentiful supply of  fat and carbo-
hydrate  (carbonaceous  food) is required  by those  who
undertake severe physical labor.   This is quite in oppo-
sition to the popular idea that meat in large  quantities
is essential  to those  doing  laborious work.  Our hypo-
thetical man will require from three hundred to six hun-
dred grams of  carbohydrate daily; four hundred grams
(thirteen and one-half  ounces)  is an average amount.
Water constitutes  nearly 90  per cent, of the human body,
so that a liberal supply is obviously  essential.   It must
be  remembered, however, that  most of our solid foods
contain a large  proportion of water.  The figures which
have been given refer to the dry weight of the foodstuffs.
The salts include such substances as common salt, which
in dilute solution (physiological)  bathes  all  the tissues, 
             GENERAL CONSIDERATIONS         197

calcium phosphate, to which the firmness and rigidity of
the bony  structures are  due,  and iron, which is a con-
stituent of the red blood cells.  Oxygen, which is absorbed
through the lungs,  is an essential agent in the chemical
changes which take place in living matter.
  The waste products of nitrogenous or protein metabo-
lism are excreted in the urine in the form of urea,  uric
acid, etc.   Part  of the protein, and practically all of the
fat and carbohydrate are "burnt up" and excreted from
the lungs as carbon dioxide.  Under pathological conditions
sugars and fats may not be  completely broken down, and
then they appear in the urine as glucose, acetone, etc.
  Food Values.—When  food is "burnt up"  or oxidized
in the  body  a  definite  amount of  heat (or  energy)  is
developed, which may be estimated quantitatively just as
in the case of an engine consuming  coal or gasoline.  It
is a familiar fact of physics that energy may be expressed
in  equivalent terms, either as work,  electrical  energy,
heat, etc.  We might express the energy of food by means
of foot-pounds,  or horsepower, but it is more  convenient
to make use of  the equivalent heat  units or calories.  A
"large" calorie is an arbitrary unit denoting the amount
of heat necessary to raise one liter of water one degree C.
(from 0°  to  1°).  The caloric  value of the various food
products  is  determined by burning them in a  special
apparatus.   For ordinary purposes, however,  we calcu-
late the caloric  values from the chemical composition by
means of certain  factors which  have been corrected to
adapt them  to the conditions found in the human econ-
omy.  These factors in round numbers are  as  follows:
protein, four; fat,  nine; carbohydrate, four.
  The method  of  calculation is  shown by the following
example:  One liter (one quart) of milk contains 40 grams
of fat, 35 grams of protein, and 45  grams of milk-sugar,
hence:
                   40 X 9 = 360 calories.
                   35 X 4 = 140
                   45 X 4 = 180
680 
198            DISEASES  OF METABOLISM
  Since heat and energy can be obtained equally well from
either  fat  or  carbohydrate, the proportionate amounts
of these foods may  be widely varied.  Except in exces-
sively  cold climates the  carbohydrates should predomi-
nate, as they are less difficult of digestion.  They do not,
however, yield as much heat, bulk for bulk, as fats.
Fig.  41.—The comparative caloric value of various foods.1
  1 Fig.  41  shows a few striking comparisons.  From left to right we
have white of egg and yolk of egg in equivalent amounts (100 calories);
beef  broth and olive oil, representing 12£ and 100 calories, respectively;
asparagus and figs, corresponding to 25 and 100 calories, and rice, raw,
boiled, and puffed, 100 calories being represented in each instance. Figs.
42 and 43 show a diet suitable for a young child.  In Fig. 42 we have a
breakfast consisting of orange juice,  cream of wheat, cream, sugar, milk,
roll, and butter, also a luncheon, consisting of milk and crackers.  In
Fig. 43 a dinner, consisting of scraped beef, baked potato, spinach, bread,
and butter, and a supper, consisting of milk and zwiebach.  The orange-
juice and spinach (as shown by the small tags) represent 50 calories, the
others 100 calories, so that by simply counting the units the value of
the  day's ration is found to  equal 1500 calories.  This diet  may be
modified, by taking simple fractions or multiples of the above amounts.
The graduated bottles are of eight to ten ounces capacity. 
GENERAL  CONSIDERATIONS          199
i	»i>- i			tv •'	'-
'. t'	1			1 f. 1	I
Fig. 42
Fig. 43 
LIQUID AND SOFT.
Description of articles.
Descriptions of portions.1
Exact measure.
Rough measure.
Grams.  I Oz., av.
Protein.

 grams.
 Fat.

grams.
Carbo-
hydrate
Milk, whole (4 per cent, fat)
Milk, skimmed (0.3 per cent, fat)
Buttermilk (0.5 per cent, fat)  .
Whey (0.3 per cent, fat)
Cream (IS.5 per cent, fat)  .
Butter (85 per cent, fat)
Sunar (granulated cane—powdered milk, malt,
  etc.)
Oatorbarleygruel(loz.oftheflourtoqt.ofwater)
Legume gruel (1 oz. of the flour to qt. of water)
Soda crackers (for use with milk) ....
Toast dried in oven (for use with milk) .

Egg............
White of egg (in glass  of water, lemonade, or
  beef extract).........
Beef (round) scraped       ......
Beef juice (pressed—Holt)......
Beef broth (Holt, mutton and chicken similar)
Olive oil (or cottonseed oil).....
Gelatin (1 pkg. gelatin, 5 lb. sugar, 2 qts. water)
Junket (1 qt. milk 2 oz. sugar)    ....
Hot custard (same with 4 eggs)   ....
Corn starch(lqt.miIk,2oz.sugar,loz.corn starch)
Rice pudding (1 qt. milk, 2oz. sugar, 3oz. of rice)
A glassful or 7 fluidounces
A glassful or 6 J fluidounces
A glassful or 6 J fluidounces
A glassful ("scant") or f> fluidounces
1$ tablespoonfuls or 5/6 fluidounce
1 teaspoonful (rounded)
2 teaspoonfuls (rounded)  of granulated, 1
 tablespoonful (heaping) of powdered
A glassful or 7 fluidounces
A glassful or 7 fluidounces
One cracker
1 thick (3" x 3" x \") or 2 thin slices (wt. as
 bread: 39 grams)
One average (weight includes shell)

Two average "whites"
Two small cakes
Two tablespoonfuls
Large cup or 8 fluidounces
One tablespoonful (even), 2/s fluidounce
7 tablespoonfuls, 3j fluidounces
8 tablespoonfuls, 4 fluidounces
5 tablespoonfuls, 2\ fluidounces
7 tablespoonfuls, 3j fluidounces
6 tablespoonfuls, 3 fluidounces
217
205
210
187
 26
  7
 13

218
217
  6
 23

 57

 49
 64
 40
250
 11
100
110
 83
100
 83
7.6
7.2
7.4
6.6
0.9
0.2
0.4

7.6
7.6
0.2
0.8

2.0
3.5
2.9
  7.1
  7.0
  6.3
  1.9
  0.6
-0.1
  0.0

  1.0
  1.7
  0.6
  3.6

  0.8

  6.0
 13.6
  2.0
  2.5
  0.0
  1.8
  3.6
  5.0
  3.3
  3.3
 8.7
 0.6
 1.1
 0.6
 4 8
 5.5
 0.0

 0.0
 0.0
 0.5
 0.5

 5.3

 0.1
 5.0
 0.2
 tr.
11.1
 0.0
 4.4
 5.1
 4.0
 3.3
10.8
10.4
10.0
 9.4
 1.1
 0.0
12.5

 5.2
 4.6
 4.4
20.4

 0.0

 0.0
 0.0
 0.0
 0.0
 0.0
11.0
11.7
 8.8
13.0
14.4
  1 Additional articles calculated in portions of 100 calories may be found in an article by Fisher, Journal of American Medical Association, 1907,
lxiii, 1316, or in "A Laboratory Hand-book of Dietetics," M. S. Rose, The Macmillan Company, New York, 1913. 
DISEASES OF  METABOLISM
201
  The accompanying  chart, arranged  for hospital use,
shows the caloric values of some of the commoner foods
as well as the amounts of protein, fat, and carbohydrate
which are contained in each portion.  The portions have
been  arranged, according to a  plan  suggested by Prof.
Irving Fisher,  so as  to yield  100  calories, or  simple
fractions, multiples, etc., of 100.
  If we recur to  our man of seventy kilos (one hundred
and fifty pounds), receiving one hundred grams of protein,
ninety grams of  fat, and four hundred grams of carbo-
hydrate, we find, as  shown by the calculation below, that
he  is getting in round numbers twenty-eight hundred
calories per day,  or forty calories for  each kilo of weight.
This is approximately twenty calories  for each pound.
                  100 X 4 =  400 calories.    V
                  90 X 9 =  810
                  400 X 4 = 1600
                           2810
   A  man at rest in bed will require thirty calories per
kilo or fifteen per pound, while a man at very hard labor
may  "burn up"  as much  as  sixty  calories per kilo or
thirty per pound. Infants during their first  year require
more than  twice as much  in  proportion as  adults at
ordinary work, e. g., eighty  to  one hundred calories per
kilo,  equivalent  to  forty  or fifty per pound.   This is
partly because of their rapid growth and partly because
of their  proportionately large surface.  The greater the
relative surface of the body, the greater the amount of
heat lost by radiation, which must be made up by increased
food  intake.  It is  for  this reason  that adults require
amounts of food  proportionate to their height  and build
(normal  weight), rather than to their actual weight.

             DISEASES OF  METABOLISM.
   Obesity.—We have  already seen that certain disorders
of the ductless glands,  and particularly  of  the  thyroid
and pituitary, may lead to obesity.  Loss of the function 
202          DISEASES OF METABOLISM

of the  ovary, as at the menopause or after operation, is
also believed to favor the deposit of excessive amounts of
adipose tissue.  The exact  action of these  internal secre-
tions is not known, but it is hardly reasonable to suppose
that their influence is in opposition to the  ordinary prin-
ciples of metabolism that have been mentioned.  Accumu-
lation of fat indicates  either that an excessive amount of
food has been ingested or that the expenditure of energy
has been diminished.   With  increasing weight another
factor comes into play, since in a heavy person the rela-
tive amount of body or radiating surface  is less than in
an emaciated individual and  therefore the loss of heat
is  proportionately diminished.  Obese  persons  are also,
as a rule, less active than  those of normal weight.  The
treatment of obesity consists therefore  either  in decreas-
ing the intake by food limitation or in increasing the outgo
by exercise, etc.  A man of seventy  kilos (one hundred
and fifty pounds) at moderately heavy work requires, as
we have seen, forty calories per kilo, or  a total of twenty-
eight  hundred  calories.  The problem, therefore, is  to
reduce the caloric value of  the food to a figure decidedly
below  the  requirements, while  keeping the exercise  at
the same level  as previously, or conversely to  maintain
the diet at a constant  level and to increase the exercise.
In practice  a combination of both  methods would  be
advisable.  As it  is  not the part of wisdom to reduce
the muscles or any of the vital organs, protein should
not be diminished below the ordinary requirements, but
the fat and carbohydrates, one or both, can be largely
limited.  A too  rapid loss of weight is  never desirable and
is  sometimes dangerous.  Many  diet  cures  have been
proposed, some of  which restrict  principally  the sugars
and starches, others the fats, etc.  It is  comparatively
simple,  however, to  arrange  such a regimen  for each
case with reference to individual  tastes or needs.  The
restriction of water which  is often advised, is not desir-
able because it interferes with proper elimination and is
moreover of doubtful efficacy.   Sweating by means  of 
DISEASES OF METABOLISM          203
hot-air or vapor baths also acts by withdrawing fluid, but
while it is not open to the same objections as the restric-
tion of water, it is usually only of temporary benefit,  as
water  is immediately retained to  replace that which has
been lost. Thyroid extract has been largely used to dimin-
ish weight and is  of unquestioned  value in myxedema,
for example,  but in other cases  is not  without  serious
drawbacks unless carefully watched.
   Inanition and Malnutrition.—Under ordinary conditions1
adults rarely suffer from  simple malnutrition without
definite underlying disease, but such cases have been com-
mon in Europe as the result of war conditions.  In  some
cases hard working, underfed persons developed a "famine
edema"  suggestive of heart disease.  In  infants, particu-
larly in those of bad heredity, acute inanition and chronic
malnutrition  (marasmus),  may  be brought about  by
improper, ill-balanced food and unhygienic surroundings.
The role of impure milk and of infection  in causing diges-
tive (intestinal) disturbances has already been emphasized.
In the cases now  under  consideration  the  difficulty  is
one of faulty metabolism.  One or more of the constit-
uents  of the food is badly assimilated or may even  be
toxic  to the  infant; fats and  sugars are  more often  at
fault than proteins.  In  a particular case the metabolic
balance  may frequently  be restored  by limiting the
offending  substance  and for  this purpose  numberless
expedients have been devised.  Thus whey, with cream,
may be used when the protein is to be reduced;  skimmed
milk or  buttermilk,  when the fat is chiefly at fault, and
ptotein  milk, when the sugar is the chief offender.2  The
   1 "Every physician now and then encounters a  case of inanition; it
may be an insane person, a cancer patient, a hysteric (or a suffragette)
suffering from complete exhaustion from lack of food, but never, until
1915, would any physician have imagined that in the twentieth century
he would  ever behold the spectacle of famine ravaging whole popula-
tions, recalling the famous plagues of Egypt and the lamentable pictures
described by our ancestors." (Guillermin and Guyot, Abstr. J. A. M. A.)
   2 Protein milk consists of the strained and finely divided curd, which
has been separated by rennet from a quart of milk, mixed with a pint
each of buttermilk and water. 
204          DISEASES OF METABOLISM

symptoms  of inanition  comprise digestive derangements
such as loss of appetite,  vomiting and diarrhea, and nutri-
tional disturbances such as pallor, weakness, loss of weight,
loose, wrinkled skin (senile expression), flabby muscles,
etc.  In severe cases nervous or toxic symptoms, restless-
ness, stupor, etc., may develop.
  Malnutrition,  both in adults and  children, is common
as a sequence of chronic disease.  The purest  variety is
that which occurs in benign stenosis (narrowing)  of the
esophagus, in which little or no food  reaches the stomach.
In chronic gastric and  intestinal disease sufficient  food
may be  introduced, but it is not properly assimilated.
In severe infections, such  as  tuberculosis  and in  malig-
nant  disease,  a  toxic factor  is  added, while in certain
forms of thyroid disease there  seems  to be an acceleration
of metabolism.
  In the treatment of malnutrition  in adults liberal but
not excessive  amounts  of  protein (seventy-five to  one
hundred  and fifty grams) should be  administered to sup-
ply material for the maintenance and repair of the wasted
tissues and organs.  Fats and carbohydrates, one or both,
should be given  in excess in order to meet the necessary
current demands for heat and energy, and to provide an
overplus  to be stored in the  form of  fat and  glycogen.
To our hypothetical  patient who normally would require
twenty-eight hundred calories, we must  supply several
hundred  extra.  One authority  states  that if one quart
(liter)  of milk, corresponding  to  six  hundred and  eighty
calories, is  given in addition to a diet which is otherwise
sufficient for a patient's normal needs, a gain of one and
one-half  pounds per week may be expected.  The effect
may be increased by fortifying the milk by additions of
cream and milk-sugar.
  In many cases of malnutrition, particularly in infancy,
it is not so much the quantity  of the food that  causes
trouble as the difficulty  in getting any food to agree with
the patient.  When the  mother's milk has failed or  been
discontinued, it  is important  and sometimes even abso- 
DISEASES OF  METABOLISM          205
lutely essential to obtain  a wet-nurse.  In cases which
have followed prolonged experimental feeding with pro-
prietary  foods,  rational milk  modifications  will  often
bring about recovery.  Mothers, on the advice of friends
and neighbors, frequently try a great variety of proprie-
tary foods, most of  which may be essentially the same.
If experimentation is to be carried out, it should be done
with an appreciation  of the composition  of the  food.
Fats, sugars, starches, and proteins most often disagree,
approximately in the order named, so that in the absence
of any diagnostic symptoms, each in turn may be restricted
or modified.
   Diabetes Mellitus.—In diabetes there is  a  disturbance
of the metabolism of  sugars and starches.   As we  have
seen, normal persons convert ordinary amounts of sugar
(less than  six or seven ounces at one time)  into heat and
energy,  or "warehouse" it, as fat or glycogen (in the
liver).  Other individuals, usually  gouty, obese, or alco-
holic, may show sugar in the  urine on an  ordinary diet.
These cases are readily controlled by moderate restric-
tion, and their condition is spoken of as glycosuria.  In
diabetes there is an  excretion of sugar when  starches
alone are taken, and in the severer cases even when the
diet is limited to fat and protein.  There seems to be a
more or less complete inability to burn up the ingested
carbohydrates, which are 'therefore excreted unaltered in
the form of glucose.  In severe cases as much as five hun-
dred grams (one pound) a day are lost in the  urine, corre-
sponding to two thousand calories.  To meet the needs
of the body the protein, even that of the tissues them-
selves, may be partly converted into sugar; this explains
in part  the rapid emaciation  and the presence  of sugar
in the urine when no sugar and starch are taken.  Finally,
 there may be a disturbance in the fat  metabolism with
 the formation of injurious fatty acids, leading in certain
 cases  to "acid  intoxication."   In the latter condition
 diacetic acid  and acetone are found in the urine. 
206
DISEASES OF METABOLISM
  Cause.-—The underlying causes of diabetes are numer-
ous, the most important being affections of the pancreas,
brain, and liver.  Diabetes is more common in men than
in women and in the well-to-do than  in the  poor.  In
young adults it is accompanied by emaciation and pursues
a subacute course.  In obese persons past middle life it
is more chronic and less fatal.  In this class of persons
the disease may be unsuspected until the urine happens
to be tested in a routine examination.  Other patients
come to the physician on account of skin complications,
particularly  itching, boils, and shingles.
  Symptoms.—The most characteristic  symptom of dia-
betes is the frequent  passage of large quantities of  pale
urine  (polyuria) of high specific gravity. If the case is
one of  diabetes, this will be found to contain sugar and
perhaps acetone.  The daily  amount  in extreme  cases
may be as  much as  ten quarts, with perhaps f>  per
cent, of sugar or in other words  a pound a day.  As a
result of the enormous excretion of water, there is severe
thirst,  harsh, dry skin, and  constipation.   The  great
waste of nutriment leads to increased  appetite,  emacia-
tion (in most cases), and weakness (in  women, cessation
of the menses).  The tongue is often dry and red.  Impor-
tant complications, not already mentioned,  are cataract,
neuritis,  tuberculosis,  gangrene,  and acid  intoxication.
One of the three last named is usually responsible for the
fatal outcome.  Acid intoxication is heralded by increased
amounts of  acetone in the urine, headache, vertigo, rest-
lessness, delirium, somnolence,  and coma.  The respira-
tion is rapid and deep ("air hunger")  and the breath is
said to have a "fruity" odor.  Acid intoxication is favored
by too prolonged adherence to a strict diet.
  Treatment.—The treatment  of  diabetes is largely die-
tetic.   It  is usual to prescribe  at  first  a diet practically
free from  sugar and starch (fifty grams or less).  If the
sugar  disappears (mild  cases),  measured quantities  of
bread or other starchy food are  added, taking care  not 
DISEASES OF  METABOLISM          207
to give enough to cause the reappearance of sugar.  Pro-
tein and fat must be given in large quantities to make up
the necessary food (caloric) value.  Saccharin may be used
for sweetening in place of sugar (two  or three  grains,
with an equal amount of sodium bicarbonate).
   If sugar does not disappear under the above conditions
(severe cases) a strict diet may be employed, but it must
yield enough energy to compensate for the sugar  that is
lost, otherwise the  patient will lose weight.  In patients
taking such  limited amounts of carbohydrate  and  such
an excess of protein and fat, the danger of acid intoxica-
tion is ever present and  the nurse should be constantly
on the watch for suggestive symptoms.  To diminish the
danger, starvation  or  green days are prescribed,  during
which the food is limited almost entirely to green vege-
tables, or an exclusive diet of  oatmeal is prescribed.  If
acetone and diacetic acid appear in the urine large doses
of sodium bicarbonate are administered by the  mouth or
rectum.   In the  actual presence of coma there is  little
hope, but large  intravenous injections of sodium bicar-
bonate solution  (2  to  5 per cent, in  physiological salt
solution) may be tried.
   Another method of treatment, for which  Dr. Allen is
largely responsible, is  based on the assumption that dia-
betes is the expression of a weakened function, and that
its manifestations may be avoided if the diet is kept well
within the  patient's tolerance.  Proteins  and fats  must
be restricted  as well as carbohydrates, which is possible,
since loss of weight, within reasonable bounds, is regarded
as rather  beneficial than otherwise.  The treatment is
initiated  by a period  of starvation,  which is continued,
sometimes with  remissions,  until the urine  is  free  from
sugar and acetone.  During this period water is allowed
freely, beef broth  and  whisky in measured  amounts.
When the urine  is sugar-free,  green  vegetables are cau-
tiously given, and then gradually other starch-containing
foods, until the amount of carbohydrate which the patient 
20S          DISEASES OF  METABOLISM

can tolerate, without the appearance of sugar in the urine,
has been determined.  Subsequently the protein and fat
toleration  is  similarly determined.   As  the  tolerance
usually improves under this careful regimen, retests may
be made from time to time, with the  object of allowing
the patient greater latitude.  Frequent examinations of
the urine for  sugar are  necessary to control this  treat-
ment.  These are made by  the  nurse  or  patient.  The
details of the Allen treatment and of the sugar test as
condensed by  Dr. Joslin, of Boston, are given on the fol-
lowing pages  (208-211).1
  Directions for the Allen Treatment.  " Fasting.—
Fast  until  sugar-free.   Drink  water  freely  and tea,
coffee, and clear  meat broth as desired.  In  Aery severe,
long-standing, and complicated cases,  without otherwise
changing habits or diet, omit fat, after two days  omit
protein and halve carbohydrate daily to 10  grams, then
fast.
  "Carbohydrate  Tolerance.—When the  twenty-four-hour
urine is sugar-free,  add  150  grams of  5 per cent,  vege-
tables, and continue to add 5 grams carbohydrates daily
up to 20, and then 5 grams every other day,  passing suc-
cessively upward through  the 5, 10,  and 15  per cent.
vegetables, o  and 10 per cent, fruits, potato, and oatmeal
to bread, unless  sugar appears or the tolerance reaches
§ grams  carbohydrate per  kilogram body  weight.
  " Protein Tolerance.—When the  urine has been sugar-free
for two days add 20 grams protein (3 eggs)  and thereafter
15 grams protein daily  in  the form of meat until the
patient is receiving 1 gram protein per kilogram body
weight, or if  the carbohydrate  tolerance is zero,  only
a gram per kilogram  body weight.
  " Fat Tolerance.-—While testing the protein tolerance  a
small quantity of fat is included in the eggs and meat
given.  Add no more  fat until the protein reaches 1 gram

  1 Cards (Forms J5 and J8) for sale by Thomas Groom & Co., 105 State
St., Boston, or  Joslin, Diabetic  Manual (popular), Lea &  Febiger,
Philadelphia, 
Strict Diet.—Meats, Fish, Broths, Gelatin, Eggs, Butter, Olive Oil,			
Coffee, Tea, and Cracked Cocoa.			
Foods Arranged Approximately According to Percentage of			
	Carbohydrates.		
vegetables			
(Fresh or canned)			
5%i	10%	15%	20%
Lettuce Tomatoes	Pumpkin	Green peas	Potatoes
Cucumbers Brussels	Turnip	Artichokes	Shell beans
Spinach sprouts	Kohl-rabi	Parsnips	Baked beans
Asparagus Water cress	Squash	Canned lima	Green corn
Rhubarb Sea kale	Beets	beans	Boiled rice
Endive Okra	Carrots		Boiled
Marrow Sorrel Cauliflower	Onions		macaroni
Sauerkraut Egg plant	Mushrooms		
Beet greens Cabbage			
Dandelion Radishes			
greens Leeks			
Swiss chard String beans			
Celery Broccoli			
FRUITS			
Ripe olives (20 per cent.)	Lemons	Apples	Plums
Grapefruit	Oranges	Pears	Bananas
	Cranberries	Apricots	Prunes
	Strawberries	Blueberries	
	Blackberries	Cherries	
	Gooseberries	Currants	
	Peaches	Raspberries	
	Pineapple	Huckleberries	
	Watermelon		
NUTS			
Butternuts	Brazil nuts	Almonds	Peanuts
Pignolias	Black walnuts	Walnuts	
	Hickory nuts Pecans	(English) Beechnuts	
			
	Filberts	Pistachios	40%
		Pine nuts	Chestnuts
                        MISCELLANEOUS
Unsweetened and unspiced pickle     Clams         Oysters
Scallops                            Liver          Fish roe
       30 grams (1 oz.)         Protein,
   contain approximately:      grams.
Oatmeal, dry weight  .   .   .   .  5.0
Cream, 40 per cent.....1.0
Cream, 20 per cent.....1.0
Milk........1.0
Brazil nuts......5.0
Oysters, six......6.0

Meat (uncooked, lean)   .   .   .  6.0
Meat (cooked, lean)  .   .   .   .  8.0
Bacon........5.0
Egg (one).......6.0

Vegetables 5% group    .   .   .  0.5
Vegetables 10% group   .   .   .  0.5
Potato........1.0
Bread........3.0

Butter........0

Broth........0.7

Small orange or J grapefruit    .   0
 Fat,
grams.
   2
  12
   6
   1
  20
   1

   3
   5
  15
   6

   0
   0
   0
   0

  25

   0

   0
 Carbo-
hydrate,
 grams.
  20.0
   1.0
   1.0
   1.5
   2.0
   4.0

    0
    0
    0
    0

   1.0
   2.0
   6.0
  18.0

    0
10.0
Calories.
   120
   120
    60
    20
   210
    50

    50
    75
   155
    75
 10
 30
 90

225

  3

 40
1 gram protein,      4 calories.
1 gram carbohydrate, 4    "
1 gram fat,          9    "
1 gram alcohol,      7    "
6.25  grams protein  contain  1
  gram nitrogen.
1 kilogram = 2.2 pounds.
30 grams (gm). or cubic centimeters
  (c.c.) = 1 ounce.
A patient at rest requires 25 calories
  per kilo body weight.
  ' Reckon available carbohydrates in vegetables of 5 per cent, group as 3
per cent., of 10 per cent, group as 6 per cent.
Consult the Chemical Composition of American  Food Materials, Bulletin
  No. 28, U. S. Dept. Agriculture, by sending 10 cents in coin to Superin-
  tendent of Documents, Washington, D. C, also Annual Report of the
  Connecticut Agricultural Experimental  Station, New Haven, Conn.,
  Food Products and Drugs, 1913, Part I, Section 1.—Free. 
210          DISEASES OF  METABOLISM

per kilogram (unless the protein  tolerance is below this
figure) but then add 25 grams daily until the  patient
ceases to lose weight or receives not over 40 calorics per
kilogram body  weight.
  " Reappearance of Sugar.—The return of sugar demands
fasting for  twenty-four hours or  until sugar-free.   The
diet is then increased twice as rapidly as before,  but the
carbohydrate should not exceed half the former tolerance
until the urine has been sugar-free for two weeks, and it
should not then be  increased more than 5 grams per week.
  "Weekly Fast Bays.—Whenever  the tolerance is less
than 20 grams carbohydrate, fasting should be practised
one day in seven; when the tolerance is between 20 and 50
grams carbohydrate, upon the weekly fast day 5 per cent.
vegetables and one-half the usual  quantity of protein and
fat are allowed; when the tolerance is between 50  and 100
grams carbohydrate, the 10 and  15 per  cent, vegetables
are added as well.   If the tolerance is more than 100 grams
carbohydrate upon weekly  fast  days the carbohydrate
should be halved.    (See preceding page.)

  "FORMULA AND DIRECTION'S FOR THE BENEDICT TEST.
    Copper sulphate (pure crystallized)   .  .  .  .    17.3 g.
    Sodium or potassium citrate.......173.0 g.
    S<idium carbonate (crystallized)1.....200.0 g.
    Distilled water to make........1000.0 c.c.
   "The citrate and carbonate are  dissolved together (with
 the aid of heat) in about 700 c.c. of water.  The  mixture
 is then poured (through a filter) if necessary, into a larger
 beaker or casserole. The copper sulphate (which should
 be dissolved separately  in  about  100 c.c. of water)  is
 then poured slowly into the first solution, with  constant
 stirring.  The mixture is then cooled and diluted to one
 liter. This solution keeps indefinitely.
   "For the detection of glucose in the urine about 5 c.c.
 of the reagent are  placed in a test-tube and 8 to  10 drops
 (not more) of the  urine to be examined are added.  The
1 One-half the weight of the anhydrous salt may be used. 
DIABETES INSIPIDUS
211
mixture is then heated to vigorous boiling, kept at this
temperature for one or two minutes, and allowed to cool
spontaneously.  In the presence of glucose the entire body
of the solution will be filled  with a precipitate,  which
may be red, yellow, or greenish in tinge.  If the quantity
of glucose be low (under 0.3  per cent.) the precipitate
forms only on cooling.  If no sugar be present, the solu-
tion either remains perfectly clear, or shows a faint tur-
bidity that is blue in color, and consists of precipitated
urates.  The chief points to be remembered in the use of
the reagent are (1)  the addition  of a  small quantity of
urine (8 to 10  drops) to 5 c.c. of the reagent, this being
desired not because larger amounts of normal urine would
cause reduction of the reagent, but because more delicate
results are obtained  by this procedure; (2)  vigorous boil-
ing of the solution after addition of the urine, and then
allowing the mixture  to  cool  spontaneously; and (3)  if
sugar be present the solution (either before or after cool-
ing) will be filled from top to  bottom with a precipitate,
so that the mixture becomes opaque.
   "It is often convenient to perform the test by placing
the tube containing the mixture of the solution and urine
in bubbling, boiling water, where it must remain with the
water actually boiling for five minutes."
  Medical  Treatment.—The medicinal treatment of diabetes
has little  rational  basis, but arsenic and  opium (codein)
sometimes seem to be of benefit.   Local pruritus (itching)
is common in women;  it may  be relieved by scrupulous
cleanliness and lotions or ointments of boric acid, phenol
(carbolic acid), menthol, etc. If gangrene occurs amputa-
tion is necessary, though often ineffectual or fatal.
  Diabetes Insipidus.—Diabetes  insipidus is  character-
ized by the passage" of large amounts of pale urine of very
low specific gravity,  containing  neither albumin,  sugar,
nor casts.   The quantity of urine is sometimes enormous
and thirst correspondingly severe,  but  the  disease is not
in itself dangerous to life.  In this disease the kidneys
are unable to retain the water  which is brought to them, 
212
DISEASES OF  METABOLISM
or in other terms, the kidneys are incapable of secreting
urine of normal concentration.
  Gout.-—Gout is a constitutional disease associated with
an  increase of the uric  acid in the blood, and  deposits
of uric acid in the cartilages and tendons and about the
joints.  In the acute form the great toe is  most frequently
involved, but many other joints may  also  be attacked.
In  the chronic form "chalky" deposits  are most often
seen near  the margins  of the  ears and about the small
joints  of the hands and  feet.  Many ailments of obscure
origin—joint  and muscle pains, sore  throats, dyspeptic
attacks, etc.—have been conveniently  attributed to the
gouty  or uric-acid diathesis, but up to the present it has
not even been proved that gout itself is due to uric acid,
though as  we have said, the two are closely associated.
Uric acid is derived from the nuclei cells and is therefore
abundant in glandular organs.  Ordinary meat (muscle)
contains comparatively little.   The amount of uric acid
can be reduced by  avoiding  articles like liver,  kidney,
sweetbreads, and, to a less extent, meats, peas, beans, etc.
But even if the patient lives  on milk,  eggs, starch, oils,
and other  articles devoid of uric acid, a certain  amount
can still be found in the blood  and urine.  This portion
is derived  from the  normal breaking down  of the body
cells themselves in consequence of ordinary wear and tear.
  Gout is  brought about by high living and a free con-
sumption of heavy wines and malt liquors. Lead  workers
are also liable to it.  Heredity is said to be an important
factor.   It is  traditionally frequent among the upper
classes  in  England,  but typical  cases,  either acute  or
chronic,  are rare in  this country.  It is  unusual to see
more than one  or two  cases a  year in a large hospital
service.  An attack of  acute gout  comes on suddenly,
often in the night, with  intense pain, usually in the foot
or great toe.   The joint is swollen, red  and shiny and
extremely sensitive, so that it is necessary to arrange  a
cradle  to keep off the weight of the bedclothes.  There
is usually little or no fever.  With or without cold appli- 
PLATE  V
Rachitis.
   Showing the euboidal shape  of the head, the thoracic deformity,
the beaded  ribs, the  protuberant abdomen,  the  enlarged  lower
end of  the radius.  (Koplik.) 
 
RICKETS
213
cations and other treatment, the intensity of the swelling
soon subsides but nocturnal exacerbations  may prolong
the attack for several days.  Recurring attacks  are com-
mon, induced by indiscretions of diet, excessive  drinking,
etc.  Chronic gout is characterized by knobby  swellings
about the joints of the fingers and toes, producing great
deformity.  It has nothing to do with arthritis deformans
which  is sometimes called "rheumatic  gout."
  Treatment.—From  what  has been  said  the dietetic
treatment is obvious.  Considering the comparative rarity
of the disease it would hardly be profitable to discuss the
treatment in detail.  It may be mentioned that colchicum
is supposed to have an almost specific effect in acute gout.
  Rickets.—The striking feature  in  the metabolism of
rickets is the inability to retain or make use of the  cal-
cium salts (phosphates),  the principal mineral  constitu-
ents of bones, in spite of the fact that there may be no
lack of them in the food.  The disease is due to  defective
food and bad hygienic surroundings.   It usually begins
in the first year in infants whose diet has been insufficient
or improper.  It occurs in breast-fed infants, but much
more  often in  those  who have been artificially  fed on
mixtures deficient in fat and protein.   Condensed milk
and starchy proprietary foods are principally responsible.
  The  earliest  symptoms are sweating about the head,
restlessness during sleep, persistence of the fontanels,  soft
spots in the skull  ("craniotabes"), delay in teething  and
walking, etc.  Later deformities  are noticed:  a  square
head  with  lateral  and  frontal bosses, beading  at  the
junction of the ribs and rib cartilages ("rosary"), lateral
grooves  in  the  chest,  pigeon-breast and funnel-breast,
lateral curvature of the spine, enlargements near the large
joints  (e. g., the  wrists), curvature of the long bones
(bow-legs and knock-knees),  etc. The abdomen is prom-
inent and the  spleen large.  Dyspeptic symptoms  and
constipation are usual.  It is believed by some that rickets
is answerable for ptosis of the stomach and kidneys, so
fruitful of symptoms in later life. 
214          DISEASES  OF METABOLISM

  In the second or third year when the diet becomes more
varied,  the  acute symptoms  usually clear up  and  the
deformities,  if not extreme, almost vanish in time.  Many
cases, however,  remain  in  which braces or subsequent
operative  procedures are required to correct deformity
(orthopedic surgery).
  Treatment.—The medical treatment  consists  in good
hygienic surroundings,  fresh  air (seashore), abundant
food,  with fats  (cream,  butter, and  olive oil),  and  the
administration  of phosphorus and  cod-liver oil.   The
latter is to be considered merely as a food.  In infants,
if a proper dietary or milk mixture is prescribed at the very
beginning, severe symptoms may often be  prevented. Many
cases are complicated by intolerance of fatty food, etc., so
that the disease  is warded off  with the greatest difficulty
or not at all.  If there is anemia, iron may be of benefit.
  Scurvy.—Scurvy  is a  metabolic disorder due  to  an
unbalanced  diet and  particularly  to the lack of certain
substances which are found in fresh fruit (oranges, limes,
lemons), green vegetables, potatoes, etc.  It was formerly
extremely prevalent in ships on long voyages, in prisons,
asylums, and almshouses.  About a century ago  it was
found that lime-juice would prevent the development of
the disease, so that its use was made compulsory, first, in
the English  navy, and later in  the  merchant vessels of
England and other nations.  As a result the disease has
become  rather rare.  Several years ago I happened to see
a severe case in a foreigner who had lived alone, subsisting
entirely on sausage, bread, and beer, with an occasional
doughnut.   Since  that  time  scurvy  has  become  quite
common in some of the  war-ridden countries of  eastern
and southern Europe.  Infantile  scurvy is by no  means
rare and almost always follows the exclusive use of steril-
ized milk and other cooked foods.
  In adults  the symptoms are  swelling and sponginess
of the gums, which are of a purple color and bleed  easily,
bloody urine, anemia, and subcutaneous  and subperiosteal
hemorrhages.  The latter are situated, as a rule, along  the 
                      BERIBERI                   215

tibia, at the front of the leg, and are accompanied by
tenderness.
  Scorbutic infants may or may  not be rickety.   The
baby cries  when  handled  and superficial swellings are
seen, particularly  near the  joints.  With a history  of an
unsuitable diet and the presence of  spongy gums the
diagnosis is easy.  The condition  may be mistaken for
rheumatism.
  Treatment.—The treatment is of the simplest.  In adults
an ordinary nourishing diet with orange juice and  green
Fig. 44.—Scurvy showing petechia? and extensive hemorrhagic infiltra-
     tion about ankle. The patient had spongy, bleeding gums.
vegetables rapidly restores health.  In infants a diet  of
fresh  milk and  orange-juice,  and  in older children the
same,  with the addition  of potatoes, accomplishes the
same marvellous results without any medicine whatever.
  Osteomalacia.—Osteomalacia is a rare nutritional dis-
ease, occurring most often in pregnant women.   In this
affection there is a peculiar softening (decalcification) of the
bones which permits of free bending and great deformity.
  Beriberi.—Beriberi is a form of multiple neuritis (q. v.)
which  is due in whole or  in part to nutritional disturb-
ances.   The part that infection may play in its etiology 
216          DISEASES OF  METABOLISM
has not been finally settled.   It is widely prevalent in
Japan and in our own Philippines, and is there attributed
to the use of polished rice.  The process of milling removes
substances which, though found only in minute amounts,
are vital to the organism.  These "vitamins" are abun-
dant  in a mixed diet, but are deficient in the exclusive
rice  diet of the tropics.   Cases have also  been reported
from  Newfoundland (!)  where the food of many of the
Fig. 45.—Pellagra.  (Siler, Garrison, and MacNeal-Thompson-
           McFadden Pellagra Commission.)
inhabitants is limited to salt meat, fish, and articles made
from flour (bolted).  Bolted flour is probably as unsuit-
able as polished rice, as an exclusive article of diet.
  The disease is subacute or chronic and is characterized
by the symptoms of multiple neuritis (including weakness
and paralysis of the extremities), with or without gener-
alized dropsy.  The  dropsical variety is known as  wet
beriberi, the  simple paralytic as dry. 
PELLAGRA
217
  Pellagra.—This  disease, which has long been  a well-
known scourge in northern' Italy,  Roumania,  and else-
where, has  assumed  great  importance  in this country.
In the Southern States it  vies  with hookworm  disease
in absorbing the attention of medical men.  Even in the
North cases have been reported from many if not all of
the States.  That a disease of such chronicity and appar-
ently such slight infectivity—if it be infectious at all—
should have spread so rapidly is astounding.  It is perhaps
more reasonable to  suppose that mild cases have been
present, but not diagnosed, for a much longer time. The
chief interest in pellagra has been in its etiology.   In the
countries  where the disease has been  most  prevalent
Indian corn (polenta) has long been a staple  article of
diet among the people.  Many attempts have therefore
been made to  trace this disease  to spoiled corn, but that
this cannot be the essential factor is shown by the fact
that many people develop  the  affection who have never
tasted Indian  meal.  At the present time some authorities
believe it to be due to a  poorly balanced, monotonous
diet,  lacking in certain essential elements, while others
attribute it to an insect-borne (sand-fleas) infection.
   The chief symptoms are cutaneous, gastro-intestinal,
and mental.  The  disease, except  in  occasional acute
cases, lasts for several years,  improving in winter and
getting worse in the  warm weather.  The eruption  is
found on the back of the neck,  on the backs of the hands
and forearms,  on the lower part of the legs, etc.  The skin
is pigmented and  reddened and presents an appearance
not  altogether unlike eczema.   The eruption  is  almost
always symmetrical.  The general symptoms are those of
recurrent digestive disturbances and diarrhea with weak-
ness and emaciation.  As the disease progresses, it is com-
plicated by confusion, hallucinations, mental depression,
etc.,  progressing  to complete dementia.   The ultimate
prognosis is bad, both as to recovery and improvement.
   Myalgia and arthritis deformans are discussed  in the
section on Diseases of the Muscles, Bones, and Joints. 
 
PART  VII.
DISEASES  OF THE  URINARY
   PASSAGES AND  KIDNEYS.
General Considerations.
  The Urine.
  Functional Tests of the Kidney.
  Miscellaneous Signs and Symp-
   toms.
  Catheterization, etc.
Diseases of  the Urinary Pas-
   sages and Kidneys.
  Incontinence of Urine  and Enu-
   resis.
Ascending and Descending Infec-
  tions.
Cystitis.
Pyelitis.
Stone.
Tumors.
Abscess.
Movable Kidney.
Nephritis and Uremia.
  General Considerations.—The Urine.—The daily excre-
tion of urine ordinarily amounts to one and a half to three
pints  (seven  hundred and fifty to fifteen hundred c.c),
but may vary widely even beyond these limits, depending
on the fluid intake, temperature of the  air, etc.  Anuria,
oliguria,  and  polyuria  denote pathological variations;
suppression, diminished and  increased  secretion respec-
tively. The urine is often temporarily suppressed in acute
nephritis, it is scanty in fevers, it is increased in amount
in chronic interstitial nephritis and in diabetes.  In col-
lecting twenty-four-hour specimens the bladder should be
emptied  at a certain hour and the specimen discarded.
All urine passed subsequently  should be saved until the
same hour the next day when the bladder should again be
emptied and  this final specimen added  to the total.  In
certain cases (chronic nephritis) it is advisable to measure
day and  night  specimens separately. The urine should
be kept in a cold place in a large clean bottle.  If conditions 
220  DISEASES OF URINARY PASSAGES AND KIDNEYS

require it powdered camphor (teaspoonful) is the best pre-
servative.  The bottle should  be frequently shaken after
each addition to distribute the preservative.  The specific
gravity is usually inversely proportional to the quantity:
in diabetes, on the other hand, in  spite of the increased
volume of urine, it is high.  The specific gravity, normally,
varies between 1015 and 1025 (water being taken as 1000),
the night urine being  smaller in quantity and higher in
specific gravity than that of the day.  In chronic nephritis
and  diabetes insipidus  the  specific gravity  is low,  in
diabetes  mellitus it is high.  The reaction to litmus is
usually acid (blue litmus paper is  changed to red), but
may be  alkaline  (red  litmus  paper is changed to  blue)
after heavy meals, or after certain  drugs such  as sodium
bicarbonate, etc.  In cystitis with ammoniacal decompo-
sition the  reaction is persistently alkaline.   The color
varies between pale yellow and a deep reddish yellow or
amber.  Perfectly normal urine is transparent with a deli-
cate floating cloud.  If the urine is alkaline a heavy white
precipitate  of phosphates soon separates out.  These may
be redissolved  by adding a little acid.   If the urine is
concentrated (reddish color)  and  acid,  or  the weather
cold, a profuse brick-red  sediment will settle on standing,
or minute garnet-like crystals  will be seen at the bottom
of the container.  These sediments consist of urates and
uric acid respectively and may be  dissolved by heating.
Patients  frequently attach great  significance  to  these
sediments,  believing that they are signs of serious disease.
As a matter of fact they  may  indicate nothing of impor-
tance (low  water intake, cold weather, etc.).  Permanent
sediment or cloudiness, not abolished by heat or acid, may
be due  to  suspended  bacteria (e.  g., in typhoid), pus,
blood, etc.   The final arbiter in these cases is the micro-
scope.  A  "smoky" or distinctly red color of the  urine
suggests  blood,  an orange  color,  bile  (yellow foam on
shaking), a green or blue color, drugs (methylene blue).
  Albumin in the urine  may  mean pus or blood and is
then usually small  in  amount.  The pus or blood may 
GENERAL  CONSIDERATIONS
221
originate from a focus of inflammation or irritation any-
where in the urinary passages, or may be an accidental
contamination (from the vagina).  For the latter reason
catheterization is sometimes necessary in doubtful cases.
If pus or blood is absent or casts are present, the albumin
may be assumed to be of renal origin.  It  may be very
scanty in chronic nephritis or the urine may boil solid
when the disease is acute or severe.  Albumin is  almost
constant in the congested kidney of heart disease  and in
fevers.  The simplest  test for albumin is by boiling.  A
little dilute (2 per cent.) acetic acid is added after boiling
to bring other substances (phosphates) into solution and
to aid in the precipitation of the  albumin.   Being  similar
to egg-white the albumin is coagulated by  the heat and
appears as a cloud or in large flakes. Another simple test
depends on the coagulation of the albumin by concen-
trated nitric acid.  About 2 c.c.  (f dram) of nitric acid
are poured into  a test-tube  and then an equal amount of
urine is allowed to flow in  slowly so as to form a layer
above the heavier acid.  A  white ring at the junction of
the fluids indicates the presence of albumin.
  The presence  of sugar (glucose) is most certainly indi-
cated by fermentation. A fermentation tube is filled with
urine to which a portion of a compressed yeast-cake has
been added, and is allowed to stand for twenty-four hours
in a warm place.  If  sugar is present, carbonic-acid gas
will collect in  the upper part of the  tube.  The most
commonly employed test is the one known as Fehling's,
which depends on the decomposition of an alkaline solu-
tion of copper sulphate by glucose.  The details of the
Benedict test (a simplified  "copper" test for sugar) are
found in the section on Diabetes.  Other substances sought
for in  an ordinary routine  examination are acetone and
indican.  The  former indicates  the possibility  of acid
intoxication, the latter suggests  putrefactive  changes  in
the intestine.  The diazo test is a color reaction  which
occurs in typhoid fever and miliary tuberculosis,  rarely
in other conditions. 
222  DISEASES OF URINARY PASSAGES AND KIDNEYS

  The microscopic examination  of the urine confirms the
presence of blood (red blood cells), pus,  bacteria, and the
various crystals and formless sediments. Epithelial cells,
characteristic of the various portions of the urinary tract
and  of the vagina, are  seen in  large  quantities.  The
most important objects are casts;  these are  pale, elon-
gated, and cigar-shaped  (hyaline casts).  They  may  be
covered with, or composed of,  epithelial cells, granules,
blood, or pus, depending upon the character and  severity
of the kidney affection (epithelial,  granular,  blood, and
pus casts).
   Fig. 46.—Hyaline casts from a case of acute nephritis.  (Musser.)

  Functional Tests of the Kidney.—The excretory function
of the kidney  is often determined by so-called functional
tests.  An explanation of the principle underlying the one
most commonly employed, the phenolsulphonephthalein
test, will serve as an illustration.   A known quantity (one
cubic centimeter)  of  the  special  dye is injected into the
lumbar muscles with aseptic precautions, by means of an
accurately graduated glass syringe.  If the kidneys are
normal the dye begins to be excreted wTithin ten minutes 
GENERAL  CONSIDERATIONS
223
and the greater part (80 per cent, approximately) is elim-
inated within two hours. In practice the urine is collected»
at the end of one hour and ten minutes and two hours and
ten minutes in separate portions, treated with an alkali
to bring out the color,  and compared with a color scale.
A catheter may be used if the patient is unable to void.
  Miscellaneous Signs and Symptoms.—The  blood-pressure
is elevated  in chronic  diffuse nephritis and in  uremia.
Systolic pressures of 200 to 300 mm. are not rare.  With
high  blood-pressure the pulse is of  high  tension.  The
technic of blood-pressure estimations has been described
under Cardiovascular Diseases (page 84).
   Cheyne-Stokes respiration, also  described  previously,
(page 114) is  peculiarly characteristic of uremia.   Some-
times the respiratory distress in uremia  closely simulates
asthma.
   The edema of kidney  disease differs from  that of cardiac
disease in  that it  is not  dependent upon gravity, but
appears first in  the eyelids rather than  in the ankles or
back.  It may  be general in the subcutaneous  tissues
without being excessive in the lower extremities.   When
cardiac dilatation takes place, the edema will partake of
the character of cardiac edema.
   The convulsions  which occur in uremia are of the epi-
leptiform type,  like  those described in the section  on
Nervous Diseases;  the  coma in  many instances  is also
indistinguishable from that of cerebral disease.  The con-
vulsions  which occur in pregnancy  and the puerperium
are designated as  eclamptic.  They are often, but  not
always, due to primary  kidney insufficiency.
   Catheterization, etc.—Catheterization  is  required  not
only  in  primary  disorders  of the  bladder and urinary
passages, but  also  in diseases of other organs (e.  g., the
brain and  spinal  cord).   Sometimes it is necessary  to
secure uncontaminated specimens for examination.   In
the case of women, the nurse will  frequently be  called
upon to  perform this operation.  On account of the lia-
bility  of  the  diseased  bladder  to  infection,  the most 
224  DISEASES OF URINARY PASSAGES A ND KIDNEYS

scrupulous care should  be used  in  the sterilization of
catheters  and  the disinfection of the  hands,  urethral
surroundings, etc.  The best technic includes, in addition
to ordinary disinfection  of the hands, the use of rubber
gloves.  The glass, or better, soft-rubber catheter, should
be boiled and well lubricated with sterilized olive oil or a
similar lubricant.  The urethra and the labia should be
thoroughly cleansed,  with or without the use of boric
acid or weak bichloride solution, and, while the labia are
separated with one hand,  the  catheter should be  intro-
duced directly  into the urethral opening without touch-
ing surrounding structures.  For this a good light is essen-
tial. The details of this operation are given in books on
nursing.  For males, woven silk or metal catheters may
be  needed  in  addition to  the  soft-rubber ones, though
the latter will  usually suffice in ordinary medical  cases.
A solid metal sound, curved somewhat less than a male
catheter, is  employed  to detect  the presence of  calculi
(clinking sound or sensation).   At the present day the
physician  also  has the .r-rays  at  his command for this
purpose.
  The  use  of the  cystoscope for  observing the  mucous
membrane of the bladder directly is seldom called  for in
simple  medical cases.    Catheterization of the  ureters,
which involves  the use of the cystoscope,  is more  likely
to be of use, e. g., in the determination of the particular
kidney involved by tuberculous disease.   If an examina-
tion of this sort were needed a  specialist would be  called
in for the purpose of making it.

DISEASES OF THE URINARY PASSAGES AND KIDNEYS.

  Incontinence  of  Urine  and Enuresis.—Incontinence of
urine is common in the aged and in organic nervous dis-
eases, as a result  of relaxation (perineal tears), partial
obstruction (stricture or enlarged prostate), and disorders
of innervation.   It may  also occur in the young as  the
result of malformations.  In infants it is a normal condi- 
    ASCENDING AND DESCENDING INFECTIONS  225

tion until the end of the first or second year.  Control
during the day is first acquired, later at night.   Even
normal  children  may wet  at night for several  years.
Enuresis or  incontinence of  urine in late  infancy and
childhood is usually nocturnal, but may occur during the
day as well.   The principal causes of the latter type of
enuresis  are  irritability of the  bladder  and functional
or organic disturbances of  the central nervous system.
It  may  be  persistent  or  permanent  in those of low
mentality.
  Treatment.—The treatment  of enuresis in children con-
sists in systematic training, "moral" suasion, restriction of
fluid at night, and the use of drugs, belladonna (atropin),
or  strychnin.  Atropin is  usually  the  most  effectual
remedy.   Masturbation,  phimosis, vaginitis, "worms,"
and other  local causes  should be corrected.  The child
should pass urine on going to bed and  again when the
parents retire.
  Ascending  and  Descending Infections.—The urinary
passages  comprise the following natural subdivision from
the kidney downward: the pelvis of the kidney, the ureter,
the bladder,  and the urethra.  As the affections of this
tract have a close connection one with  the other, the
general causes and symptoms which  they have in com-
mon may be  considered  together.  Chemical and mechan-
ical  factors are of great  importance,  particularly  when
combined with infection,  in the  etiology of  disorders  of
the urinary tract.  Mobility  of the  kidney may  cause
kinking of  the ureter, but this is usually acute and leads
to severe pain and colic rather than to chronic obstruc-
tion.  If  the  latter should occur from this cause or from
inflammatory stricture, a hydronephrosis may result, that
is, distention of  the  pelvis of the kidneys  with  urine.
Sometimes the obstruction is intermittent, and temporary
retention is followed by the passage of enormous quanti-
ties  of urine  (intermittent  hydronephrosis).  Stones  in
the kidney or  bladder  may cause mechanical irritation
and inflammation, and  in the ureter or urethra, pain  or
     15 
221)  DISEASES OF URINARY PASSAGES AND KIDNEYS

obstruction.  The commonest causes of chronic obstruc-
tion are  gonorrheal  stricture and hypertrophy of the
prostate.  If infection is added to obstruction the disease
travels upward, successively involving the urethra, blad-
der, ureter, pelvis, and kidney.   This is spoken of as an
ascending infection and is common in neglected cases  of
obstruction from all causes.  If the infection, on the other
hand,  begins in the kidney  or pelvis and travels down-
ward it is called a descending infection.  Infections by the
typhoid bacillus and tubercle bacillus are  commonly  of
the latter type, beginning above and travelling downward.
Infections by the gonococcus and colon bacillus, on the
other hand, usually begin in  the urethra or bladder and
travel  upward.  Even if these infections are at first pure,
they are  liable soon  to be associated with  infection by
the ordinary pus organisms  (mixed infection).   To the
latter are due ordinary septic symptoms such as irregular
fever, sweats, and chills.
  Cystitis.—Cystitis  (inflammation of the bladder) may
be due to overdistention, to sudden chilling, etc., without
obvious evidence of  infection, and to the general causes
which  have been mentioned. A fruitful cause of infec-
tion is carelessness in the use of the catheter, particularly
after pelvic operations, which may reduce the resistance
of the bladder.  So  much is this the case that at the
present day routine  catheterization  has  been  largely
abandoned by operators, with a greatly lessened incidence
of cystitis.  Simple cystitis is usually acute and tends to
spontaneous cure.   The infectious form, unless carefully
treated, is liable to become chronic.
  Symptoms.—The  symptoms suggestive of cystitis are
frequent and painful  urination, and the passage of urine
containing pus (pyuria).  If the  reaction of the urine  is
alkaline the condition is almost certainly cystitis; if acid
it may be pyelitis.  In chronic cases where there is doubt
the diagnosis may be made by direct  inspection of the
mucous membrane through the  cystoscope  or  by cathe-
terization of the ureters. 
PYELITIS
227
  Treatment.—The prophylactic treatment of cystitis is
of great importance.   The bladder should be emptied at
regular intervals, and false modesty or carelessness should
not be allowed to interfere, as it frequently does in young
girls.  Special care in the use of the catheter,  as  men-
tioned above, is essential.   Carelessness in this respect
should  not be  encouraged  by  the  stories of  patients
who have performed  the operation on themselves  for
years without precaution, as such persons have unusual
resistance which cannot be counted  on by the  nurse  or
physician.
  The medical  treatment of cystitis in the acute  cases
consists  in the  administration of mild diuretics such  as
potassium citrate, sedatives  such   as  belladonna  and
hyoscyamus, demulcents such as flaxseed tea and uva
ursi, and antiseptics such as urotropin and sodium ben-
zoate.   In subacute and  chronic cases local stimulants, of
which  oil of sandalwood and copaiba are types, are also
employed.  Local treatment consists in irrigation  with
salt  solution,  boric-acid  solution, silver-nitrate  solution,
etc.  It is conveniently carried out by means of a catheter,
a long rubber tube and funnel,  and a connecting  cannula.
Frequently it is desirable to retain the silver solution in
the bladder for  some time (e. g., twenty minutes).   For
this  purpose  as  well as for irrigation a two-day  catheter
is convenient.   Topical  applications through the cysto-
scope or operations fall within the domain of the surgeon
or gynecologist.
  Pyelitis.—Pyelitis or inflammation of the pelvis of the
kidney, may be due to an "ascending" infection,  to infec-
tion  through the blood,  to tuberculosis, or to stone.  In
many  cases  of  purulent  pyelitis the kidney  becomes
riddled with small abscesses or  is entirely disorganized
(pyelonephritis).   The urine in  pyelitis  is increased  in
amount, acid in reaction  and contains pus cells intimately
mixed  (cloudy).   The albumin  is more abundant than in
cystitis and there may be a few casts.  In the tubercu-
lous  variety admixture of blood is frequent and  tubercle 
228  DISEASES OF URINA R Y PASSAGES A ND KIDNE YS

bacilli are found (catheterized specimens). In mixed infec-
tions hectic fever with sweats is a characteristic feature.
There may also be tenderness over the affected kidney
(this is very usual in nephritis).  Pyelitis may be unilateral
or bilateral. By catheterization of the ureters it is possible
to determine whether one or both kidneys  are involved
and  what  degree of function is retained in each.  For
this purpose certain dyestuffs (indigo-carmin or  phenol-
sulphonephthalein)  are employed  as described  at the
beginning of the chapter,  but the urine is collected from
each kidney separately by catheterizing  the ureters.
  Treatment.—The  medicinal treatment is  on the same
principles as that of cystitis.  Local treatment  is only
possible  in exceptional  circumstances.  The  operative
treatment  includes drainage or excision of one  of the
kidneys.   The  latter operation is  only admissible when
the presence of a normal  organ on the opposite side has
been ascertained.
  Stone.—Stone in the kidney and in the bladder is not
as common in  this country as in  some  other lands.   It
is said to  be especially frequent in the Orient  (China).
Kidney stones  consist in  whole or in part  of uric acid,
phosphates, lime salts, etc., and are  of varying density.
They increase in size like snowballs by the  deposition of
successive layers of the various salts.  In the  kidney the
stones may be  large enough  to occupy the  whole pelvis,
accurately   fitting  every  little projection  and  cavity.
Such stones resemble branched coral.  With  or without
these larger masses there may be  numerous smaller cal-
culi, some of them small enough to find their way through
the ureter. The smallest fragments are called  gravel.
Kidney stones  may form the nucleus of large calculi in
the bladder or the latter may arise de novo.   In the
presence of stone in the bladder urination is  frequent and
painful, the distress being often referred to  the  mouth
of the urethra.   Sometimes the flow of urine is suddenly
checked by some change  in position  of the  stone  or the
urine may contain  blood.  The stone can sometimes  be 
TUMORS
229
felt by a metal sound or demonstrated  by the or-rays.
The treatment is surgical.
  The presence of  stone  in the kidney is suggested by
dull pain and tenderness in the loin, the passage of bloody
urine,  and attacks  of colic.  In colic, whether following
exertion or independent of it, agonizing  pain radiating
from  the lumbar region to the bladder  and urethra is
typical.  There is a constant desire to void urine.   With
these distinctly urinary symptoms are associated nausea,
vomiting, cold sweats, faintness, and collapse.  Finally,
after some hours the stone either passes or falls back into
the pelvis with prompt relief of the pain.  The stone may
become  impacted  in the ureter and lead to successive
attacks  of  colic, or cause  permanent  obstruction with
hydronephrosis.   In this condition the  urine is dammed
back distending the pelvis  and ultimately causing atro-
phy of the kidney.   After the attack the urine should be
carefully watched  for large calculi, or filtered through
gauze to catch minute stones.  The diagnosis of stone in
the kidney can, as a  rule, be confirmed by the x-rays.
Very small or soft stones may not cast a shadow.
   Treatment.—The treatment of stone  in the bladder is
surgical.  The calculus may be either crushed or removed
by perineal or suprapubic lithotomy.   Mild antiseptics,
sedatives, and diuretics may be used to relieve symptoms
or  to  improve the  condition of the urine.  In renal  cal-
culus  similar medicinal  measures,  a bland diet, and an
abundance of pure or distilled water may diminish the
frequency of acute attacks and perhaps limit the growth
of the calculus.   It is impossible to dissolve the calculus
by drugs.   In aggravated cases, if the age and condition
of  the patient permit, the stone (s) may  be removed by
incision into the kidney  (nephrotomy).  The attacks of
colic will  require  the free  use of morphin and atropin
hypodermically, hot stupes, hot baths, etc.
   Tumors.—Tumors of  the kidney also  cause  pain  and
bloody urine ("tumors, tuberculosis, stone").  The com-
monest variety is peculiar to the kidney and is known as 
230  DISEASES OF URINARY PASSAGES A ND KIDNEYS

hypernephroma.  It gives rise to metastasis, frequently
to secondary  growths in the  lung.  These tumors are
malignant and only amenable to operation in the early
stages.
  Large benign cystic tumors are of occasional occurrence;
these, though congenital in origin, increase in size in after-
life.  They  consist of a  great mass of cysts of all sizes
and of the most varied colors like a crazy quilt.   I have
removed a pair at autopsy either  of which would equal an
adult's head in size  (average  weight slightly  over four
pounds).  They  produce remarkably little disturbance
considering their size and the " apparent" total destruction
of kidney tissue.
  Abscess.—Abscesses in the neighborhood of the kidney
(perinephritic abscesses),  whether due to injury or other
causes, are frequently mistaken for disease of the kidney
itself.  They require  surgical treatment, that is,  incision
and drainage.
  Movable Kidney.—Movable kidney and floating kidney
are varying degrees of the condition designated as nephro-
ptosis.  In  this affection the kidney (usually  the right)
may be felt below the edge of the ribs, or it may  "float"
freely in the abdominal cavity.  Movable kidney  is asso-
ciated in many instances  with ptosis of the stomach and
colon (q. v.).  It may occur independently, however, in
persons who have lost a great deal of weight, or in women
who have borne many children.   If the kidney is freely
movable the ureter may become  twisted, causing  attacks
of intense  colicky pain  similar to renal colic.   Usually
floating kidney produces merely a sense of weight or a dull,
dragging pain in the lumbar region on the affected side.
  Treatment.—The treatment of the freely floating variety
with crises of severe pain should be surgical, fixation by a
suture, etc.  In the variety associated with gastroptosis
the measures recommended for that condition  usually
suffice and operation  is now only undertaken in rare and
aggravated cases.  The medical treatment consists in rest,
overfeeding, and support by belts or special corsets. 
NEPHRITIS AND UREMIA           231
  Nephritis  and Uremia.—Nephritis is commonly called
Bright's disease in  honor of the English physician who
first noted  the  association  of dropsy and albuminuria
with disease of the  kidneys.  We now know that dropsy
is not an invariable accompaniment of nephritis, though
a small amount at  least is usually to be detected (puffy
eyelids).  Under nephritis  we  include  one acute  and
several chronic forms.   The acute variety and the corre-
sponding chronic type are designated as parenchymatous
nephritis.  This term implies that the essential secreting
tissue is primarily  attacked.  At autopsy, in the acute
parenchymatous form, the kidneys are often swollen and
congested, in the chronic form, large and white.   Dropsy
is usually marked, and  albumin and casts abundant.  In
the chronic  interstitial type  the  supporting or connective
tissues were formerly thought to be primarily  affected,
though at present the process is more commonly considered
as diffuse, that is,  involving all the  structural elements
of the kidneys.  At autopsy, in typical cases, the kidneys
are  small,  shrunken, studded  with  minute cysts,  and
externally granular.  In  these  cases  dropsy  is  usually
slight, albumin scanty,  and casts few.  The quantity of
the  urine is increased,  and  the  specific gravity  low and
uniform, the blood-pressure is often high, and uremia is
common.  Somewhat similar  to this type is the kidney
of  arteriosclerosis,  and the indurated kidney resulting
from the long-continued passive congestion of  chronic
heart disease.  The "type"  cases of chronic nephritis are
distinctive  enough, but  intermediate  forms are  often
puzzling.  It is common, e. g., for an acute nephritis to be
engrafted upon a chronic form, so that features of both
may be present.
   In insufficiency of the  kidneys there is a retention of
certain substances in  the  blood,  which under normal
conditions are picked out and eliminated by these organs,
and also a resulting toxemia which expends itself largely
on the  nervous system. This state is known as uremia,
and is often the cause  of death in chronic Bright's dis- 
232  DISEASES OF URINARY PASSAGES AND KIDNEYS

ease.   Chemical examination of the blood shows a great
increase in the amount of urea and similar waste products,
but since urea  is not poisonous, when injected  subcu-
taneously, the cause of uremia is still in doubt,  in spite of
more  or  less constant research in  the seventy-five odd
years  which have elapsed since Bright first recognized the
signs and symptoms of nephritis.  Uremia may be acute
in its onset with convulsion and coma,  or subacute  or
chronic with headache, mental  hebetude, dyspnea, etc.
'ig. 47.—Large white (a) and small granular (6), contracted kidneys
(one-half natural size), showing relative size.   (Adami and McCrae.)
The commonest manifestations of uremia  are  headache,
vertigo, delirium, convulsions, transient paralyses, Cheyne-
Stokes respiration, asthma, vomiting, and diarrhea.  Very
often it is impossible,  without an  examination of the
urine, to distinguish a uremic from an apoplectic attack.
Rarely we see cases in which an uncontrollable diarrhea
is the most striking symptom.  Uremia is always a serious
development  in  nephritis, but recovery is  not  unknown
and patients frequently pass through a number of attacks
before succumbing.  The ultimate prognosis is bad. 
NEPHRITIS  AND UREMIA
233
  Acute Bright's disease is due to a multiplicity of causes,
and above all to the  poisons of  the specific infections.
In scarlet fever it  is  so common that  the  prophylaxis
against nephritis constitutes an essential part  of the after-
treatment of that disease.   Poisons, other than those of
the infectious diseases, such as cantharides and bichloride
of mercury, may have a selective action on  the kidney.
There remains a group for which we can at present assign
no better cause  than "cold." A form of acute Bright's
disease, known as "trench nephritis," has prevailed exten-
sively during the present war.  The onset is  sudden,  the
dropsy well marked, but the outcome is usually favorable.
  Acute  nephritis is  insidious in its onset;  edema and
pallor may be the  first symptoms to attract the  atten-
tion of the patient  or his family.  In addition there may
be slight  malaise, headache, nausea,  or other dyspeptic
symptoms and scanty, red, or "smoky" urine. On  exami-
nation the urine contains  a large quantity  of  albumin,
red blood cells,  and casts  of all varieties.   Pain  in  the
back is not a common manifestation, contrary  to popu-
lar opinion,  and is more  suggestive  of  lumbago, stone,
or abscess than of nephritis.   Severe cases  may begin
with convulsions (uremia)  or acute suppression of urine.
Though  relatively  acute  in comparison with chronic
nephritis, the disease is likely to last for  a month or two,
at least, and may  end by  death, by recovery, or  by  the
development of chronic nephritis.
  Chronic nephritis, of the  so-called parenchymatous type
(large white kidney), is very similar in its manifestations
but more prolonged in its course.  The face is pallid and
puffy, especially about the eyes,  and the subcutaneous
tissues are  edematous wherever  their  loose  structure
favors  the accumulation of fluid. The serous cavities
(pleura, pericardium, and peritoneum) often  contain free
fluid.  The urine resembles in a general  way that  of  the
acute variety with  an abundance of albumin and many
casts.
  In the  chronic interstitial form (granular, contracted 
234  DISEASES OF URINARY PASSAGES AND KIDNEYS

kidney) the symptoms  are quite difl'erent,  although the
types sometimes blend in a confusing manner.  This type
is seen in persons with cardiovascular disease, in the aged,
in the syphilitic, and in the victims of chronic poisoning
(lead and possibly alcohol).  Very often it develops with-
out apparent cause.  The course is very chronic; often
the first symptoms to attract attention may be headache,
failing vision, puffy eyelids, dyspepsia, "asthma," poly-
uria, itching  (eczema), or distinct uremic manifestations.
It is  very  common for patients to seek the  oculist or
stomach  specialist before any trouble is suspected.   In
the eye the former may detect hemorrhagic or albumin-
uric retinitis.  Frequently attention is called  to  the
patient's condition by the discovery of high blood-pressure,
which  is so common as to be almost diagnostic in this
disease.  In the fully developed form most or all of the
above symptoms may be present, the most characteristic
being  edema of the  eyelids,  failing vision,  high blood-
pressure, and the passage of large quantities of dilute
urine containing a faint trace of albumin and  occasional
casts.  As  the  disease progresses  hypertrophy and  dila-
tation of the heart with dropsy, or the manifestations of
uremia assume  a prominent place. In addition to cardiac
failure and uremia, apoplexy and pneumonia play impor-
tant parts as causes of death.
  Treatment.   The treatment for each of the various forms
of nephritis is similar in  principle, but variable in practice,
according to the conditions to be met.  The diet is gener-
ally arranged  to  spare the  eliminative powers of  the
kidney so  far as possible.  For this purpose  protein is
restricted and in severe cases  limited to the forms found
in milk and  milk products, eggs, and vegetables.   The
"extractives" which are found  in meats are thought to
be  more  irritating than the protein itself.   Difficulty in
the elimination of nitrogen  (protein) is most likely to
be  met in  chronic  interstitial  nephritis  and  in  threat-
ening uremia.  In parenchymatous nephritis with dropsy
there is more difficulty  with salt and water.  Some phy- 
NEPHRITIS  AND UREMIA
235
sicians  hold a  contrary view  and  administer sodium
chloride  (salt)  and  sodium  carbonate  by  continuous
enteroclysis.  The pure milk diet is valuable because its
proteins are easily dealt with and its content  of salt is
low.  On the other hand, if given in  quantities sufficient
to meet the caloric needs it contains  an excess of protein
and water,  e. g., four liters  (quarts) of  milk, yielding
twenty-seven hundred and twenty calories, contain one
hundred and forty grams of protein.   The latter is  more
than  twice  the minimum  requirement.   A  better  diet
would include a moderate amount of milk or cream with
cereal foods.  Except in the severest cases a diet can
easily be selected from the ordinary bill of fare.
  Elimination by  other channels than the kidney is fav-
ored  by a warm, dry climate,  suitable  clothing (wool),
warm baths, and laxatives.  The eliminative power of the
skin has been grossly exaggerated, but  may be encour-
aged  by Turkish and Russian baths, by steam, hot-air,
and electric-light cabinet baths, as well as by the ordinary
warm bath as mentioned above.
  Diuretics, apart from the less irritating varieties,  are
usually eschewed, except possibly in the late stages.   The
simplest are the citrates and acetates of potassium, the
most active, caffein,  theobromin, and theophyllin.  Bas-
ham's mixture, which combines tonic and diuretic qualities,
is an old favorite in this disease.
  In  the presence  of complications active measures  are
essential. In uremia, hot packs, hot-air, and vapor baths
serve as a  useful purpose.  Bleeding and intravenous
injections of salt solution are of great value in occasional
cases to eliminate and dilute the uremic poison. 
 
PART VIII.
DISEASES OF THE MUSCLES, BONES.
                 AND JOINTS.
Diseases of the Muscles.      I  Heberden's Nodes.
  Myositis and Myalgia.          Spondylitis Deformans.
Diseases of  the  Bones and   Monarticular Arthritis.
   Joints.                    Rheumatoid Arthritis.
  Acute Arthritis.               Infectious Arthritis.
  Chronic Arthritis.              Nervous Arthropathies.
   Arthritis Deformans.          Pulmonary  Osteo-arthropathy.
            DISEASES OF THE MUSCLES.

  Myositis and Myalgia.—Myositis implies an inflamma-
tory affection of a muscle; myalgia merely a painful one.
Cases  with demonstrable  inflammatory foci  are rare
except in surgical practice and in trichinosis (see Part X).
In the latter disease there is intense inflammation about
the invading parasites which  subsides after they have
become encapsulated.  Muscular rheumatism is the com-
monest disease under this  caption. We usually speak of
it as myalgia because of  the lack of  definite evidences
of inflammation.  Masseurs, however,  frequently find
indurated areas and nodules with tenderness in the mus-
cular and tendinous structures.  To these cases the term
myositis would apply.   Myalgias affecting certain groups
of muscles have received specific names, for  instance,
myalgia of the  lumbar muscles is called lumbago, while
intercostal "rheumatism"  is designated  as pleurodynia.
The  term rheumatism is  a bad one because  the  disease 
23S  DISEASES OF MUSCLES,  BONES AND JOINTS

has  no connection with  acute  articular  rheumatism to
which  the name should properly be confined.  It is well
to remember in this connection  that pain and tenderness
in the muscles and tendons are not  at all rare  in joint
disease (arthritis deformans).  So far as we know  myalgia
is a local affection independent of general disease,  induced
by  local chilling  and overexertion.  Some believe  that
there is  an underlying "rheumatic" or "gouty  habit."
Fibrositis is another  name  sometimes applied to "rheu-
matic" affections, particularly of the tendons, ligaments,
and their membranous expansions.
  An attack of lumbago,  to use the  commonest  variety
for an  example, begins suddenly with  intense cramp-like
pain in  the  lumbar  muscles,  which  is aggravated  by
movement and relieved by rest, pressure, or heat.   There
is seldom much, if any, constitutional disturbance. After
persisting from a few  days to a week or more, the pain is
relieved,  but the patient is often liable to repeated attacks
upon severe exertion  or exposure to cold or wet.   If  the
muscles of  the chest  are affected there is  severe  pain on
breathing or coughing, simulating pleurisy.  In the neck
the painful spasm of the  muscles causes the head to be
held stiffly  and perhaps drawn down on the affected side.
Myalgic  pains also occur in the diaphragm,  abdominal
muscles,  the extremities (e. g., brachialgia),  and the scalp.
In the  latter situation a form of indurative headache has
been described, characterized by the nodules previously
mentioned.
  Treatment.—Persons who  are subject  to attacks of
myalgia  should wear  silk, wool  (merino), or linen mesh
underwear.  Too  heavy  underwear is deleterious,  as it
leads to  excessive perspiration and invites chilling.  In
view of  the possibility of intestinal  toxemia,  attention
should  be given to regularity of the bowels.   In an attack
the  local treatment is the most important.   Except in
mild attacks the patient should  be confined to his bed,
as a uniform  temperature  combined  with  rest  hastens
recovery. 
       DISEASES OF  THE BONES AND JOINTS    239

   All the ordinary local applications  have been used in
 this disease with more or less success, e. g.,  acetic acid,
 blisters, mustard  and  belladonna plasters,  liniments of
 every  variety, salicylic acid, and other ointments, dry
 cups, etc.   Heat has been applied by mud  and flaxseed
 poultices, hot  stupes,  the tailor's "goose,"  and baking.
 The most  effectual measures are strapping  in the acute
 stage, and  massage as the disease subsides.  The adhesive
 straps should be applied to splint the affected part and
 not with any  idea  of  introducing medicinal substances
 (belladonna).  In the lumbar region  this object  is  best
 attained by applying broad overlapping strips like clap-
 boards.  During the application the patient should bend
 backward as far as possible, as  this will make the  straps
 firmer when he resumes a normal attitude.  In the nodular
 variety massage alone may effect a cure, but it is bene-
 ficial in all forms, after the acute stage, if the patient's
 pocket-book will permit of its use.  Internally salicylates
 (aspirin), sodium bicarbonate, ammonium chloride, and in
 the later stages nux vomica are commonly prescribed.

      DISEASES OF THE BONES AND JOINTS.

   Acute Arthritis.—The most important form of  acute
 arthritis is acute articular rheumatism, which is described
 under the infectious diseases.  Acute joint symptoms may
 be found  in a number of infectious  diseases, such as
 septicemia, influenza, dysentery, scarlet fever, etc.   Some
 of these cases  may terminate in  suppuration or lead to
 permanent joint changes.  Local injury or infection* also
 leads to acute arthritis (synovitis); this type is considered
 in books on surgery.   The same is true of the irritative
 joint symptoms,  brought  about by flat-foot, sacro-iliac
 disease, and other orthopedic conditions.
   Chronic Arthritis.—In chronic arthritis there is almost
 always  more or  less extensive  change  in  the  synovial
membranes, joint  cartilages, or bones.  In this respect
it  differs from true rheumatism  (acute  and subacute) 
240  DISEASES OF MUSCLES, RONES AND JOINTS

which  does not  injure  the  joints  permanently.  Mild
types of chronic  arthritis (joint inflammation) are com-
monly described as chronic articular rheumatism, but the
designation  is not so popular as formerly because  it  is
admittedly misleading.   Most people think that it is a
chronic form  of acute  articular  rheumatism,  whereas
there is no connection between the two.  Some of these
cases may be gout, but many of them are mild cases  of
arthritis deformans.  A variety of  "chronic rheumatism"
which is known as villous arthritis  or "dry joint" attacks
the  large articulations  (shoulders,  knee, etc.), and  is
characterized by  pains, stiffness, and soft grating.  The
latter is easily felt when the joints are manipulated.   This
"crepitation" is due to fringe-like folds of synovial mem-
brane projecting into  the joint cavity.  Sometimes these
fringes are caught between the  bones, causing exquisite
pain; at other times bony spicules  may be present which
irritate the joint in certain positions,  and account for the
attacks of pain and effusion.  Since the joints are relaxed
they  are  improved  if  supported  by straps  or  elastic
hosiery.  Similar symptoms are  often observed in young
men (athletes) who have dislocated  the semilunar carti-
lages of the knee.  This accident causes sudden sickening
pain and effusion of fluid.
  Arthritis  Deformans.—The   more  extreme degrees  of
arthritis, most of them accompanied by bone  changes,
are grouped under  the  title  of arthritis deformans.  In
some of these cases the joint and adjacent bony structures
are  wasted (atrophy),  in others there  is  overgrowth
(hypertrophy).   If  the  bones are  extensively  involved
the term  osteo-arthritis is applicable.  The four types
described below are the most  important.
  Heberden's Nodes.—Heberden's nodes  are  little  bony
nodules at the bases of the terminal phalanges of the
fingers and toes.   As they increase  in size they restrict
the movements of the terminal joints, and eventually the
latter may  become partially dislocated  to  one  side  or 
      DISEASES OF  THE BONES AND JOINTS     241

the other, or even ankvlosed.  These nodes are common
in persons past middle life and seldom lead to any serious
disability.   In  the earlier stages the small joints may be
tender and swollen from time to time.
   Spondylitis Deformans.—Another  form  of  arthritis  in
which hypertrophy  predominates attacks the joints  of
the  spinal  column  (spondylitis),   Adjoining  vertebrae
become lipped  by bony outgrowths, or the whole anterior
surface of the  spinal column  is plastered over  with new
bone.  The ultimate result is complete  ankylosis of the
joints and rigidity  of the spine.  Sometimes the disease
may extend to  the hips and shoulders.   The patient may
complain at first of stiffness and  pain in the back  on
movement.   The pain is severe and often radiates  along
the course of the spinal nerves,  some of which may  be
pressed  upon  and  irritated  by  the  bony outgrowths.
Even at an early stage the back may be absolutely rigid,
but this is due  in part to muscular spasm and may disap-
pear almost entirely with treatment.  The normal curva-
tures of the spinal column are obliterated ("poker back")
and  the head is held stiffly and cannot  be rotated more
than an inch or so  in either  direction, if  at all.   If the
hips  are ankvlosed the  patient is absolutely helpless.
With treatment there may be temporary improvement,
but the course of the disease  is usually progressive until
the spine is locked.   After  this the patient may remain
in statu quo for a long period of years.  In some cases the
disease is  confined  to certain  regions—the   neck, the
back, or the  lumbosacral  region.   A  slight   degree  of
arthritis of  the spine is  almost normal in the  aged, but
the cases we have been  describing often develop in the
prime of life.
  Monarticular  Arthritis.—In  the aged  arthritis of the
large joints  with atrophy may lead to considerable dis-
ability.  The hip and knee are the joints usually affected.
In the former  case the head  of the bone becomes  flat-
tened like a mushroom and the joint cavity shallow.  On
account of the  destruction of the cartilage there is  grat-
      16 
242  DISEASES OF MUSCLES,  BONES AND JOINTS

ing,  while the overlapping or lipping of the  edges of the
joint causes great restriction of  movement.  Usually one
joint only is affected.  The symptoms are pain, stiffness,
and  lameness.  The weakening of the joint  predisposes
to intracapsular fracture (hip).
  Rheumatoid Arthritis.—Rheumatoid arthritis is charac-
terized  by  a  chronic  progressive course, with  atrophy
and  deformity  of many joints  (hence the term  chronic,
progressive, polyarticular arthritis).  It is accompanied
by wasting of the muscles and atrophy of the skin.  The
disease was  formerly thought to be due either to  disturb-
ances of metabolism or to  disease of the nervous system
with trophic changes.  The tendency at the present day
is to attribute these cases  to chronic toxemia, the result
of some  cryptic (hidden) or apparently trivial infection.
The  following are  examples of such infections:  pyorrhea
alveolaris, sinus  disease, pyelitis, and  chronic endome-
tritis.  This theory has the advantage that it  offers  a
reasonable  basis  for therapeutic attack  in  many  cases
which would otherwise  be  beyond  the  reach of  medical
treatment.   Rheumatoid arthritis may begin acutely and
frankly  (being at first indistinguishable from acute artic-
ular  rheumatism),  or it may be chronic and insidious
from the beginning.  In either  case periods of activity,
with fever,  pain,  and swelling  of the joints, alternate
with intervals of comparative freedom.  The small joints
are more particularly involved, and during the inflam-
matory  stage assume a  peculiar spindle-like form due to
the infiltration  of  the soft  parts.  With each succeeding
attack the deformity becomes more and more marked,
but finally after  a term of years the disease reaches  a
stationary, quiescent stage, leaving  the victim partially
or completely  crippled.  In  the  advanced  stage  the
hands are crumpled and distorted, the small joints of the
fingers are ankylosed,  and  the  hand is turned strongly
to the ulnar side (toward the little finger).   If the patient
has been confined to bed the hips are fixed at  a right
angle and the knees bent.  The elbows are also frequently 
      DISEASES  OF THE  BONES AND JOINTS     243

ankylosed so that the patient cannot  comb his hair or
feed himself.
  The disease, though common at all ages, begins, as a
rule, in the prime of life and drags along into old age.
Our hospitals,  homes, and almshouses harbor scores of
these unfortunate patients (chiefly females).  In children
there is a  special form distinguished by more  acute
symptoms and by enlargement of the glands and spleen.
  Infectious Anthritis.—The  types  of  chronic  arthritis
which we have been considering hold an obscure, although
an  important, relation to infection.  In other types the
symptoms may be almost identical, but the  relation to
Fig. 48.—Hands showing marked late deformity.  (McCrae.)
infection  may be  quite frank.  The  permanent joint
changes which may follow acute infectious arthritis have
been  alluded  to above.  The  following infections  are
prone to lead  to subacute or chronic arthritis: gonorrhea,
tuberculosis, and syphilis.
  Gonorrheal  infection may attack one or more of  the
larger joints or certain small joints (e. g., the articulations
of the jaw and  clavicle).  The symptoms  are  at  first
acute-—fever,  pain, tenderness, redness,  and effusion—
but later become subacute  or  chronic.  (See Part  X.)
Tuberculous arthritis ("white swelling") is  very charac-
teristic in its manifestations.  It involves most frequently 
244  DISEASES OF MUSCLES, BONES  AND JOINTS

the spine  (Pott's disease), the hip, the  knee,  and the
elbow.  The treatment is purely surgical, but the disease
is important from a medical point of view, since a latent
hip or Pott's disease may give rise to meningitis or miliary
tuberculosis.  Syphilis also attacks the bones and joints,
particularly  the  former.   Necrosis  of the bones  of the
skull  is common, sometimes  with loss of substance and
consequent deep  depression in the forehead.  The fingers
may be diffusely enlarged like spindles (dactylitis), but
the commonest situation for syphilitic bone disease is  in
the legs.   The tibiae are frequently enormously thickened,
rough, and  in  children  bowed anteroposterior^  like
sabre blades.  During the acute stage the bone and its
investing periosteum is very tender.   A form of syphilitic
arthritis, similar  in  its manifestations to  articular rheu-
matism, is also described.
  Nervous  Arthropathies.—In nervous diseases, and above
all in tabes,  severe destructive joint disease occasionally
takes place.   The  knees are most  often  affected. The
disorder  is  attributed to  trophic disturbances  (nervous
arthropathy).
  Pulmonary Osteo-arthropathy.—Hypertrophic pulmonary
osteo-arthropathy or clubbing of the fingers is seen char-
acteristically in chronic ulcerative tuberculosis,  bronchi-
ectasis (dilatation of the  bronchi),  and  empyema. The
ends of the fingers are large and bulbous  and the nails
are curved like tortoise shells.  There is also thickening
of the phalanges.  The clubbed fingers of  congenital and
chronic heart disease are similar in character.
  Treatment  of Chronic Arthritis.—In the acute stages  of
arthritis salicylates are of  use to relieve  pain but do not
exert  any  curative  effect  on the lesions.   As a matter
of fact they are injurious in so far as they  interfere with
digestion and nutrition.  Phenacetin may also  be used
for the same purpose but with greater caution.   Locally,
at the same stage, evaporating lotions,  magnesium  sul-
phate in saturated solution, raw cotton, and similar dress-
ings are of use.  In the more acute forms and in infec- 
      DISEASES OF  THE BONES  AND JOINTS     245

tious arthritis splints at times give considerable relief.  In
infectious arthritis incision into and drainage of the joint
is sometimes necessary.  The diet, if there is fever, may
be moderately restricted, but in the intervals it  should
be generous, with an abundance of fat and protein (meat,
eggs, and milk).
  After the acute attack is over or in cases in which the
disease is chronic from the outset, the articulations should
be manipulated daily and the patient, as soon as he is
able, should  be encouraged to make as full use as pos-
sible of all the muscles and joints.   This will tend to pre-
vent distressing contractures which so frequently cripple
these patients  entirely and prevent them from walking
or even from feeding themselves.  I have seen remarkable
improvement  in the  use  of the hands  and arms follow-
ing a prolonged course of passive movements, exercises,
and  massage.  Baths are not of much use; occasionally
patients  derive benefit from  sulphur springs, or at home
from alkaline baths.   In  rare cases ankyloses  in vicious
positions may be improved by forcible manual correction
under ether or by operation. 
 
PART IX.
DISEASES DUE TO HEAT AND OTHER
     PHYSICAL CAUSES AND TO
                   POISONS.
Physical Causes.
  Sunstroke.
  Heat Exhaustion or Other Effects
   of Heat.
  Caisson Disease.
Poisons.
  Alcohol and Alcoholism.
  Opium Poison and the Opium
   Habit.
Cocain Habit.
Lead Poisoning.
Food Poisoning.
Auto-intoxication.
Arsenic,  Mercury,  Antimony,
  Phosphorus, etc.
Atropin and Strychnin.
"Mustard" Gas.
       DISEASES DUE  TO PHYSICAL CAUSES.

  Sunstroke.—Sunstroke or insolation results from exces-
sive heat and exposure to the  direct  rays of the  sun.
Alcoholic excess is a predisposing cause.  It is common
in hot climates or at midsummer in the temperate zone,
and attacks those whose duties  keep them  in the open.
It occurs with special frequency, for example, at army
maneuvers when large numbers of unseasoned recruits
are exposed to the direct rays of the. sun.  In this climate
the majority of  cases are observed during the  few days
or weeks of  midsummer when the temperature in the
shade exceeds 90°.
  The patient may have premonitory symptoms such as
headache, dizziness,  and nausea.  The onset is usually
sudden with loss of consciousness and complete coma.
Convulsions sometimes occur. 
248    DISEASES DUE TO PHYSICAL CAUSES

  Symptoms.—When the patient is admitted to the hos-
pital the skin is red, hot, and dry, the pulse rapid, full,
and  strong, and the temperature extremely high—10N°,
110° or more.  If the temperature is allowed to continue
at this height, there  will be  irreparable  damage to  the
nervous system, but the  prompt use  of  cold baths will
usually reduce it rapidly and the patient  will pass into a
refreshing sleep.  From this he may awake showing com-
paratively  slight signs of illness.  In  many cases death
occurs without reduction of temperature  as the result of
damage to  the vital centers; in other cases a condition of
collapse precedes the fatal outcome.  A patient who has
suffered from sunstroke is frequently  subject  to severe
headaches,   due perhaps  to  chronic   thickening of  the
meninges,  and is liable to  subsequent attacks of inso-
lation.
  On excessively hot  days, when cases of sunstroke  are
being  hurried  into the receiving  tent,  other diseases
accompanied by high fever and unconsciousness are liable
to cause confusion.  I have seen patients (Fig. ni)) treated
by "ice baths" in  whom subsequent examination of the
blood revealed the presence of malarial parasites.  In these
instances the mistake was fortunately a harmless one.
  Heat Exhaustion and Other Effects of  Heat.—Heat
exhaustion  occurs in persons who have been exposed  to
prolonged high temperature and humidity  in ill-ventilated
work-rooms, factories,  holds of ships,  etc.  The patient
is prostrated, but may be conscious, the  color is pale  or
cyanotic, the skin cold and "leaky," and  the pulse small
and feeble.   In fatal cases death occurs in collapse.
  Persons who are exposed to the direct  effects of very
high temperatures,  such as stokers, firemen, and iron-
workers,  sometimes develop  intense cramp-like pain  in
the legs, with spasmodic contraction of the calf muscles.
The common limitation to the lower extremities is prob-
ably due to special exposure.
  After prolonged residence in the tropics, natives of the
temperate zone, particularly women and  children, suffer 
       DISEASES DUE TO  PHYSICAL CAUSES    249

from anemia, loss of appetite, poor nutrition, and general
weakness and lassitude.  Some physicians who have had
large  experience in the tropics  believe that the intense
light, independently of the heat, is in itself deleterious
to blond races.
  Treatment.—('ases of sunstroke should be given cold
baths to reduce the temperature as promptly as possible.
Although these baths are popularly described as ice baths
the temperature of the water does not fall  below 65° or
70° in spite of the free addition of ice.  The patient should
be  rubbed  vigorously while  in the bath to encourage
radiation of heat from the surface of  the body, and an
ice-cap should be applied to the head.  The patient should
be removed from the tub before the temperature reaches
normal,  as  the fall  is likely  to continue after  removal.
In heat  exhaustion, on the other hand, heat should be
applied to  the feet and  body  by hot-water bags and
bottles and free stimulation  should be  employed as well
as aromatic spirit of  ammonia, strychnin,  atropin, etc.
Cases of sunstroke and heat exhaustion are usually treated
in tents rather than in hospital Avards.   If the tents  are
Avell Aentilated, Avhich is  not always the case, they  are
much cooler than the Avards  at night.   In  the  daytime
they present no advantages beyond free ventilation and
greater convenience.   Those residing in the tropics require
an  annual  vacation in a  colder  climate.  Officers and
civilians  in  the Philippines often go to Japan; in  India
the Europeans seek the foot-hills of the Himalayas.
  Caisson Disease.—Compressed  and   rarefied air may
cause  unpleasant  or  even   dangerous symptoms.  In
caissons,  which are  sunk for  the purpose of constructing
bridge piers, etc., beneath  the water, pressure is used to
exclude water from the Avorkings.  At the depth of one
hundred  feet this may amount  to fifty to sixty  pounds
to the square  inch.  The  workmen gain access to the
Avorking chamber  through intermediate  compartments in
which the pressure is raised.  By gradually increasing the
pressure Avhen going in and still more gradually (one-half 
250    DISEASES DUE  TO PHYSICAL  CAUSES

to one and one-half  hours) decreasing  it when coming
out,  injurious  symptoms  may  be avoided;  otherwise
caisson disease or the "bends" may arise.  This affection
is characterized by pain and cramps in the limbs, or par-
alysis.   In some cases death follows.  Divers are exposed
to the same dangers when working at great depths.
  The  rarefied  air of high mountains and  plateaus fre-
quently causes disturbances of the  respiration and  circu-
lation in those suffering from cardiovascular disease,  or
in normal persons Avho overexert themselves.  Nosebleed
is  a  common symptom.   These symptoms  are  probably
due to deficiency of oxygen in the rarefied air.  Physicians
are loath to send patients Avith myocardial disease to lofty
altitudes, particularly if the transition from the lower to
the higher level is abrupt.

                      POISONS.

   In this section only those poisons which give rise  to
well-marked clinical  pictures or  lead to inveterate habits
will  be considered.   For  a complete list of the several
poisons and their antidotes the reader is referred to  books
on "materia medica," "first aid," "emergencies," etc.
   Alcohol and Alcoholism.—Ethyl  alcohol  is the  essen-
tial  constituent  of all fermented beverages and distilled
liquors.  It is one of a series of alcohols, which includes
methyl or wood  alcohol, amyl  alcohol, and many  others
less  well known.  Alcohol is closely allied to the carbo-
hydrates  (sugars and starches), but theoretically  has^ a
much  higher fuel value, the factor being seven calories
per  gram as compared Avith four for carbohydrates (see
Part VI).  A  contro\Tersy has raged  for many  years
between those who  assign  a food value to alcohol and
those who regard it  as a poison pure and simple.  Con-
servative opinion inclines to the view that small quanti-
ties  may be utilized with  profit for  the production of
heat and  energy under certain conditions, for example
in diabetes and in exhausting fevers (sepsis and typhoid). 
POISONS
251
As a stimulant alcohol is now much less favorably regarded
than formerly.   Its principal action is to dilate the super-
ficial bloodvessels inducing a full, soft pulse.  As a heart
stimulant it  is ephemeral in action and may be classed
with aromatic  spirit  of ammonia.  For these and other
reasons the prescription of alcohol for medicinal purposes
has been greatly restricted in the last ten or fifteen years.
  The effect of the prolonged use of alcohol on the various
organs and tissues is  to some extent a matter of dispute.
Some  authorities, though fewer  than formerly,  believe
that small quantities well diluted produce no deleterious
effects, even when long  continued.  In larger amounts
and in concentrated solution (spirit) there is no question
but that  alcohol  causes  catarrh  of the gastro-intestinal
canal and cirrhosis of the liver.  The writer has rarely
seen a  case of uncomplicated  gastritis in which  alcohol
has not played a major part.  To judge from the histories
of our patients, the effect of alcohol on the kidneys and
cardioAvascular  system seems to be hardly less striking.
Statistical inquiries appear to  show, hoAveA'er,  that it is
not an important cause of  arteriosclerosis.   Alcohol is a
direct  cause  of certain forms  of  insanity (toxic) and is
thought to be an indirect cause, not only of insanity but
of many ner\rous diseases.
  Acute alcoholism is too familiar a condition to  require
description.  It does not lead  to  delirium tremens, alco-
holic neuritis, or other serious complications,  unless the
bout is unduly prolonged, or the acute excess associated
Avith  chronic  overindulgence.   Its  chief importance in
internal medicine is as a predisposing cause of penumonia
and rheumatism on account of the incidental  exposure.
At times  there is some difficulty in distinguishing acute
alcoholism from opium poisoning, apoplexy, uremia, dia-
betic coma, and "status epilepticus."  Mistakes are most
likely  to  happen  in  ambulance  and  police Avork, with
scanty histories and small opportunities for careful exami-
nation. When treatment is necessary the most effectual
mode  of  relief  is the  administration  of a hypodermic 
 252    DISEASES DUE  TO PHYSICAL  CAUSES

 injection of apomorphin  hydrochloride,  or  better  still,
 lavage of the stomach.
   Chronic alcoholics are of two general types  those avIio
 indulge in moderately large or excessiAc quantities (a pint
 or more daily), continuously or almost continuously, and
 those in AA'hom periods of excessiAc  indulgence alternate
 AA'ith periods of complete abstention from, and even dis-
 gust for alcohol.  The  latter type is undoubtedly in the
 nature of a psychosis.   The former includes many persons
 who drink from wilful choice,  and  not  because of any
 imperative impulse.
   Persons who drink steadily  may sIioav  very 1'cav signs
 of alcoholic excess, perhaps a little squeamishness in the
 morning, tremor of the hands, etc., but if they are attacked
 by acute disease or suffer from some injury severe enough
 to confine them to bed, they are prone to deAelop delirium
 tremens.   I have  seen this most often in pneumonia and
 in fractures of  the loAver extremities.  Chronic periodical
 drinkers and alcoholic subjects generally after a prolonged
 spree may also develop  delirium  tremens.   The symp-
 toms most suggestiAe of impending delirium tremens are
 anorexia, tremor of the hands, tongue, and lips, restless-
 ness, and  obstinate  insomnia.   The  tongue  is  heavily
 coated  and  often  dry  and broAvn.   The characteristic
 delirium has been described  preATiously  (see page  21).
 The patients are  often difficult to control and struggle
 violently to escape from their terrifying hallucination.   If
 they can  be induced to sleep, they frequently awake
 refreshed and  prompt recovery occurs.   Other  patients
 exhaust themselves and die of asthenia, while still others
 pass into a state  of  semistupor Avhich  may persist for
 Aveeks (alcoholic wet brain).
  Neuritis, gastritis, cirrhosis of the liArer, bronchitis,  and
 bronchopneumonia, are complications of alcoholism Avhich
 are described in their appropriate sections.
  Treatment.—The curatiA^e treatment of chronic alcohol-
ism  under ordinary conditions  is  not hopeful.   At  the
Philadelphia General Hospital Ave have patients Avho have 
POISONS
253
been  admitted for alcoholism more  than one  hundred
times and many others with records almost equally bad.
Periodic drinkers in any class of society are most difficult
to cure and only do well when under institutional care,
or when far removed from any probability of temptation.
Ordinary alcoholism is more susceptible to improvement
if the cooperation of  the patient is  assured  and if the
influences which  surround  him are helpful.  In hospital
work most  of  the patients have no  desire to be cured
and the conditions by which they are surrounded at home
are all conducive to a continuation of the habit.  Many
systems of treatment  for the cure  of  chronic alcoholism
have been proposed, most of them unfortunately tinged
with  more or less quackery.   A common and legitimate
method is by  institutional  supervision and by  the  pro-
longed use of full doses of atropin and  strychnin.
   In threatening  delirium  tremens free lavage at the
beginning  may ward   off  serious  symptoms.  Delirium
tremens is sometimes  treated as an "acidosis" by intra-
venous injections of sodium bicarbonate solution.   (See
Diabetes.)  Once symptoms have appeared sedatives and
physical restraint become necessary.   It is Aery  common,
however,  for patients  to be  overdosed with hypnotics or
injured  by too  strict restraint.  If  there  are enough
attendants  to  control  the patient it  is better  to avoid
handcuffs and restraining  sheets altogether.  Sometimes
patients are kept quiet by continuous full baths at body
temperature.   Lumbar  puncture  is  also  an  effective
measure under some circumstances.  The sedative drugs
most in use are: bromides, paraldehyde, chloral, hyosin,
and morphin.  Physicians differ as to the wisdom of stop-
ping the alcohol immediately,  or cutting it off gradually.
 Stimulants such as strychnin  and digitalis are necessary
 for most patients at one stage or  another.  The diet in
 the acute stage is perforce liquid, but must be as nourish-
 ing as possible, e. g., milk and eggs.
   Wood alcohol will  produce an acute intoxication not
unlike  that due  to   ordinary  alcoholic beverages, but 
 254     DISEASES  DUE TO  PHYSICAL CAUSES

 chronic poisoning by this substance is much more serious,
 as eATen moderate doses may cause atrophy of the retina
 and partial or complete blindness.   Poisoning may be due
 to the fraudulent substitution  of Avood alcohol for grain
 alcohol in whisky and other liquors, or topers may deliber-
 ately make  use of it  Avhen other supplies are exhausted.
 EA'en external applications made from wood alcohol,  e. g.,
 cheap hair  tonics,  have  been  known  to  induce  ocular
 changes.
  Opium Poisoning and the Opium Habit.—Acute opium
 poisoning is most frequently due to morphin or laudanum.
 These may be taken in overdose by mistake or Avith sui-
 cidal  intent.  The  leading  symptoms are  somnolence,
 stupor, slow respiration,  stertor,  and  pin-point pupils.
 The  respiration may  fall  to  10 to  12  or less and if the
 patient is alloA\~ed to sleep, may stop entirely.
  Treatment.—The  treatment consists  in getting  rid of
 the drug so far as  possible  by repeated lavage  (because
 morphin is eliminated into the  stomach even when taken
 subcutaneously), in the administration of moderate doses
 of atropin and caffein (coffee)  to  antagonize the  effects
 of the opium,  and in the prevention of sleep.  The latter
 object is  usually attained by  walking the patients, by
 flipping Avith  a  towel,  by the electric brush  (painful),
 and  by alternate hot and cold douches.  W'alking  and
 AA'hipping, used without judgment, sometimes cause death
 from  physical exhaustion.   On the other  hand,  I have
 seen  excellent  results, Avithout harmful incidental effects,
 following the use of  electricity, hot and cold Avater, etc.
  Opium Habit.—The opium habit is induced by  the
 above-mentioned preparations, by opium itself, by lauda-
 num,  by  paregoric, by heroin, and rarely by codein.
 Opium is smoked, paregoric and laudanum are taken by
 the mouth, morphin is usually taken by hypodermic injec-
tion, and heroin is used as a snuff.   Indulgence in opium
 (smoking) and heroin, and to a less extent in morphin,
may  be a purely  vicious habit; many cases of morphin
addiction,  however,  folloAv the prolonged therapeutic use 
POISONS
255
 of the drug for pain and discomfort.   Nurses as \vell as
 physicians are likely to acquire the habit if they prescribe
 for their own  aches and pains.  It should be an invariable
 rule Avith  the nurse  never to  take a dose of these  and
 similar drugs without a specific  order  from  a physician.
   The opium habit is quickly acquired and difficult to
 shake off.  The drug  gives a sense of well-being with
 dreamy  visions and  freedom from pain, but increasing
 doses are required to get an effect. As much as a dram
 of morphin a  day may be taken by addicts without fatal
 results.  In the intervals between doses the patient suffers
 from gastro-intestinal symptoms, irritability, restlessness,
 and insomnia.  These symptoms are vulgarly designated
 as the "habit."  If the drug is withdrawn entirely there
 may be intense  physical and mental distress, particularly
 vomiting, diarrhea, intestinal colic, tremor, and delirium.
 After prolonged or excessive use anemia and emaciation
 develop.   In  elderly  persons  using moderate  amounts
 there may be no unpleasant symptoms.
   Treatment.—The opium  may  be withdraAvn  immedi-
 ately or gradually.   During the  first feAv days of  treat-
 ment the patient suffers intensely from nausea, vomiting
 (green), and insomnia.  It is necessary to have the patient
 in an  institution, othenvise he will obtain  supplies by
 stealth, as most opium habitues cannot be trusted.   Dr.
 Lambert, of New York, has treated large numbers of cases
 successfully by  active and repeated purgation with blue
 mass and  compound  cathartic pills, by the  administra-
 tion of belladonna and hyoscyamus, and by  the gradual
 withdrawal of the drug.
  Cocain Habit.—Cocain ("coke") addiction is even more
 deleterious than the morphin habit.  It acquired a foot-
 hold largely through the use  of  the drug  in nose and
 throat practice  before its dangerous nature was knoA\n.
 The  stringent  laAvs that haAe been enacted are  limiting
 its use so that cases of the habit are not very frequently
observed in hospital practice.  It is usually taken as a
snuff and is frequently combined with heroin. 
 25(i     DISEASES DUE  TO PHYSICAL  CAUSES

   Acute symptoms are sometimes seen after the use of the
 drug as a local anesthetic—rapid  pulse, excessive rest-
 lessness, insomnia, and the  like.  The habitue  after his
 dose is said to experience a most delightful sense of satis-
 faction in his own ability, both mental and physical, but
 subsequently becomes irritable, morose, jealous, and vin-
 dictive.  Terrifying  hallucinations  are   common.  The
 treatment is  similar to that suggested for the opium habit.
 Immediate AvithdraAA'al of the drug is  usually practised.
  Lead Poisoning.—Lead is the  most important of the
 industrial  poisons.  More than a  hundred  occupations
 have been  known to occasion  "plumbism."  Those in
 AA'hom it most frequently occurs are white-lead  Avorkers,
 makers of storage batteries,  painters, smelters, plumbers,
 printers, etc.  The large incidence of the disease  in Avhite-
 lead workers is to a great extent due to neglect of Avell-
 knoAvn precautions by the manufacturers, by the  Avork-
 men, or  by both.  Poisoning may also occur from medi-
 cine ("lead and opium pills"), Avater contaminated from
 lead pipes, etc.
  The principal manifestations of lead poisoning  are: lead
 colic, lead  anemia, lead palsy, and  lead encephalopathy.
 The pains  of lead colic are  usually felt about the naA'el
 and are Aery  intense.   Obstinate constipation is associated
 Avith the pain.  I have seen a case  which simulated per-
 fectly  renal  colic.  There is a "blue" line near the free
 border of the gums,  but this  is absent  Avhen the teeth
 are missing.   Anemia  is rapid  and severe and a peculiar
 granulation  of the red  blood cells is demonstrable by
 straining.  The latter  is Aery suggestiAe,  but not in itself
 diagnostic of lead poisoning.   Palsy may develop with or
without preceding attacks of colic.   Wrrist-drop and foot-
drop are the types of  paralysis ordinarily seen, but mul-
tiple neuritis is possible.  Recovery is  the rule in lead
palsy except in neglected cases.   Other nervous symptoms
occasionally  seen  are  tremor, delirium, convulsions, and
insanity.  Lead is an important  cause of arteriosclerosis,
nephritis, and gout. 
POISONS
257
  Treatment.—Prophylactic treatment is most important.
White lead  may  be made by a AAret process which  does
away Avith the dangerous dust, or the workmen may wear
respirators (because of discomfort they seldom do).  Good
nutrition and the free use of milk is thought to be of
value.  Thorough Avashing of the hands before handling
food is the simplest and most generally applicable precau-
tion, though not sufficient in itself.
  In  a subacute  attack, with  colic, rest, purgation by
Epsom salt, morphin, and local  applications (hot stupes,
etc.), are of value.  Later potassium iodide, in small doses,
and  iron are indicated.  For lead palsy the same drugs
are used, perhaps with the addition of strychnin, and also
local measures such as massage and electricity.
  Food Poisoning.—Under this heading may be included
toxic symptoms produced  by food products of all sorts,
fish,  shell-fish, meats, milk and cheese,  vegetable foods,
etc.  The symptoms may be brought about by the poison-
ous nature of the food itself, by "ptomaines" resulting from
putrefaction, or by contaminating microorganisms intro-
duced Avith the food.  Examples of the first are poisonous
fish,  toadstools, and sprouting potatoes; of the second, de-
caying lobsters and cheeses; of the third, infected sausage
and shell-fish contaminated by sewage (see Typhoid FeA-er).
  The general symptoms of ptomaine poisoning are those
of acute gastro-enteritis:  fever, seAere pain,  vomiting,
purging, and collapse.  Nervous symptoms may be prom-
inent or there may be special symptoms,  e. g., gangrene
in those who eat diseased rye (ergot).
  Auto-intoxication.—Auto-intoxication (" self-poisoning")
is a  condition induced by the action  of poisons formed
Avithin the body itself.  The acid intoxication  of diabetes
is a  good illustration of  such an auto-intoxication.   The
term is more often,  if  less correctly, applied to vague
symptoms Avhich are presumably due to poisonous prod-
ucts  formed in the intestinal tract by the action of putre-
factiAe  bacteria.   An excess  of  indican in the urine is
suggestiAe of excessive intestinal putrefaction.
      17 
25S     DISEASES  DUE TO PHYSICAL CAUSES

  The symptoms of the latter condition are indefinite—
headache, vertigo, disinclination to work, flatulence, con-
stipation, diarrhea.   Treatment consists in dietetic restric-
tions of various kinds and in the administration of butter-
milk or lactic-acid bacilli (Bulgarian bacillus).
  Arsenic,  Mercury,  Antimony,   Phosphorus,   etc.—
Arsenic, mercury, antimony,  and  phosphorus may give
rise to chronic poisoning in those Avho have been exposed
to these poisons at  their  Avork or who  have  received
medicinal doses.  Acute poisoning arises Avhen large doses
have been taken by accident or Avith suicidal or homicidal
intent.  Arsenic frequently causes slight gastro-intestinal
and renal irritation, and less often multiple neuritis, when
administered in large doses or over a prolonged  period
for  syphilis (salvarsan), chorea, and pernicious anemia.
Mercury under similar conditions causes ptyalism, loosen-
ing of the teeth, and gastro-intestinal irritation, but these
symptoms  are  now infrequent  except in susceptible per-
sons.   In former times Avhen mercury was  used with
greater freedom they Avere very common.  Antimony and
phosphorus are seldom used in medicine and toxic  symp-
toms are extremely rare.  Industrial poisoning from mer-
cury occurs in smelters, in chemical workers, in makers
of physical apparatus, in hat makers, etc.  It is said to
cause tremor,  painful convulsions  without unconscious-
ness,  and emotional  disturbances.   Chronic phosphorus
poisoning is seen in  match workers and may be prevented
if the  form of phosphorus  known  as red  phosphorus is
employed.  In this  country legal restrictions are at fault
in this respect.  Phosphorus workers suffer from a match-
like taste in the mouth and, if the teeth are carious, from a
destructive necrosis of the jaw.  If  the poisoning is more
severe, acute fatty degeneration of the liver with jaundice
may occur (usually fatal).
  Acute poisoning due to arsenic and mercury  is accom-
panied  by severe  irritation and  inflammation of the
gastro-intestinal tract.  It is difficult to control and com-
monly fatal either  immediately or ultimately.  In the 
POISONS                    259
middle  ages arsenic  was a  favorite with  poisoners,  on
account  of its tastelessness and insidious effects, but it
has now lost its exil preeminence, if for no other reason,
on account of the readiness with which it may be detected
by the chemist.  In most countries the use of arsenic in
embalming is forbidden because of the danger of conceal-
ing the criminal use of the drug. Acute arsenical poison-
ing may be treated by immediate lavage and the admin-
istration of the antidote (ferric hydroxide with magne-
sium oxide, four ounces).  Lavage  should be repeated at
intervals.  Acute mercurial  poisoning commonly results
from the accidental or suicidal  ingestion of bichloride of
mercury tablets.  If the patient survives the acute gastro-
intestinal manifestations he is likely to succumb  later
from acute nephritis  and uremia.   Recovery is possible
even after several tablets have been taken. The treatment
consists of prompt lavage and the administration of milk
and Avhite of eggs in the early stage.  Subsequently rest in
bed for  three weeks, restricted carbohydrate diet,  daily
lavage, and enteroclysis (plain or medicated)  are employed.
  Nitrate of silver administered continuously over a long
period causes a ghastly bluish  discoloration of the skin
which is permanent.  I once saw a patient with " argyria"
in a syncopal attack.  The resident physician in charge,
supposing that he had to deal with a case of dangerous
heart failure, made reckless  use of hypodermics, but  by
good fortune did the patient  no harm.
  Atropin and Strychnin.—Atropin very commonly  occa-
sions toxic symptoms even in therapeutic doses. This is
due in part to the varying susceptibility of different indi-
viduals.  Serious results are rare because of the  care with
which the drug is employed and the distinctive  character
of the manifestations.  I have seen  marked dilatation of
the pupils  and rapid  pulse after the use of an ordinary
belladonna plaster.  The writer once suffered from  toxic
effects, including in addition to the  above, insomnia and
extreme restlessness, after drinking out of a  beaker which
had been used in the preparation of eye-drops. 
2t)0    DISEASES DUE TO  PHYSICAL CAUSES

  Strychnin  poisoning  is characterized by  seAere  tonic
convulsions Avithout  loss  of consciousness.  In  a case
Avhich I saw  many years ago fatal asphyxia  was induced
by an attempt to wash out the stomach.  Considering the
reckless freedom Avith Avhich the drug is used by all classes
of persons the rarity of acute poisoning  is remarkable.
  " Mustard" Gas.—Of the many poison gases employed
in the recent Avar "mustard" or  "yperite" (dichlorethyl-
sulphid)  attained by far the Avidest use.  Its poisonous
effects Avere observed not only among  combat troops but
also  among laboratory Avorkers  and in those employed
in its manufacture and in  the loading  and handling of
shells.   Even minute  concentrations  led  to distressing
symptoms  AA'hile  exposure   to full concentrations Avas
frequently fatal.  In those more or less protected by masks
extensive  burns  were  produced, primarily in  exposed
regions  (face, neck, and hands) and about the buttocks,
genitals, and flexures of joints where the skin is thin and
delicate,  but any part  might be affected if sufficiently
exposed.  When contact Avas not  direct the burns Avere of
the first  and second degree  (redness and blistering) but
in regions where it Avas difficult to  maintain cleanliness and
dryness infection Avith infiltration, ulceration, and slough-
ing were  common.  Direct  splashes of the  liquid also
caused deep  lesions.  The conjunctiva*, especially when
unprotected,  became  intensely red and  swollen and the
lids were glued together by purulent secretion.  The eyes
rarely suffered permanent damage but intolerance to light
Avas  very persistent.  In those  unprotected by masks
the most serious  lesions Avere in  the respiratory tract as
the gas caused partial or  complete destruction  of the
epithelium  of the pharynx,  larynx, trachea, bronchi, and
bronchioles.  The resulting  dead tissue became second-
arily infected with pus organisms and this in turn led
to purulent bronchitis  and  bronchopneumonia.   In the
mildest cases there Avere signs and symptoms of bronchitis
Avith cough, hoarseness,  and soreness in the chest, and in
the severer  cases prolonged irregular  fever, dyspnea, 
POISONS
261
cyanosis, increasing stupor, and finally death.  The vast
majority of the cases  recovered  (mortality under three
per cent.)  but  suffered subsequently in many instances
from eye symptoms, cough, and neuroses.  So far as known
at present there has been no special liability to subsequent
disease  (tuberculosis and pneumonia) nor  as a rule  any
permanent disability. 
 
PART X.
INFECTIOUS  AND  PARASITIC
              DISEASES.
        CHAPTER  I.

GENERAL  CONSIDERATIONS.
Infectious   and   Contagious
  Diseases.
Modes of Transmission in In-
  fections.
Classifications of Infections.
Characteristics of Classes (4).
Communicable Diseases.
Periods of Incubation.
Periods of Isolation.
Isolation and Disinfection.
Hospital Quarantine.
Immunity.
Antitoxins.
Phagocytosis and Vaccines.
Viruses.
  Summary.
Fever.
Types of Fever.
  Thermometry.
  Treatment of Fevers.
  Infectious and  Contagious  Diseases.—Infectious dis-
eases  are  caused  by the lodgment  and growth in the
body  of minute organisms which may be either animal
(protozoan)  or vegetable (bacterial)  in their  nature.
Infestations  with  larger and  more  highly  organized
animal parasites (metazoa) are often considered apart, but
for our purposes may be grouped with the infections proper,
on account of the essential similarity in the means by
which they are transmitted, and as a consequence in the
methods of prophylaxis  against them.  Formerly a dis-
tinction was  made between  contagious and infectious
diseases on account of supposed differences in mode  of
transmission.   A  contagious disease was thought to be 
 204   INFECTIOUS AND  PARASITIC DISEASES

 transmitted not only by actual bodily contact with the
 patient, or with secretions and excretions derived directly
 from him, but also by certain hypothetical "exhalations."
 Thus the atmosphere in  the neighborhood  of smallpox
 hospitals was  supposed to  be "catching."   "Contagion"
 in this sense is probably  a myth, as is also "infection"
 in the sense of a miasma arising from swamps.  Present-
 day  authorities prefer  the terms transmissible  or  com-
 municable to either of those mentioned, but the older
 terms  will  doubtless  continue to  be used—infectious
 in a broad  comprehensive sense and contagious  with  a
 narroAA-er significance, to define those diseases  which are
 readily  communicable  by  direct  or  indirect  contact
 (measles, scarlet fever, diphtheria, and the like in contra-
 distinction to tetanus, malaria, etc.).
   Modes of Transmission in Infections.—Infection may be
 acquired  (1) by direct contact  with  patients or infected
 animals;  (2) by indirect contact; (3)  through human or
 animal carriers;  (4)  through  intermediate  hosts;  (5)
 by drinking-water;  ((>) by  food; and  (7 and 8) through
 the medium of the air or soil.  Some  of  these expres-
 sions require explanation and amplification.   Infection by
 direct contact  implies close association  with patients or
 infected animals or  direct  exposure to "contagious" dis-
 charges, etc.  Infectious material is often borne in minute
 particles of moisture which are expelled by  a patient in
 coughing, sneezing, and yawning—hence the term " droplet
 infection."   Indifferent  objects,  such as bed and body
 linen (sometimes known as "fomites") which have been
 contaminated by  discharges or excretions, may  convey
 infection  by  indirect  contact.  Objects  which  have
 merely been exposed to air infection  are probably very
 slightly dangerous, possibly not so at all.  Dust infection
 may be  considered  a form of  indirect contact.  Thus
 dried up  and  pulverized  excretions  may  still contain
 virulent  microorganisms, as  was long  ago  proved   for
tubercle  bacilli  and more recently  for  typhoid  bacilli.
Fortunately the disinfectant properties of air and sunlight 
    MODES OF TRANSMISSION  IN INFECTIONS  2()5

reduce this danger to a minimum. It may be further dimin-
ished  by the employment of  damp sAAeeping and dusting
and vacuum cleaning.  By the term "carriers" Ave desig-
nate (a) individuals who, following exposure to contagion,
harbor dangerous organisms somewhere in the  economy
(throat, intestine, etc.), Avithout being themselves attacked
by the disease, and (6) persons who, having recently  or
long since convalesced from an acute illness, still distribute
organisms from some persistent focus of infection.  Diph-
theria is commonly conveyed by persons of the first  type
who carry the  causative bacilli in their throats; typhoid
infection, on the other hand, is spread broadcast, through
the contamination of food  and water supplies, by persons
whose excretions  (feces and urine) contain typhoid bacilli
for months, and even years, after  apparently  complete
recovery.  Animal (including insect) carriers may transmit
infection  to human  beings either  from  other  persons
affected Avith disease (typhus feAer is carried from person
to person by lice), or from the loAA'er animals to man (the
plague is sometimes carried from  infected rats to human
beings by the agency of fleas).   Animals also act as inter-
mediate  hosts, i. e.,  they lodge  the  infecting  parasite
during some necessary cycle of its existence which may  be
quite different from that seen in man.  Thus the ordinary
beef tapeworm in its adult form lives in the human intes-
tine and scatters its eggs in the fecal discharges.  Cattle
become infected by eating grass, hay, or other food contami-
nated by these eggs.   The eggs develop into embryos  in
the gastro-intestinal canal of these animals, and then pene-
trate  into the  voluntary muscles  in Avhich they become
encapsulated (larvae) as minute oat-like  bodies.  When
infected beef, either raAv  or insufficiently smoked, is eaten
by man the parasites quickly develop again into the adult
state  and the cycle is complete.   If  no raAv meat Avere eaten
the disease  would die out  without further  precautions.
Impure drinking-w^ater and infected foods (including milk)
are important  in  the spread of infections invoking the
gastro-intestinal tract  and in the  propagation of animal 
200   INFECTIOUS AND  PARASITIC DISEASES

parasites.  It is unlikely that infection is carried to any
great extent through the air except in the form of dust or
droplets; much that Avas formerly  called air infection is
iioav attributed with certainty to insects or carriers.   The
soil is of importance as a vehicle for conveying infectious
matter to air (dust) or Avater.  In tetanus (and similarly
in gas bacillus infection)  and hookworm disease, infec-
tious material  contained  in  earth  may enter  through
the skin, in the former case  only in the presence of wounds
or abrasions, in the latter through the intact skin (" ground
itch").
  Classification  of  Infections.—With  these preliminary
explanations  aac may proceed to a  classification of infec-
tious and parasitic diseases, arranged primarily in accord-
ance Avith the mode of  transmission, and only secondarily
in  harmony  Avith  other   criteria.  Diseases  which are
transmissible in several  ways are  included under what
seems to be the most  important  division, while  diseases
concerning whose transmission we  are entirely ignorant
are classified  by analogy.
  Class  I.  Characteristics.—The infectious  agent enters,
as a rule, through an  abrasion or wound of the skin or
mucous membranes.
  (a) Infections due to pyogenic  bacteria.—Septicemia,
erysipelas, gonococcus infection.
  (6) Animal diseases  transmissible to  man.—(1)  Bac-
terial.—Tetanus, anthrax, glanders.  (2) Due to fungi.—
Actinomycosis.   (3) Caused  by  an  unknown  agent.—
Rabies.
  (c) An infection (primarily human) due to a protozoan
parasite.—Syphilis.
  General Prophylaxis.—General prophylaxis in this group
depends  on careful  protection and treatment of wounds,
abrasions,  and susceptible   mucous  membranes.   It
demands the  application of ordinary aseptic or antiseptic
methods to the treatment  of every trivial injury.   Boric
acid,  phenol (carbolic acid), potassium, permanganate,
and silver solutions are often used on mucous membranes 
          CLASSIFICATION OF  INFECTIONS       267

to prevent infection.  Wounds may be treated according
to circumstances by simple aseptic methods or by incision,
drainage,  cauterization,  and antiseptics  (bichloride  of
mercury, etc.).  In  certain diseases  special preventive
measures are useful, e. g., the disinfection of hides from
infected countries  to prevent anthrax, the  prophylactic
use of antitoxin after Fourth-of-July and war injuries  to
afford protection against tetanus,  the muzzling of dogs
to prevent rabies,  and hospitalization (as well as special
"prophylactic" measures) to limit gonorrhea and syphilis.
Most of these special measures will be mentioned again
under the individual diseases.  Accidental  transmission
of these infections to others  is unlikely (except perhaps  in
erysipelas) if ordinary care is taken to destroy infectious
discharges and objects (such as dressings) soiled by them.
Towels and linen should be sterilized by boiling or by the
use of disinfectant solution, bichloride of mercury 1 to 1000,
phenol  1 to  20, "formalin"  (i.  e., 40 per cent, formalde-
hyde solution) 1 to 10 (40 X 10  = 4 per cent, formalde-
hyde gas), or compound solution of cresol 1 to 100.   Partial
quarantine  or isolation is the rule in erysipelas, gono-
coccus infection with discharge,  tetanus, rabies, syphilis
(active), etc.
  Class  n.   Characteristics.—In  this  group infection  is
disseminated through the agency  of insects which act
either as carriers  or as intermediate  hosts.  A goodly
portion  of these  infections is due to protozoa.  The
causative organisms in the remaining and larger fraction
are either bacterial or uncertain.
  Transmission.—(a)  By Mosquitoes.—Malaria, filariasis,
yellow fever, dengue.
  (b) By Flies.—Sleeping sickness and other mainly tropical
affections.   (Typhoid fever,  dysentery, the exanthemata,
etc., in which flies play an important but secondary role
in the transmission of infection, are classified elsewhere.)
  (c)  By Ticks.—Rocky Mountain fever, Texas fever, etc.
  (d) By  Fleas.—The  plague   (bacterial).  Rats and
squirrels are susceptible and keep the infection  alive in 
20S    INFECTIOUS AND PARASITIC DISEASES

the intervals between epidemics.  Fleas carry the infection
from the rodents to man.
  (e)  By Lice or Bed-bugs.—Typhus fever, relapsing fever.
Trench fever.
  General Prophylaxis.—The general prophylaxis of this
group  consists  in the destruction of insects and vermin,
careful screening, cementing of rat holes, filling up of pools
and sAvamps, and similar measures of sanitation.   Disin-
fection in the ordinary  sense is  useless  but "delousing"
and the use of  larvacides and insecticides (e. g., sulphur,
carbon tetrachloride, and kerosene) is important.  The
systematic ferreting out and treatment of  infected persons
(malaria) is  one of the most efficient means of prophylaxis.
  Class III.  Characteristics.—In diseases belonging  to this
group  the  infectious agent  usually  enters  through the
respiratory  tract  (comprising  the  tonsils)  and  is  dis-
seminated by discharges from the same region,  including
sputum,  nasal, and even aural discharges  (the middle ear
is in intimate relation Avith  the  pharynx by Avay  of the
Eustachian  tube).  Desquamating epithelium is a prob-
able source  of contagion in some exanthemata and, Avhile
not so important as formerly  belieAed,  should not be
entirely disregarded.
  (a)   Due to Bacteria.—Diphtheria, cerebrospinal feAer,
pneumonia,   influenza,   Avhooping-cough,   tuberculosis,
leprosy.
  (6)  Uncertain  or Unknown Causation.—Infantile paral-
ysis, follicular tonsillitis  (streptococcic), rheumatic  fever,
glandular fever, mumps,  measles, German measles, scarlet
feAer, smallpox, chicken-pox.
  General Prophylaxis.—The general prophylaxis  of  this
group consists in the aA'oidance of direct contact  (in many
cases partial or absolute  quarantine), and in the disinfec-
tion or destruction of discharges.   "Droplet"  and dust
infection  are particularly common in diseases of this class.
The former  may be guarded against  by  the Avearing of
gauze masks and the employment of screens and cubicles
in  contagious Avards.  Carriers play an  important role, 
           CLASSIFICATION OF INFECTIONS       209

 as  in  diphtheria, pneumonia, and tonsillitis.  Old linen,
 gauze, or paper napkins, should be used instead of hand-
 kerchiefs to receive nasal discharges or sputum.   Soiled
 pieces should be put into paper bags and the Avhole burned
 at suitable intervals.  With the same end in AieAv sputum
 may be received into paper containers, or porcelain (or
 enamel) cups  containing antiseptic fluids  may  be sub-
 stituted.  The best  fluids for the cups  are  strong  lye,
 phenol (carbolic acid),  1  to 20, and "formalin."  Cups
 in  permanent use should be frequently scalded, or in
 institutions, sterilized in a special apparatus by live steam.
 Cotton  pledgets  employed in cleansing the mouth or
 dressings used for running ear should be burned.  In the
 eruptive fevers (exanthemata) the skin should be anointed
 during the com'alescent period Avith petrolatum,  plain or
 medicated,  to  prevent  the diffusion  of  scales.   Other
 special methods of prophylaxis include  vaccination for
 smallpox  and  prophylactic  injection   of  antitoxin  in
 diphtheria.
   Class TV.  Characteristics.—In this group  the infectious
 agent enters by the mouth (the hookworm is ordinarily
 an  exception) and as  a rule multiplies in  the  gastro-
 intestinal  tract.
   (a)  The infection  (generally bacterial) is disseminated
 principally by the intestinal discharges.—Typhoid fever,
 paratyphoid fever, colon  infection, Malta fever,  cholera,
 bacillary or amebic dysentery.
   (b)  Animal  microorganisms and  parasites.— 1.  Dis-
 seminated  as  in  (a).—Amebic dysentery, roundAvorms,
 threadworms,  hookworm disease (infection usually enters
 through the skin).
   2. Dissemination occurs through  the agency of inter-
 mediate hosts.  Animal parasites.—TapeAvorms, trichina,
 echinococcus,  cysticercus, etc.
   General Prophylaxis.—General prophylaxis in this group
• is principally  concerned with the protection  of the food
 and Avater supply.  For the attainment of this end disin-
 fection of discharges  (particularly  urine and feces), the 
270    INFECTIOUS AND  PARASITIC DISEASES

regulation of seAvage disposal,  provision  of  pure water
(filtration), and the inspection and control of meat, milk,
and  other foods  are  essential.  Carriers,  both insect
and hmnan,  play an important  part (typhoid).  Dust
infection  is occasionally a  source of danger.  Direct and
indirect contact are of secondary importance.
  Urine and feces may be disinfected by adding an equal
quantity  of some strong disinfectant, mixing, and alloAv-
ing to stand for  a  half-hour or more.  Phenol,  1 to 20,
cresol (liquor cresol  comp.), 1 to 50, chlorinated lime, 1 to
20  (6 ounces to the gallon), and "formalin"  1  to 10 are
used for both urine  and feces; for the latter milk of  lime
is also commonly employed.  In some modern hospitals
sterilizers have  been introduced for  the steam disinfec-
tion of bed-pans and their contents.   Precautions should
be most stringent in the case  of typhoid, cholera, and
dysentery.
  Communicable Disease.—For purposes of public health
certain infectious diseases are  designated  as communi-
cable,  and thereby  come under the supervision  of local
health officers.  The list of reportable diseases varies in
different localities and is determined in part by considera-
tions of expediency.   The  following is  an  official list set
forth by the Public Health Council of  the State  of New
York:   anthrax, chicken-pox, Asiatic cholera, diphtheria
(membranous croup),  amebic  and  bacillary dysentery,
epidemic  cerebrospinal  meningitis, epidemic  or strepto-
coccus (septic)  sore-throat, German  measles,  glanders,
measles,  mumps,  ophthalmia neonatorum, paratyphoid
fever,  plague,  acute  anterior poliomyelitis  (infantile
paralysis), puerperal septicemia,  rabies,  scarlet fever,
smallpox,  trachoma, tuberculosis, • typhoid fever, typhus
fever, whooping-cough.1

  1 The Pennsylvania law (28th of May. 1915) includes in addition the
following diseases:  actinomycosis, erysipelas, leprosy, malarial fever,
relapsing fever, tetanus, trichiniasis, yellow fever, impetigo  contagiosa,
pellagra, scabies, uncinariasis.  More recently venereal diseases, pneu-
monia, and influenaa have been added. 
PERIODS OF  ISOLATION
271
  Periods of Incubation.—According to  the  same  code
the  maximum period of  incubation (that is, the  time
between the date of the exposure to the disease  and the
latest date  at  which it is  likely to develop) of certain
communicable diseases is as follows:

    Chicken-pox............21 days
    Measles.....     .......14
    Mumps.............21
    Scarlet fever.....     ......7
    Smallpox.............  20
    Whooping-cough...........14

  To these  may  be added the following derived from
A^arious sources:

    Cerebrospinal fever.........5 days
    Diphtheria............7  "
    Erysipelas............10  "
    German measles..........21"
    Rabies.............3 months
    Tetanus............4 weeks
    Typhoid fever...........21 days
    Typhus fever...........21"

   After  the expiration  of  these  periods infection  is
extremely unlikely.   Cases may develop, however, very
much earlier; diphtheria, e. g., frequently within two days.
  Periods of Isolation.—The minimum period  of isolation
for certain diseases  is stated  as follows (this and much
that follows is quoted, with slight verbal  changes, from
the  New York regulations):   Chicken-pox, until twehTe
days after the appearance of the eruption and until the
crusts  have  fallen and the scars are  completely healed;
diphtheria  (membranous  croup),  until two successive
negative cultures have been obtained from the nose and
throat at intervals  of twenty-four hours;  measles, until
seven days after the appearance  of the rash and until all
discharges from the nose, ears, and throat haAre disappeared
and  until the cough has ceased; mumps, until  two weeks
after the appearance of the disease and one week after
the  disappearance  of the swelling;  scarlet fever,  until 
2,2   INFECTIOUS AND PARASITIC DISEASES

thirty  days after the deA'elopment  of  the disease and
until all discharges  from the nose, ears, and throat,  or
from suppurating glands, have  ceased;  smallpox,  until
fourteen days after  the  deA'elopment of the  disease and
until the scabs have  all separated  and  the scars  com-
pletely  healed; AA'hooping-cough  until eight  AA'ceks  after
the deA'elopment  of  the disease and until one Aveek after
the last  characteristic cough.  Some authorities believe
that the infection is not transmissible after the Avhoop
begins.
  Isolation  and   Disinfection.—Persons  affected  with
communicable  diseases are  usually  isolated, and  Avhen
so isolated  cannot  be removed  to any  other house  or
hospital  without  the permission of a health officer.   If
the. patients are properly isolated adult members of the
family or household  Avho do not come in contact Avith the
patient  or Avith the secretions or excretions  may continue
their usual  vocations, provided  such vocations do not
bring them in close  contact  Avith  children.  Cases  of
smallpox must  be remoAed to special hospitals  and  those
who haAe been exposed must be vaccinated.
  A physician  in attendance on any case  suspected by
him to  be Asiatic cholera, dysentery, paratyphoid feAer,
or typhoid fever, should give detailed instructions to the
nurse or other persons  in attendance in regard to the
disinfection and disposal of the excreta.  (See aboAe,  Class
IV.)  In  cases  of  diphtheria,  epidemic  cerebrospinal
meningitis,  epidemic  or  septic  sore-throat,  measles,
poliomyelitis (infantile paralysis), scarlet fever, smallpox,
or  Avhooping-cough,  he  should  similarly  give detailed
instructions in regard to  the disinfection  and disposal
of the discharges, from the nose, mouth,  and ears of the
patient.   (See aboAe, Class III.)
  The  physician  or  nurse or other necessary attendant
upon  a  case  of  diphtheria,  measles, or  scarlet  feAer,
after attendance  upon the case,  should take  precautions
and practise measures of cleansing or disinfection  of  his
person or garments  to prevent the comeyance to others 
HOSPITAL QUARANTINE
273
of infective material from the patient.   No person who
is affected with any communicable disease or who resides
in a household where he comes in contact with any person
affected with  bacillary dysentery,  diphtheria, epidemic
or septic sore-throat, measles, scarlet fever, or typhoid
fever, should handle food or milk for others in any manner
whatsoever.
   After recovery or death of a person affected with com-
municable disease adequate  cleansing,  renovation, and
disinfection of  the  premises, cleansing, disinfection, or
even destruction of furniture or belongings, and cleansing
and  disinfection of  the patient and his attendants are
required.  Convalescent patients, nurses, attendants, and
"contacts" before  being discharged  from  supervision
should shampoo the hair, take a full (1 to 10,000 bichloride)
bath and don entirely clean clothes.   I n cases of diphther ia
one or  more negative cultures from the throat or nose
should be obtained.   The above and some of the following
recommendations follow the practice of the Philadelphia
Bureau of Health.  Clothing which has been contaminated
should be  disinfected by  steam, by boiling water,  or by
formaldehyde (gas or solution).  If rooms are to be disin-
fected  by  formaldehyde,  three pints should be used for
each thousand cubic feet; all cracks and crevices should
be closed with  cotton or adhesive plaster.   In addition
there should be an ordinary thorough  cleaning with soap
and  Avater and full exposure to fresh air  and sunlight.
Articles such as mattresses and pillows, not readily cleaned,
should be sent  aAvay and sterilized by steam.
  Hospital  Quarantine.—In hospitals  strict quarantine
regulations are usually enforced differing according to the
character of the infections, local conditions, etc.  Absolute
quarantine is enforced for dangerous and highly contagious
diseases, such as smallpox and scarlet fever; partial, for
milder infections, such  as measles; special, for infection,
such as diphtheria, in which certain specific  precautions
suffice.   The nurse should be familiar with the regulations
in her particular hospital or communitv,
     18 
274   INFECTIOUS AND PARASITIC  DISEASES

  There is a tendency in many quarters to do away with
all precautions based on the idea of air  infection.   In
France and  eA'en in seAreral parts of this country patients
with various forms of infectious disease (including scarlet
fever, e. g.) are treated in common Avards, in some instances
isolated  from each other merely by  tapes.  In  other
hospitals  compartments  (cubicles)  separated by   glass
partitions are provided to  obviate  "droplet" infection.
In  the  "influenza"  epidemic  of 1918  cubicles—often
improvised  from  sheets—were extensively used to  limit
"cross"  infections.  Success has  been attained  by this
method  when'  precautions  against  direct  and  indirect
contact  have been  carried out  with  scrupulous  care
("aseptic nursing").  Carelessness on the  part  of  phy-
sicans or nurses,  e. g., hasty and  insufficient disinfection
of the hands in passing from case to case, is fatal to the
success of the plan.  For the  present  most physicians
and health  officers, while admitting that  many of the
precautions in vogue are unnecessary and therefore theo-
retically bad, are content to await a more adequate trial
before putting the newer methods  into force.
   Immunity.—Thus  far  we have  considered only the
causative agents of infection.   It is well known to eA^ery-
one, however, that infection occurs only when the patient
is abnormally susceptible or the infection overpowering.
The capacity possessed  by the body  for resisting infection
is spoken of as immunity.  Under varying circumstances
this may be entirely lacking, it may be partial or relative,
or it may be absolute.  Immunity  may be of a general
character, limited to a  related group of diseases,  or  more
often strictly specific.  Thus a  person Avho is immune to
measles or smallpox may be susceptible to German measles
or chicken-pox.  Certain persons and even whole  races
appear to have an unusual  degree  of immunity against
certain diseases,  or,  on the other hand, an undue sus-
ceptibility to these or other  diseases.  In any given case
this cannot be assumed  without  a  thorough knowledge
of all the circumstances.  Thus it was formerly believed 
ANTITOXINS                 275
that the Cubans had a natural immunity against yellow
fever.  On more careful investigation it was found that
most of  them suffered  from the disease in a very  mild
form during infancy and were thenceforth protected by
this  previous attack.   The example of natural immunity
most often cited is that of the Jews against tuberculosis;
the negroes, on the other hand, are peculiarly susceptible
to this infection.   A previous attack of many infectious
diseases yields a more or less permanent protection against
subsequent infection.   Dr. Rosenau  gives the following
list of diseases which afford such protection:
     Smallpox.               Typhoid fever.
     Yellow fever.            Typhus  fever.
     Measles.                Chicken-pox.
     Whooping-cough.        Mumps.
     Scarlet fever.            Cerebrospinal meningitis.
     Infantile paralysis.
  A previous attack of pneumonia, diphtheria, erysipelas,
or malaria seems to predispose to subsequent attacks.
  Antitoxins.—The  mechanism  of  immunity  is too
complicated and  too  obscure to  permit of any  simple
explanation which  would be at  all  adequate; it must
suffice,  therefore,  to  mention a  few  important  points
which bear on current methods of diagnosis, prophylaxis,
and treatment.  In the  course of their growth  in the
body many pathogenic microorganisms throw out virulent
poisons or toxins which evoke the characteristic symptoms
of the particular disease.  The diphtheria bacillus is the
best-known organism of this sort.  Other microorganisms,
like the tubercle bacillus, give off little or no toxin during
groAA'th, but the bacterial bodies contain endotoxins which
will  occasion symptoms when released by the death and
disintegration of  the microorganisms.  Bacteria of this
class multiply, as a rule, in  many localities in the body
and call forth local  reactions:   inflammatory exudates,
abscesses, peculiar forms of infiltration, softening, etc.  To
meet the first sort of infection the cells of the body manu-
facture  a chemical  antidote which  is  specific for the 
270   INFECTIOUS AND PARASITIC DISEASES

particular infection and is known as an antitoxin.  If the
patient can produce a sufficient quantity of this antidote
to neutralize the toxins before irreparable injury has been
inflicted on  the  Aital organs, recovery  occurs.  If the
toxin can be extracted from bacterial cultures and injected
into men or animals in repeated doses, at  first minute
but later massiAe, an artificial immunity can be produced
wiiich is due to the formation of antitoxin.  This method
has long been used to produce diphtheria  and tetanus
antitoxin in the horse.  When a horse has been sufficiently
immunized  a large portion of his blood is Avithdrawn
and the serum separated, purified,  and concentrated.  A
portion of this serum injected into a healthy person will
lend him a temporary passi\'e immunity; if injected  into
a person in the early stages of diphtheria it will supple-
ment the patient's own stock of antitoxin and bring about
a rapid recoA'ery in the  vast majority of cases.  Before
antitoxin is marketed it is tested as to its power to neu-
tralize definite quantities of toxin and its strength is then
stated in "units;" an ordinary dose of diphtheria antitoxin
is ten thousand units.
  The production of antitoxin is not  the only resource of
the body in its struggle with invading bacteria.  Other
substances are also deAeloped in the  serum Avhich  will
cause the offending bacteria  to clump together, to  lose
their  motility, to  precipitate, and  finally  to dissolve.
These  properties may also  be artificially developed in
serums for therapeutic purposes.  The Widal reaction, so
generally used for diagnosis in typhoid  fever, is based on
the above-mentioned agglutinating property  of immune
serums.  It does not appear,  therefore, at the onset of
the disease, but only after a certain immunity has begun
to develop (Fig. 66).
  Phagocytosis and Vaccines.—The  cellular elements of
the tissues also take an active part in this "battle" with
the invaders.  The presence  of infection  usually  calls
out an excess of  leukocytes  in the blood (leukocytosis),
AA'hile bacteria in the tissues are speedily surrounded by a 
PHAGOCYTOSIS AND VACCINES        277
host of these same white cells AA'hich endeavor to "devour"
them (phagocytosis).   It is not an uncommon thing to see
a half-dozen bacteria inside a single  leukocyte.  If the
outpouring  is excessive an abscess may result, but even
this apparent defeat and sacrifice of countless leukocytes
(pus cells) may lead  to recoAery by bringing about dis-
charge of the imraders with the pus.  In the more chronic
infections  (e. g., tuberculosis) cells of  other  types are
brought  into action and tend to form connective-tissue
capsules  about the bacilli and thus isolate them from the
rest of the body  (latent tuberculosis).  If the reaction
against hwading bacteria is insufficient for lack of stimu-
lus, as often happens in subacute and chronic infections,
Aaccines  may  be  injected subcutaneously  in  ascending
doses to  provoke a more active resistance on the part of
the defensi\Te (immunizing) agencies.   Vaccines are made
by suspending in salt solution a pure culture of the offend-
ing microorganisms,  previously   killed  by  a sufficient
application  of heat.   The vaccine is diluted so that each
c.c. contains a definite number  of bacteria (one to one
hundred   million or  more).  The  various  tuberculins,
although differently prepared, embody a similar principle.
Vaccines are used not only  to assist in the cure of disease,
but in the establishment of  an active immunity.  As is
well known, the whole personnel of the United States Army
is protected by antityphoid vaccination against enteric
fever.  In this instance  the immunity lasts for two or
three years, not for  life,  as is usual  after spontaneous
attacks of the disease.
  Viruses.—The injection  or inoculation of live cultures
(viruses) is  Aery commonly practised by veterinarians to
develop  immunity against certain animal disease  and
particularly against anthrax.  The cultures are weakened
or attenuated, as the phrase is, by passing them through
resistant animals, by groAAing them  under unfaArorable
conditions,  or  by exposing them to heat or drying.  In
human beings the  use of  Airuses is generally forbidden
except in specific instances in which they are of proved 
278   INFECTIOUS AND  PARASITIC DISEASES

A'alue.   The  Aims  of  rabies, attenuated  by  drying,  is
employed to develop an immunity against this  disease
after infection has occurred, but before  the  incubation of
the disease  is completed.  This  is possible because the
incubation period is fortunately Aery long.  The virus of
vaccinia (cow-pox)  or true A'accine is used to develop an
active immunity against smallpox.  Vaccinia is merely a
mild form  of  smallpox  which  has been  permanently
depriAed of its virulence and contagiousness  by implan-
tation  on a resistant animal—the cow.  The vaccines
previously mentioned are so-called because of their fancied
resemblance to the  original vaccine.  As we have  seen,
hoAA'cAer, they  consist of dead  cultures,  while the true
Aaccine is a living virus.
  Summary.— To recapitulate:  immunity may be natural
or acquired.  Acquired immunity may be passiAe, as after
the injection of antitoxin, or active, as after an attack of
one of the infectious diseases.  Immunity may follow a
spontaneous attack  of disease, the artificial inoculation
of an unmodified A'irus,  inoculation of  a  modified virus,
vaccine injections, injections of antitoxic serums, injection
of antibacterial  serums,  etc.
  Fever.—Fever  is  the  most  striking evidence  of the
reaction of  the  body against invading microorganisms.
Simple  pyrexia (rise in temperature), howeA'er, may be
due to  other causes than infection,  such as sunstroke,
anaphylactic shock, and  brain  injuries, but is not  then
associated with the ordinary  evidences  of toxemia.  The
febrile state is accompanied by  many symptoms, some
of the  more frequent of  which  are:  shivering, chills,
sweats,  headache, aching in  back and limbs, insomnia,
delirium,  stupor,  anemia,  leukocytosis,   rapid  pulse,
alterations in blood-pressure, rapid  respiration, loss of
appetite,   constipation,   scanty,  high-colored  urine,
albuminuria, loss of strength, AA'eakness, prostration.
  The  degree of fever may  be classified in  accordance
with the following simplified scheme (Rosenau): 
TYPES OF FEVER
279
Subfebrile or high normal......99° to 100° F.
Low febrile..........100° to 101° F.
Moderately febrile........101° to 103° F.
High febrile..........103° to 105° F.
Hyperpyrexia!.........105° F. and over.
103 102 101° 100° 99 98° DAY OF DIS. PULSE RES P. DATE									;							
																
																
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Fig. 49.—Measles showing remission before appearance of eruption.
                       (Musser.)
  The normal daily (morning and evening)  variation in
temperature is  less than  one degree; in fevers it is fre-
quently much greater.  The pulse and respiration ordin-
arily increase proportionately with the temperature.  In
pneumonia there  is a disproportionate  increase  in the
respiratory rate; in  scarlet fever in the pulse-rate.
  Types of Fever.—The onset or invasion of a fever may
be sudden and violent, as in pneumonia, or gradual, as in
typhoid fever.  After a fever has attained its height this 
280   INFECTIOUS AND  PARASITIC DISEASES

high temperature is usually maintained from a few days to
two or three Aveeks; this stage is knoAA'n as the " fastigium."
In some eruptiA'e feArers {e.  g., smallpox, measles) the
course of the temperature may be temporarily interrupted
by a remission. At the end of the fastigium the tempera-
ture falls either suddenly by crisis, or gradually in a step-
like  manner, by lysis.  At this stage also there may be
a temporary remission of temperature as  in the pseudo-
crisis of pneumonia.  In convalescence from feA'ers there
may  be  recrudescences, that is, temporary  eleAations
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Fig. 50.—Intermittent fever of tuberculosis.  (Musser.)
caused by overfeeding, constipation,  excitement, etc., or
there may be true relapses which repeat all the features
of the original attack.  Continued fever is characterized
by sustained temperature with only slight diurnal  Aaria-
tions.  Croupous pneumonia and typhoid fever are char-
acteristic  types  of  continued  feAer.  Remittent  fever
exhibits  wider  diurnal  variation  without,   lioweAer,
descending to normal.  Typhoid fever is remittent dur-
ing the stages of invasion and  lysis.  Estivo-autumnal
malaria is  a  typical  remittent  feAer.  In  intermittent
feAer the temperature reaches the normal or  eA'en falls 
TYPES  OF FEVER
281
below it in the intervals between the febrile paroxysms.
The most typical intermittent fever is that seen in malaria,
in Avhich there is a regular rise of temperature every day
or eAery other day, with normal records in the interim.
The hectic feAer  of advanced tuberculosis and the fever
of septicemia and pyemia may be  either remittent or
intermittent.  In  pyemia the diurnal variations may be
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 Fig. 51.—Typhoid fever.  Course of fever and relation to symptoms.
                       (Musser.)

enormous,  the temperature ranging  from subnormal to
hyperpyrexial within a few hours.   (See Fig.  21.)   The
paroxysms are accompanied by severe chills and drenching
sweats.
  Thermometry.—The   temperature  should always  be
determined by the  thermometer, for while experienced
physicians  may,  in  the majority of instances, estimate
the degree  of fever very accurately by the hand, in other 
282   INFECTIOUS AND PARASITIC DISEASES

instances they may be entirely at sea.  The best idea of
internal temperature is obtained by taking the observa-
tion in  the  rectum.  This method is  in  general use in
tuberculosis sanatoria  since slight febrile variations  are
of great importance in early or incipient tuberculosis.
It is also commonly used in infant practice.  In ordinary
cases the mouth and axilla are the most convenient for
this purpose  and the  readings   obtained  sufficiently
accurate.  The temperature  in  the axilla is  at  least a
degree lower than in the rectum.  The temperature in
the mouth is intermediate betAA^een the two.   It is hardly
worth  Avhile to  dwell  on the technic of thermometry,
Aug.
DAY	|2»					29				80				:ti				1				2				a	
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Fig. 52.—Intermittent tertian fever.  Malaria without chills.
but a few points may be emphasized.  The mouth tem-
perature is likely to be low if the patient has been breath-
ing through the mouth or has taken cool or cold food or
drink shortly before.  If the temperature is much below
normal  the  observation  should be repeated to exclude
an error in technic.  Shortly before writing this paragraph
I noted, Avhile making  "rounds"  in a ward of twenty-
six  beds, that eight patients  had temperatures of  95° or
lower!  On  investigation it was found that an inexperi-
enced nurse had  made  the  observations.  Most ther-
mometers, however marked, give more accurate readings
if left in the mouth for at least five minutes.  This is of 
TYPES  OF FEVER
283
importance  in detecting  subfebrile  rises  in  incipient
tuberculosis.
  Treatment  of Fevers.—The reduction of temperature
may be accomplished by drugs, antipyrin, acetophenetidin
(phenacetin), acetanilid,  quinin, salicylates, etc., but this
method is  noAV largely discountenanced and abandoned
except in acute fevers accompanied by headache, pain,
and aching, in which most of these drugs serAe a  double
purpose, and  if used with discretion can hardly do any
harm.  For prolonged fevers hydrotherapeutic methods
are preferable, as they not only reduce fever but stimulate
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		\	a/i											\					g								
						' \					*,		J	>	\		r\			-							
					r	,j		\		V	V		/		1		f	^								\-	
					/			V	N			\	/			/			'\							\j	r
				l	i							V			V											V	
RE3P.	26		28		24		32		24		32		28		30		28		28	|24			22		20		
PULSE	120		120		112	150			112		120		110		114		112		120	J104			108	.	104	1 1	
Fig. 53.—Estivo-autumnal fever.
the nervous system  and impro\re the circulation in the
peripheral Aessels and the  lungs.  Cool or cold water is
applied in many Avays, the best known of which are tub
baths, cold  packs, sponging, and the application of cold
compresses,  ice-bags, caps,  etc.  As these are sufficiently
described in nursing manuals it is not necessary to  dwell
on them here.  Cold air also tends to keep the tempera-
ture down and has  a  most beneficial and  stimulating
effect on many patients suffering with acute respiratory
disease, e. g.,  croupous pneumonia.  Bronchitis in chil-
dren, the weak, and the aged is  more favorably influenced
by warm, moist air, which,  however, should be frequently 
284    INFECTIOUS AND PARASITIC DISEASES

changed (free A-entilation).  The air in the room may be
moistened by boiling Avater over  a gas flame  or a  spirit
lamp.   Sunlight  is also  a valuable aid in the treatment
of chronic I'eAers.  It should  be avoided in many  acute
exanthemata in which the eyes are affected.  In tuber-
culosis  fresh, cold air,  sunlight,  rest, and diet  are the
physician's chief  AAeapons.  Rest is the most essential of
all factors in treatment, but in acute disease only  needs
to be enjoined upon the patient  in exceptional  cases or
at certain stages of the  disease.   In chronic infection  it
is often the most difficult condition  to secure,  either
because of the disinclination  of the  patient to adopt  it
or on account of  his inability  to leave his A\ork.
  The diet of  fevers should  be largely  liquid or  semi-
liquid and if the disease is prolonged should be more than
adequate  to supply  the nutritiAe requirements  of the
patient.   These questions are  considered in more  detail
under Metabolism and in the  section on Typhoid Fever.
In feA'ers AA'hich do not inArol\re the gastro-intestinal  tract
or impair the function of the  kidneys a  rapid return to
solid food may be instituted  at  the beginning  of con-
Aralescence. 
CHAPTER II.
INFECTIOUS AND PARASITIC DISEASES-
                   CLASS I.1
            (a)
Toxemia, Septicemia, and Pyemia.
Erysipelas.
Gonococcus Infection.
Gonorrheal Arthritis.

            (6)
Tetanus.
Anthrax.
Glanders.
Actinomycosis.
Rabies.
            (c)
Syphilis.
    A.  INFECTION DUE TO PYOGENIC BACTERIA.

  Toxemia, Septicemia, and  Pyemia.—Toxemia, septi-
cemia, and pyemia may be considered  at  the beginning
of our study of bacterial infections because they do not
represent  definite diseases but  systemic states that may
be  occasioned  by a large  number of infectious agents.
In  a narrower  sense these terms are applied to general
infections caused by the pus-producing (pyogenic) organ-
isms, gonococci, etc.  Those varieties in which there is a
definite or accessible  source of  infection  as in  wound
infection or puerperal  sepsis come under the care of the
surgeon or obstetrician, and are discussed in  works on
surgery and obstetrics.  The more occult or hidden forms
come  under  medical care  and will  form  the  principal
subject of this section.   The investigations of recent years
have tended to  break doAATi the sharp distinctions between
these  three manifestations of  infection,  but they  still
serve a useful purpose from the point of view of treatment
and prognosis.
  Toxemia, though it  may bear a  different significance,
is used in the present connection to designate the  systemic
                      1 See p. 266. 
286   INFECTIOUS AND PARASITIC  DISEASES

state brought about by the circulation in the body of the
poisons, specific and non-specific, produced by the growth
of various bacteria.  The bacteria may  themsehes circu-
late in the blood or they may be confined to a limited area
AA'hence their toxic products may be distributed through-
out the body as in tetanus and diphtheria.   Sapremia is
a term of similar import usually applied to a mild toxemia
resulting from the retention and  bacterial putrefaction
of necrotic material or tissue (c. g., retained membranes
after childbirth).  In septicemia the bacteria themselves
are carried by the blood to all  the tissues and elaborate
their  poisons  AA'hereAer  they  may  become  established.
In this condition we are no longer able to cure the patient
by remoAing the original focus of infection.  In pyemia
there  is not only toxemia and bacteremia  (bacteria in
the blood), but also multiple abscesses  which are  set up
in fa\rorable locations by pus organisms  circulating in the
blood.  The prognosis in these  cases is usually  very bad,
but not  so invariably fatal as Avas formerly   believed.
The mortality in cases of septicemia and  pyemia due to
pus organisms (streptococci and  staphylococci) is more
than 80 per cent.
  Symptoms.—The symptoms of toxemia in the specific
infections are  considered under the respectiA'e diseases,
pneumonia, typhoid, etc.  The general  manifestations of
toxemia  as seen in pyogenic  infections  are:  chilliness,
irregular   feArer,  rapid  pulse,  headache,   restlessness,
delirium, loss of appetite, etc.,  the first-named  being the
most suggestive.   In septicemia the chills are more severe,
oft repeated, and associated with high remittent or inter-
mittent  fever, and correspondingly severe constitutional
symptoms.  In pyemia similar symptoms occur but are
usually even more severe and the febrile  paroxysms are
frequently  followed  by drenching sweats.  In  malig-
nant endocarditis  I have seen  the temperature range in
a few hours from  95° to 105°  or  106°,  and occasionally
tAvo such paroxysms have occurred in a single  day (Fig.
21).  The patient's mind frequently remains  clear but at 
     INFECTION DUE TO PYOGENIC BACTERIA   287

other times stuporous states  supervene.  In the severe
cases of septicemia  rapid emaciation,  severe  anemia,
jaundice, hemorrhages into the skin, local abscesses, and
bed-sores  develop.  In many instances, however,  and
particularly in the so-called terminal  infections  (which,
according to Osier, carry  off  the  "majority of cases of
advanced arteriosclerosis and of Bright's disease"),  the
symptoms  are Aery indefinite and the diagnosis  is made
by  cultures from the blood during life or  at autopsy.
The duration of these cases varies  from a week or two to
many months.  The following is  an  incomplete list of
some of the commoner conditions  which give rise to  the
symptoms  of  toxemia, septicemia, and pyemia: septic
endocarditis, purulent pericarditis,  empyema, purulent
peritonitis  and meningitis,  abscess  or purulent infiltration
of  the  liver  (suppurative cholangitis), of  the   kidney
(pyelonephritis and  pyonephrosis), of  the prostate, and
of the bladder, and infections of the bones,  joints, teeth,
and sinuses.
  In most  of the above-mentioned conditions if  cultures
are  taken from the veins (usually at the bend of the elbow)
the causative organisms may be  grown  and identified.
Several  hours before a blood  culture is to be taken  the
nurse should prepare the skin in the region of the elboAV
(anterior surface) as if for a major operation,  by scrub-
bing Avith  soap  and water, alcohol and bichloride solu-
tion, and by applying a dry sterile  dressing.   At the time
the culture is taken  the physician paints the region of
the Arein with 5 per cent, tincture of iodin as an additional
precaution. At present  iodin alone is frequently used.
After a constricting bandage has been applied to the upper
arm the physician plunges  a large  hollow needle into  the
distended vein and withdraws (usually AAith a syringe) as
much blood as he requires.   Before he removes the needle
the constricting bandage  should be completely  relaxed,
othenvise hemorrhage into the subcutaneous tissue is
liable to occur.   Measured quantities  of the blood thus
withdrawn  are placed in tubes and flasks containing cul- 
2SS    INFECTIOUS AND  PARASITIC DISEASES

ture media.   An  alcohol lamp should  be at hand for
flaming the necks of the flasks, etc.
  Treatment.—The treatment should aim to remoA e the
original focus of infection AA'hen this can be discovered
and  is accessible.   Teeth may need to be Avithdravvn or
extensiA'e  surgical  operations  undertaken.   At  autopsy
deep abscesses are occasionally discoA'ered Avhich, if prop-
erly  opened, Avould haAe prevented pyemia and death.
Recently I saw two cases of this sort,  one  with a sub-
mammary abscess,  the other Avith an abscess deep  in the
thigh.   When  cultures from  the  blood  are  obtained,
special serums may be employed or autogenous vaccines
may be prepared.  The  defences  of the body may also
be stimulated by  drugs such  as  collargol.  Aside from
these measures medicinal treatment is stimulant, suppor-
tiAe, and tonic.
  An abundant diet of high caloric A'alue, including milk
and  eggs, is usually advisable and fresh  air should be
"administered in large doses."  The open-air treatment,
useful in tuberculosis and pneumonia, is equally indicated
here, although of course not equally successful.
  On account  of  the  frequently  prolonged  course,  the
extreme degrees of weakness and  emaciation, and  other
depressing  factors,  the most careful nursing is  required
to secure comparati\e comfort to the patient, to  aA'oid
passive  congestion  of the organs, to prevent bed-sores,
and to maintain a healthy condition of the mucous mem-
branes.  Mouth washes, dusting powders, etc.,  as des-
cribed  under Typhoid  Fcaxt Avill  be required.   Prophy-
lactic measures will depend entirely upon the character of
the infection.  Frequently there are no external evidences
of infection.  Discharges,  if  present,  should  be  dealt
with as described under the individual infections.
  Erysipelas.—Erysipelas  is a  pyogenic  infection caused
by  the streptococcus  pyogenes.   This  microorganism
under certain  conditions,  AArhich AAre  do not fully under-
stand, produces a specific inflammation of the  skin accom-
panied  by  symptoms  of  toxemia.   The  infection  is 
      INFECTION DUE  TO PYOGENIC  BACTERIA  2S9

transmitted in most cases by direct contact; it  may be
carried by physicians or  nurses, or bedding, clothing,  and
perhaps walls and floors may be the indirect vehicles of
contagion.  Healthy  persons are not  susceptible, as  a
rule,  but patients Avith  wounds, newborn children,  and
puerperal women are particularly liable and should  not
be exposed to even a remote chance  of infection.  Nurses
who have been in attendance on cases of erysipelas should
not go directly to cases of the character mentioned above
except after unusually thorough disinfection, and with
the knowledge and consent of the physician in attendance.
The ordinary form  which  affects the face  is probably
inoculated through unperceived fissures and  abrasions in
the nasal mucous membrane.  It is especially liable to
attack persons suffering from debilitating chronic  diseases
such  as  nephritis or  the  victims  of  alcoholism.   The
symptoms of infection develop from three  to ten days
after exposure.
  The disease begins Avith rigors or a severe chill folloAved
by  high  feA'er Avhich  persists for several days and then
becomes   irregular.  The temperature  usually   falls  in
about a  week by crisis  or a little  later by lysis.   The
usual symptoms of feA'er  are present—thirst, loss of appe-
tite, coated  tongue, scanty urine,   headache, backache,
general  aching, and  nocturnal  delirium.  In alcoholics
delirium  tremens is  frequent.  The eruption in typical
cases  first appears as a  red spot near the bridge of  the
nose,  and, assuming  the shape of  a  butterfly,  spreads
laterally, upward and  downward.  It invades the scalp,
causes enlargement and  thickening of the ears and infil-
trates the neck.   The inflammation of erysipelas is distin-
guished by  a peculiar "fiery red"  color (St. Anthony's
fire), infiltration of the skin, and a sharply defined border
as the process advances.  In some cases the erysipelatous
inflammation  may  "wander" oAer  a  large  part of  the
body.  In traumatic cases the situation is determined by
the site of the wound.   In babies it begins in the umbilical
stumps.
      19 
290    INFECTIOUS AND PARASITIC  DISEASES

  In some severe cases localized abscesses develop.   In
one instance I saw gangrene of  both hands.  Other com-
plications that may be mentioned are phlebitis, arthritis,
pneumonia, pleurisy, endocarditis, and nephritis.  Relapse
may occur and  second  attacks are common.   The mor-
tality in babies, in the aged, and in complicated cases is
large, but in the vigorous it is small.  The average hos-
pital mortality is about 7 per cent., which is possibly less
than that of typhoid.
  Treatment.—From AA'hat has been said  the prophylactic
treatment is easily deduced.   Erysipelas cases in hospitals
should  be isolated  completely from  the  surgical and
obstetrical wards.  Nurses and physicians in  charge of
such cases should not come  in contact  with patients in
the aboA-e-mentioned wards.   Care should also be  taken
to protect subjects of chronic disease, although the precau-
tions may be less stringent when open AAounds are absent.
The patient or patients should be  quarantined and  the
usual precautions against contagious diseases  should  be
carried  out.  Clothing,  bedding,  discharges, dishes, and
food should  be disinfected.   The  nurse and  physician
should wear gowns and disinfect hands and wash the face
when leaving the ward.  The ward should be cleaned
and fumigated from time to time or Avhen the patients
are discharged.   Similar  precautions  hold for private
cases.  The principal precaution should  be against con-
veyance of infection by the hands or infected objects.
  The  diet should be ample as the patients  are  often
debilitated.  Milk with  cereal additions,  eggs, and broths
will be the mainstay during the febrile period.
  The  medicinal treatment  is not, as  a  rule, specific,
though serums and vaccines  have been used with more or
less success.  Tincture of the chloride of iron and quinin
in large doses are old-fashioned remedies  still much used.
Stimulation is frequently required.  Local applications
are employed in great  \rariety, from  simple cold-Avater
dressings to ichthyol and collodion.   A recent favorite
has been saturated solution of Epsom salt  applied on a 
     INFECTION DUE TO PYOGENIC BACTERIA  291

thick gauze mask and covered with oiled silk.  All appli-
cations should extend beyond the zone of inflammation.
Hypodermic injections of antiseptic solutions, bichloride,
carbolic, etc.,  in  advance of the border of  inflammation
are sometimes used.
  Gonococcus  Infection.—The   micrococcus  gonorrhea?
attacks with great frequency the mucous membranes of
the urethra, A'agina, etc., in adults and of the conjunc-
ti\ra in the newborn.  The conjunctivae are also occa-
sionally  involved in  adults.  It  is one  of the leading
causes  of  blindness.  These  manifestations as  well as
those which follow direct extension from  genital infec-
tions,  such as prostatitis, pus  tubes, pelvic peritonitis,
etc., do not often fall  within the province of the internist.
On the other  hand, the vaginitis of little  girls  (babies)
is  a serious problem  in the management of babies'  and
children's  wards  because it is  difficult to control with
ordinary precautions.  The infection is apparently con-
veyed  by  sheets, night-dresses, napkins,  wash-cloths,
towels, etc., as aacII as by  nurses' hands.  Usually it is
necessary to isolate every case admitted with the slight-
est discharge until a bacteriological examination has been
made,  and in positive cases  to continue the isolation until
no gonococci are found on microscopic examination.  The
patients should wear  a napkin of some  sort to save their
own hands from contamination.   After handling the child
the nurse should disinfect  her own hands with the greatest
care.  It is well to have special  nurses for these cases.
  Treatment.—The treatment of vaginitis is by irrigation
with various silver salts and by the use of vaccines (v. i.).
  Gonorrheal  Arthritis.—The general manifestations of
gonorrhea  Avith which we are directly  concerned are of
two principal  forms:  1. a general septicemia  in which
fever and other symptoms of a mild or severe degree may
develop  with  or  without ulcerative endocarditis.  The
symptoms and treatment of septicemia and endocarditis
haAe been described elsewhere.
  2. Gonorrheal  arthritis or  "rheumatism."  This may 
292    INFECTIOUS AND  PARASITIC DISEASES

be of varying degrees of severity from a simple arthralgia
or pain  in the affected joints  to a seAere suppurative
inflammation.  Occasionally the tendons and periosteum
alone are involved.  The majority of cases arc character-
ized by pain and SAA'elling, frequently of one joint,  as the
knee, at other times of many joints.  Unlike acute artic-
ular rheumatism the SAA'elling  tends to remain more or
less  persistently in the joints primarily affected instead
of skipping about from one to  another.  Unusual joints
such as those of the jaAV or  spine are also attacked.  The
constitutional symptoms such as feA'er and sAveats are less
marked than in rheumatic fever; s\Aeats  indeed are usually
absent.  The local symptoms moreo\rer  are obstinate, and
do not yield readily to treatment by salicylates.
  Careful  questioning  will  usually  elicit  a history  of
gonococcus infection, but in women and children the clue
may be given by microscopic examination  of Aaginal or
urethral discharges, the patient  frequently being entirely
ignorant of the existence of  infection.  To secure a speci-
men the labia should be  separated  and a fresh drop of
pus as it exudes from the urethra or \ragina collected on
a sterile swab and spread on a coAer-glass or slide.   After
the specimen has dried it should be sent  to the pathologist
for examination.   Specimens from the cenix will ahvays
be obtained by the physician, as the use of a speculum is
necessary.  The gonococcus fixation (blood) test is similar
in principle to the Wassermann reaction but less reliable.
Gonorrheal arthritis is said to attack more than 16 per cent.
of those  Avho have acquired the usual form of infection.
It occurs at all ages and  in both  sexes, more frequently
in men.  One author found  that more than 7 per cent, of
his cases of arthritis were of gonorrheal  origin.   Valvular
heart disease  is much  less  common than  in rheumatic
fever; the joint involvement,  however, is much more serious
and frequently leads to permanent disability.
  Treatment.—The  medicinal treatment of  gonorrheal
arthritis  is unsatisfactory.   Salicylates and iodides  are
frequently  employed, but the former are of use only in 
  ANIMAL DISEASES TRANSMISSIBLE TO MAN 293

relieving pain.   In severe  cases splinting is of value  in
conjunction with moist compresses (saturated magnesium
sulphate solution or lead AA'ater and  laudanum) covered
AAith oiled silk or wax paper.  Passi\'e hyperemia (con-
gestion) is also used.  A rubber bandage is placed about
the limb  some  distance above the  affected joint with
sufficient force to obstruct the venous, but not the arterial,
flow.   The extremity will become bluish red in color, but
should not become cold; the artery should be felt in order
to see that it is pulsating normally.  After the patient
becomes accustomed to the compression it may sometimes
be kept up for half a day  at a time.  Active congestion
produced  by moist compresses as described aboAe, or in
the latter stages by baking, is a pleasanter form of treat-
ment and often quite as effective.   If stiffness deArelops
in convalescence the nurse aaUI  be  called  upon  to use
passiAe movements and  massage.
  Gonococcus \raccine has  been found of use in obstinate
arthritis as well as in the vaginitis of  children.  The vac-
cine should be thoroughly  shaken to  emulsify or mix the
bacteria and the required  amount injected  into the sub-
cutaneous tissue by means of a  sterile  syringe, filled
directly from the container.   A point should be selected
Avhere the connectiAe tissue is loose and the  needle should
be  plunged in A^ertically to  aA'oid  pain.  A preliminary
sterilization of the skin AAith alcohol or iodin is of course
advisable. Some  physicians plunge  the needle through
a drop of carbolic solution Avhich acts as an analgesic  as
well as an antiseptic.
  Prophylactic precautions are unnecessary, except when
a discharge exists.   In such cases napkins, linen, and other
articles liable   to  contamination  should  be  carefully
sterilized.

  B.  ANIMAL DISEASES  TRANSMISSIBLE TO  MAN.
  Tetanus.—Tetanus is  primarily a disease of the lower
animals and particularly of horses, and is due to a bacillus
(bacillus tetani) which is abundant about  stables and in 
294    INFECTIOUS AND PARASITIC  DISEASES

garden earth.  The organisms flourish  only  when  pro-
tected from the air and are therefore apt to infect punc-
tured or contused AA'omids, but rarely or never open incised
wounds.   Birth injuries in Avomen and umbilical infections
in babies are occasional  portals of entry.  At times the
site of inoculation is so  slight as  to be  oAerlooked  alto-
gether.   Vaccination wounds  have occasionally  been
infected  by this organism, but AAith very 1'cav exceptions
this has been due to lack of care in the treatment of the
abrasion  and not to the virus  itself.  Vaccine  virus is
prepared Avith great care  to avoid any contamination, and
as an additional safeguard animal injections are made to
determine its freedom from the  bacilli.   Tetanus is  Aery
preA-alent in tropical countries Avhere conditions are fav-
orable to its growth.  In this country  it almost  always
arises from  wounds, and until the  agitation for a "sane
celebration"  aajis  a common sequel of Fourth-of-July
injuries.   The disease is a very fatal one, its severity being
gauged by the length of incubation.  Those cases which
develop AA'ithin  a  feAv days of injury are extremely fatal,
AA'hile those which develop after several weeks are usually
mild. The  symptoms are due to a toxin which attacks
the neiwous tissues; the bacteria themselves do not invade
the blood.
  Symptoms.—The first symptom is usually stiffness of the
jaAvs Avhich may ultimately lead to "lock jaw," hence the
popular name of the disease.  The spasm of the facial
muscles often gives the victim a ghastly  "sardonic" grin.
The  muscles of the neck and back become still' and the
abdomen is  board-like in its rigidity.  The limbs are less
rigid than the trunk.  In severe cases the slightest irrita-
tion, such as a flash of light, a loud noise, or a sudden
movement or touch, brings on severe tetanic  spasms
(tetanus  means straining) which  are most distressing to
the patient.  The head is drawn  back  and the spine is
arched.   Sometimes the cramps are so severe as to prevent
respiration;  in other cases death follows from starvation
on account  of  the  impossibility  of feeding the  patient 
  ANIMAL DISEASES TRANSMISSIBLE TO MAN  295

through the locked jaws.  The fatal issue may be due to
simple exhaustion  or to  complications.  In favorable
cases the rigidity gradually relaxes, the spasms cease, and
ultimately complete recovery ensues.
  Treatment.—When  infection is suspected, antitetanic
serum may be given to the patient with reasonable cer-
tainty of preventing  the  onset  of the disease.  In  war
injuries it is customary to give  1500 "units" at once or
in divided doses  (500 "units" weekly).  In severely lacer-
ated wounds Avhich cannot be made aseptic amputation
is sometimes a life-saving measure.  I have several times
seen lives sacrificed in an attempt to save a badly crushed
finger or hand.  Deep punctured wounds, e. g., by nads
incrusted with garden  or stable soil, should be  freely
incised.  The  South Sea islanders are said  to have  poi-
soned their arrows by coating them with gum and  soil.
The patient himself is not a danger to others but should
be isolated for his own benefit in a perfectly quiet, dimly
lighted room.  He should be disturbed as little as possible.
  When  there is sufficient room between the teeth the
patient should be fed  in the usual manner with a feeding
tube or spoon; at other times gavage may be employed.
The tube is passed into the esophagus through the nose,
or even through the mouth after several teeth have been
removed. Rectal  feeding  is  another  possible  resource.
All these measures are bad inasmuch as they disturb the
patient  and are  only  employed  to avert starvation  and
exhaustion.  The  foods  employed  should  for  obvious
reasons be as concentrated as possible.
  Medicinal treatment  consists  in  the use  of sedatives
to palliate the symptoms  and to permit  of the adminis-
tration  of  necessary  treatment, and  of various  drugs
which have been thought from time to time to be of some
special value,  e. g., carbolic acid hypodermically.  The
use of antitoxin  is the most rational mode of treatment,
but unfortunately is of little avail if given late, when the
nervous tissues have been seriously or irreparably dam-
aged.  Recently I  have seen good results in severe cases 
296     INFECTIOUS AND PARASITIC DISEASES

following the use of multiple antitoxin injections into the
region of the wound, into the veins, into the nerves prin-
cipally affected, and into the spinal canal.
  Anthrax.—Anthrax  is a disease  of  sheep  and cattle
(particularly in the Orient) but is occasionally communi-
cated to man.  The causatiAe agent is a spore-bearing
organism known as the anthrax bacillus A\hich is notable
for its large size and its  resistance to disinfectants.  This
organism is frequently used as a crucial test of the effi-
cacy of any given method of sterilization.  When animal
anthrax has once  gained a foothold in a  country, it is
extremely difficult  to  eradicate  it  from  pastures  and
fields.   Fortunately strict quarantine has largely barred
it from this country.  Infection in human beings generally
results  from handling hides, hair, and avooI taken from
animals that have died  of the disease.  During the Avar
a  considerable  number of cases  have been traced  to
sha\ing brushes.  At times outbreaks result from eating
the flesh of infected animals.   If the disease results from
accidental inoculation, as is usually the case in this country,
it is known as "malignant pustule."  Internal anthrax
may affect either the lungs or  the gastro-intestinal tract.
In the former case it is  often called woolsorter's disease.
A combination of internal and external anthrax may occur.
  Symptoms.—The internal variety of anthrax is  charac-
terized  by seArere constitutional symptoms,  general pains,
bronchitis, or diarrhea, and in the fatal cases by collapse.
The duration is very variable and mortality high.  In
the absence of  an  external pustule the  diagnosis is sug-
gested  by the  patient's occupation.  My  experience is
limited to tAvo  or  three cases  of  the external type.  In
these, after an incubation  of "one to five days,"  a large
central  blister  appears  surrounded by  a  ring of small
blisters, the Avhole fancifully compared to  a signet ring.
The center is subsequently converted into a black slough
while all the surrounding tissues become hard and sAvollen,
simulating pigskin.  The disease is more fatal when the
face is affected than when it attacks the extremities. 
  ANIMAL DISEASES TRANSMISSIBLE TO MAN  297

  Treatment.—Hides, hair, etc.,  from infected  localities
should be effectually disinfected.   Cases under treatment
should be isolated.  Any discharges from the wound or
from the nose or throat should be received on gauze  and
burned.  If disinfectants are  needed these should be used
in strong solution and for a prolonged period.  Injections
of phenol (carbolic acid)  solution around the pustules are
sometimes useful in limiting the disease.  Some authorities
adA'ise destruction of the pustules Avith the cautery.   In
conjunction Avith these measures anti-anthrax serum may
be administered, locally (by  injection),  intramuscularly,
and intraAenously.
  Glanders. — Glanders  is due to the  bacillus  mallei.
Like anthrax it is found, as a  rule,  in  animals;  in  this
case in the horse. It is  accidentally inoculated  into per-
sons Avho come in close contact Avith diseased animals.   It
may affect either the skin (farcy) or the nose and respira-
tory tract, and  in either case may assume an acute or a
chronic form.   In the nose,  nodules like large pimples
form and later discharge pus.   The mortality is extremely
high.  Osier  states that it has caused more deaths among
laboratory workers from accidental inoculation than  any
other germ.  On account of  its  rarity a discussion of its
symptoms and treatment is hardly necessary.  The pre-
ventive measures would be  similar to  those  used in
anthrax.
  Actinomycosis.—This,  again,  is  a disease  ("lumpy
jaAv")  primarily of cattle and pigs, and only  secondarily
of man.   It  is due to the ray fungus, a Aegetable para-
site of a higher type  than the bacteria.  This fungus may
gain entrance through wounds or abrasions of  the skin
or mucous membranes (although by what means is uncer-
tain), or it may be conveyed by food.  Various forms of
the infection  haAe been described affecting the  skin,  the
digestive  tract,  the  brain,  and  the  lungs respectively.
The form last mentioned, Avhich is the one we usually see
in man,  resembles  chronic  bronchitis  and  pulmonary
tuberculosis.   Fever, wasting, cough, consolidation, and 
29S     INFECTIOUS AND PARASITIC DISEASES

cavity  formation  in the lung occur just as in the latter
disease.  The diagnosis is made by the discoAcry of the
ray fungus and the absence of the tubercle bacillus.   The
prophylaxis is uncertain on account of our ignorance of
the mode of transmission.   Disinfection of the sputum or
of other discharges is in order.
  Rabies.—This  disease,  also  knoAvn  as  hydrophobia
and  lyssa, occurs  primarily in dogs  and is communicated
by them to human beings.  In England, a Icav years ago,
the disease  was practically stamped out by rigidly muz-
zling all dogs for a period of  ten  months.  Since  that
time muzzling has been relaxed  except in certain districts
where sporadic cases haAe occurred.  A strict quarantine
has also been maintained against all imported dogs.   The
disease  persists  in this  country owing to varying  and
poorly enforced  regulations.  Other  domestic animals are
susceptible,  including cats, cows, and sheep.  In Russia
Avolves  also  transmit the disease.  The virus is contained
in the nervous system and in the saliva, and is transmitted
by the  bite of rabid animals.   Free local  bleeding and
deep  cauterization Avith nitric  acid are thought  to be
preventives  if promptly employed.   If this method is to
be effectual  anesthesia should be given.
  The  causative  organism has  not yet  been definitely
isolated, but substantial progress has recently been made
in that  direction.   It is probably a miscroscopic animal
parasite.  The incubation  is long,  varying from tAvo or
three Aveeks to as  many months or even longer.  A very
prolonged incubation is suggestiAe of hysteria; no disease
is mimicked oftener than  rabies.  For this condition of
affairs exaggerated dread, morbid curiosity, and newspaper
notoriety  are responsible.  It is a serious mistake, Iioav-
eAer, to deny the existence  of the disease altogether which
some persons,  eA'en physicians,  have been foolish enough
to do.   At the present time experimental evidence and a
distinct  pathology  make scepticism appear baseless.
  Three stages  of the disease  are  described in human
beings:  a preliminary stage of mental depression  and 
    INFECTION DUE  TO PROTOZOAN PARASITE   299

 dread, with irritability of  the  special  senses; a stage  of
 excitement,  occasionally amounting to mania, in which
 this  irritability  becomes excessive  and spasms of the
 throat and  other parts develop; a final stage in which
 paralysis and unconsciousness  announce  the fatal  out-
 come.  The hydrophobia (dread of water) is said to be
 due to spasm of the  throat  caused by swallowing.  Its
 prominence  as a symptom has probably been  exaggerated
 by popular opinion.  The duration of the disease is from
 a few days to a week or more.  The mortality is very high.
   Treatment.—The preventive  measures  as' before men-
 tioned are  largely governmental.  Of  course the saliva
 and secretions of the nose should be destroyed and atten-
 dants  should see that  any abrasions on  their hands are
 protected by collodion, although I  have never heard of
 infection  taking place in this  manner.  It is  a vulgar
 superstition  to suppose that if the dog  is killed  before he
 develops the acute symptoms,  the  person  attacked  will
 be protected.  It is far better to have the animal confined
 and after a proper time killed  and examined.   In this way
 a vast amount of needless worry may be avoided.
   The patient is isolated, but  more for his own protection
 against irritating lights, noises,  etc., than for reasons of
 prophylaxis.   Persons who have been bitten by rabid dogs
 should  receive the  Pasteur  preventive inoculations as
 early as possible.  In the treatment of  the active  disease
 the  free use  of sedatives  and  anesthetics is justifiable.
 If necessary food may  be administered by the nasal tube.

   C. INFECTION  DUE  TO A MINUTE PROTOZOAN
                      PARASITE.
   Syphilis.—This infection, though primarily a venereal
 disease, is  of great importance  in internal  medicine on
 account of its far-reaching consequences.  Even the pri-
mary lesion is occasionally "accidentally," and frequently
innocently, acquired;  in  the  latter case from  infected
husbands, wives, or parents  (congenital form),  as the
case may be.  It deserA^es, therefore, to be  considered 
300    INFECTIOUS AND PARASITIC DISEASES

from a purely medical point  of vieAv Avithout any  neces-
sary reference to morals.  The causative agent is a spiral
microorganism, the treponema pdlidum (spirocheta pal-
lida), AAiiich is generally considered to be of animal  rather
than of vegetable  nature.  The disease may be congeni-
tal, or acquired after birth, and deAelops in three  stages
—primary,  secondary,  and tertiary.  In addition there
are seA'eral  diseases and conditions which  may develop
as the result of the infection, but which have never been
Fig. 54.—Chancre.  (Knowles.)
considered as strictly  a  part of  the disease.  Recently,
however, the treponema has been found even in "paresis,"
which  is  one of these so-called parasyphilitic  diseases
(tabes  and paresis).
  The  primary stage usually manifests itself about three
AA'eeks  after infection by an  indurated  papule (chancre)
on one of the mucous  membranes or occasionally on the
skin.   In the congenital form infection occurs before birth
and the secondary symptoms are  present at birth or soon
after. 
  INFECTION DUE TO PROTOZOAN PARASITE   301

  The secondary stage usually develops from  three  to
six weeks later and is manifested by fever, indisposition,
general enlargement of the lymphatic glands, sore-throat,
skin eruptions, mucous patches in the mouth and  else-
where, and falling of the  hair.  If the eruption is slight
and no general examination is made the case may be dis-
missed as one of simple sore-throat.  The mucous patches
are covered with a grayish-white exudate.  They fre-
quently occur  at the junction of the skin and mucous
membrane and may transmit infection, as in kissing.
 Fig. 55.—Treponema pallidum stained by India ink (Burri method).
                        (Park.)

  The tertiary stage follows after several months and may
last, with latent periods, for years.  It is characterized by
the appearance of widespread manifestations:  skin erup-
tions  in great variety, degenerative diseases of the blood-
vessels in the brain and elsewhere, destructive bone dis-
ease,  tumor-like formations (gummata) in many  tissues
and organs of  the body, etc.  According to  the parts
principally affected the disease  comes under the care of 
   302    INFECTIOUS AND PARASITIC DISEASES

   the dermatologist, surgeon, or physician as the case may
   be.  A brief enumeration of some of the principal condi-
   tions which may be due to this infection folloAA's:  enla rge-
   ment of the lymphatic glands, secondary anemia, general
   arteriosclerosis,  atheroma and aneurysm,  chronic  Aahu-
   lar heart disease, myocarditis, ulceration of the nose and
   larynx, syphilis of the lung, gumma of the tongue, tonsils,
   and palate, stricture of the esophagus and rectum, gumma
   of the liver,  syphilitic  cirrhosis of  the liA'er,  venereal
   AArarts and other genito-urinary conditions, cerebral syphilis
   (tumor), paresis, spinal syphilis, locomotor ataxia,  falling
   of the hair, multiform  skin eruptions, ulcers  (especially
   in upper half of leg), syphilitic rheumatism, periosteitis,
   induration and destruction of the bones (e. g., those of the
   nose, forehead, sternum, and shins).
      As a rule syphilitic processes  are  accompanied  by no
   pain, or  by very much less than Avould be anticipated
   from the extent  of the damage inflicted.  The pains when
   present are often Avorse at night.   Skin eruptions are
   usually free from itching which often distinguishes them
   from diseases similar in appearance.  In women habitual
   abortion or miscarriage is suggestiAre of syphilis.   In the   ,
   last feAV years the diagnosis of early and of late  or obscure
   cases has  been  greatly facilitated by the Wassermann
   reaction.   This  is a complicated test for which h\re or
   more  cubic  centimeters  of blood  are desirable.  This
   may be obtained by aseptic puncture of a vein as in mak-
   ing blood cultures or by a puncture  of the finger or ear,
.   as in making a  blood count (a deep stab is necessary).
   The  blood is collected in clean, narrow test-tubes and
   allowed to  stand until  the serum has separated. The
   pathologist uses the clear serum for the test.   A positive
   report indicates  that the  patient has had syphilis, not
   always, however, that his present disease  is due to that
   cause.
      The disease varies  greatly  in  virulence,  due to the
   resistance of the individual, the  results of treatment, or
   other causes.  In many persons the primary and second- 
   INFECTION DUE TO  PROTOZOAN  PARASITE   303

ary manifestations may be so slight as to escape observa-
tion, and yet severe tertiary or parasyphilitic affections
may develop, and vice versa.   In the congenital form per-
sistent rhinitis,  skin eruptions,  and fissures about the
mouth and anus are the  commonest manifestations.  In
later youth and early adult life, interstitial keratitis, deaf-
ness, destruction of the nasal bones (saddle-nose), bone
disease, and nen^ous affections are perhaps the most com-
mon results.
   Treatment.—The treponema has been found in practi-
cally all the lesions  of syphilis, so that care should be
used in  collecting  and destroying nasal and other dis-
charges  or secretions from  moist lesions.  Dishes  and
other utensils liable to contaminations should be kept
separate or disinfected by boiling or by bichloride of mer-
cury solution.   In hospitals  separate  wards should  be
provided for active  cases AAith  external manifestations.
Municipal or state control of prostitution has not met
with success, except perhaps in the army and nsivy, largely
on account of the  inherent  social and moral difficulties
of the  situation.  Compulsory "prophylactic" treatment
as enforced in the army and navy has on the other hand
been most effective.  In one state a  law was recently
passed requiring medical examination before marriage, but
it was declared unconstitutional by the courts.  The most
practical  methods  aside  from  moral  instruction are:
education in regard to the dangers of the disease, the pro-
vision  of adequate hospital  facilities for the treatment,
so far  as possible, of all active cases, and  compulsory
notification to secure proper supervision of the patients.
Information thus obtained should of course be regarded
as confidential in order to aA'oid unpleasant notoriety for
the unfortunate victim.   Even ordinary active treatment
may be regarded in a real sense as prophylactic, since it
prevents the development of contagious lesions and in
pregnant women often insures the; birth of a living child.
  Until recently the accepted treatment AAras by mercurial
preparations—mercury  ointment (inunction), gray pow- 
304    INFECTIOUS AND  PARASITIC DISEASES

der (infants), calomel (inhalation), bichloride of mercury,
yelloAv iodide  and  red  iodide  (by mouth),  salicylate of
mercury  (hypodermically)—in appropriate  doses,  suc-
ceeded or combined Avith potassium iodide.   The mercury
was usually giA'en in as large doses as the patient could
tolerate without poisonous manifestations  (saliAation and
diarrhea).  The iodide aajis  also giA'en in ascending doses.
For early cases a course of about tA\o years aa;is usually
recommended.   If the treatment aajis taken up at a differ-
ent stage it AAas Arariously modified.  A  few years ago
Ehrlich's  sah'arsan and later his neosalA'arsan (similar
or identical compounds are arsenobenzol, arsphenamine,
neoarsphenamine,   neoarsaminol,  etc.) were  introduced.
These are powerful arsenical preparations which -ire admin-
istered in sterile solution intraAenously.  All the apparatus
used must be  sterile and the arm should be prepared as
for a blood culture.  In the case of  neosahrarsan cold
sterile  AA'ater is used for  preparing the  solution.  The
special funnel is first filled Avith Avater or Avith salt solution
to expel air from the apparatus, the needle is introduced,
and after a free Aoav is assured the water is replaced by
the freshly prepared medicinal solution.  The fluid is
run in  sIoavIv and is followed by a little water to secure a
full dose and to prevent irritation of the tissues by the
arsenic.  On account of the  variations  in  technic  and
apparatus a fuller description is unnecessary.  It Avas at
first  hoped that salvarsan Avould effect a complete cure
after one or  tAvo  injections,  but although  the results
obtained have in many  cases been remarkable they have
fallen short of this ideal.  It has been found that a series
of doses  is preferable and most physicians combine  this
treatment Avith an old-fashioned "course"  of mercury and
iodides. 
CHAPTER  III.
INFECTIOUS AND PARASITIC DISEASES-
                   CLASS II.1
         (a)
Malaria.
Filariasis.
Yellow Fever.
Dengue.
            (&)

Sleeping Sickness.
            (c)
Texas Fever.
Rocky Mountain Fever.

            (d)
The Plague.
            (e)
Typhus Fever.
Relapsing Fever.
Trench Fever.
      A. INFECTION SPREAD  BY  MOSQUITOES.

   Malaria.—Malaria has always been, and still is, one of
 the most  common  and fatal  diseases of the tropics; in
 temperate zones it is far less serious and in recent years,
 owing to improved  sanitation, has decreased enormously
 in frequency.  In the past many conditions were falsely
 labelled malaria, but the discovery of the parasite in the
 blood has  enabled physicians  to diagnose the cases  Avith
 more  accuracy.   In malarial  districts,  typhoid fever,
 tuberculosis, gall-stone  disease,  and subacute  infections
 generally  are  mistaken  at  certain  stages  for  malaria;
 headaches  and neuralgias are also frequently attributed
 Avithout sufficient reason to the same cause.
  Varieties, Etiology, and Prophylaxis.—Malaria is due to
 a minute protozoan parasite known as the Plasmodium
 which is found  particularly in the blood and spleen.
 There are three "specific" varieties of this parasite,  each
 of AA'hich has a special cycle of  development in  the red
 cells  of the  blood.  The "tertian"  organism  ("Plas-
modium vivax") completes  its  cycle within forty-eight
hours.  At the end of this period the parasite Avhich  now
      20
                       1 See p.  267, 
306   INFECTIOUS AND  PARASITIC DISEASES
completely fills the red blood cells segments into eighteen
or more spore-like bodies.  The latter penetrate fresh red
cells and the cycle begins aneAv.  The malarial paroxysm
(chill, fever,  and sweat) coincides with the ripening and
segmentation of the parasites.   If the patient has a double
infection one group of parasites  matures  each twenty-
four hours ("quotidian"); if there is a  single  infection
paroxysms occur on alternate  days (Fig.  52).   This is
the common  form of malaria in this climate.   The "quar-
tan" parasite (plasmodium malaria?) reaches full develop-
ment in seventy-two hours, producing a chill every third
  Fig. 56.—Some of the principal forms assumed by the plasmodium
of tertian fever \v the course of its cycle of development.  (After Thayer
and Hewetson.)

day.  If there are multiple infections there may be chills
on two  days with a free interval of one day, or Avith three
infections, chills every day.  This form of malaria is rare
in this  country but common in the tropics.  The third
variety  of parasite  (plasmodium  falciparum)  causes the
" estivo-autumnal" form of the  disease, so called from its
prevalence in the late  summer and autumn.  Like the
tertian  parasite  this  organism  causes  a  paroxysm  on
alternate days, or in case of double infection,  every day,
but  the fever soon loses its  intermittent character and
tends to become remittent instead of intermittent, that is,
the temperature does not return to normal in the intervals 
         INFECTION SPREAD BY MOSQUITOES     307

 between the febrile attacks (Fig. 53).   After a few days
 peculiar sickle-shaped bodies, known as "crescents,"  are
 found in the blood.  This type of malaria is very prevalent
 in tropical and subtropical climates and is not infrequently
 brought to our sea ports from  the  "Spanish  Main."
 After the  Spanish-American War the  disease was fairly
 common in  Philadelphia.  This  variety  is  sometimes
 known  by the  appellation "remittent fever," and  by
 various local names, such as "Chagres feAer" at Panama,
 and "Roman fever" on the Roman Campagna.
   The malarial parasite finds its natural habitat in  the
 body (digestive tract) of a particular species of mosquito,
 known as  the "anopheles."  It  there undergoes  a cycle
 of development entirely distinct from that which occurs
 in the human  blood cells, and  ultimately reaches  the
 salivary glands of the insect.  Man is an  intermediate
 host and receives the spores from the bite of this insect.
 Mosquitoes in turn are infected or reinfected by biting
 malarial subjects.  The  conditions  for the  spread  of
 malaria are therefore the presence of a special variety
 of mosquito and of infected human beings  to  keep the
 disease alive.   If there were no  human "carriers,"  the
 disease would soon die out on account of the short life of
 the mosquito, and if there were no mosquitoes, the same
 result  would ensue, because there Avould be no means of
 transferring the disease  from person  to person.  Pre-
 ventive  treatment  accordingly concerns itself Avith two
 principal objects.  First,  the cure  of  infected persons,
 and  second, the destruction of  mosquitoes and of their
 breeding places.  In Italy the government supplies quinin
 in malarial districts in the  hope of curing  the chronic
 cases which carry the  disease over  from  year to year.
 In other infected localities (Panama) hospitals and houses
 are screened with fine mesh wire.  Pools, cisterns, and
 receptacles,  even tin cans, which might  serve as breeding
 places for the mosquitoes are screened, filled up, or other-
wise rendered  harmless.  Pools,  swamps, and sluggish
streams which cannot be filled up or drained are treated 
308    INFECTIOUS  AND PARASITIC  DISEASES

with petroleum and other insecticides.  During the recent
Avar a combination of the use of quinin Avith measures of
sanitation was successfully utilized  to  control  malaria
in the cantonments of the rice field districts.
   Symptoms and  Treatment.-—Ordinary  tertian  malaria
is characterized by a regular  succession of severe chills
and rigors  folloAved  by high fever and profuse sAveats.
Eacii  during the  chill  the rectal temperature  will  be
found to  be high.  The patient  appears to be extremely
ill, but after the lapse of four or five  hours the tempera-
ture falls  and a state of complete or comparatiAe  comfort
is restored, which  persists until the onset of the following
paroxysm  tAventy-four or  forty-eight  hours  later.  In
untreated cases the chills tend to become less regular and
to occur  a feAv hours earlier  than Avould  be expected.
During the  paroxysms the  patients frequently suffer
from headache, backache,  and general pains.   Occasion-
ally  there is delirium or eAen stupor and coma.  Loss of
appetite, coated tongue, and disturbances  of  the bowels
(diarrhea  or  constipation)  are  symptoms of common
occurrence in this disease.  After  a succession of severe
chills there develop decided weakness, pallor, yellow or
sallow hue,  enlarged spleen,  and albuminuria.   Fever
blisters on the lips and nose are  very characteristic of
this  affection.  In this form of malaria quinin  is an abso-
lute  specific acting  in  an almost miraculous manner.
Usually 15 to 30 grains are given in divided doses shortly
before an  expected chill.  This does not entirely prevent
the  chill,  but destroys the minute parasites,  which are
at that time set free into the blood stream by the bursting
of the ripe  segmenting parasites.  (There are other less
plausible explanations.)  If there is a double  infection a
similar dose  is required the following day.   After that
quinin is continued in  decreasing doses and finally stopped.
It is  usual, however, to administer a large dose at intervals
of a AA'eek or less  until the possibility of recurrence has
disappeared.
  The estivo-autumnal type, Avhich is also occasionally 
        INFECTION SPREAD BY MOSQUITOES     309

seen in our hospitals runs a course in the early stages very
like  that of typhoid fever,  although the temperature
is somewhat more irregular and remittent.  The patient
is prostrated and may present most, if  not  all,  of the
so-called typhoid symptoms, such  as  stupor, low  deli-
rium, brown tongue.  These cases also respond readily to
quinin but not  so rapidly as the ordinary  " intermittent."
Arsenic  is frequently used  as an  adjuvant  to  quinin
during con\ralescence.
  Malignant types of malaria, popularly known as "con-
gestive chills,"  are  marked by  profound  prostration,
unconsciousness,  and sometimes a fatal  termination.
In hot weather I have  seen severe attacks of ordinary
malaria  AAith  unconsciousness mistaken  for   sunstroke.
Another grave  malarial condition is the  so-called black-
water feAer, seen in South Africa and elsewhere, in Avhich
the patients pass  urine deeply stained with blood pigment.
  Filariasis.—Filaria  are small thread-like worms which
infect  man  through the  agency  of mosquitoes.  The
embryos live in the lymphatic vessels and at night wander
into the blood.   They may be found in smears taken at
this time, but not during the day.  The ordinary species,
Filaria  sanguinis hominis, is found  in the tropics and
causes swelling of the scrotum or leg (elephantiasis) and
chyluria (milk-like  urine).  These  effects are  due  to
obstruction of the lymphatics.  Imported cases are occa-
sionally seen in our hospitals.
   Yellow Fever.—Yellow  fever is  an acute infectious
disease of  warm climates,  which occasionally invades
northern latitudes.  In the  eighteenth and early nine-
teenth centuries  severe epidemics occurred in Philadel-
phia and other  Northern cities, and prior  to the Spanish-
American War  local epidemics were not at all  uncommon
in the South.  The disease in the latter case was imported
from Cuba  and Central and South American countries
Avhere  it  was  formerly endemic (constantly present).
Since the Avar,  increased knowledge  of the disease and
improvements in sanitation have caused  it to disappear 
310   INFECTIOUS AND  PARASITIC DISEASES

in this country.   The organism Avhich causes vcIIoav fever
is  in  dispute, but  it is certain  that it  is disseminated
by a special Aariety of mosquito.  This discovery has led
to a  complete change  in  methods of propliA'laxis, and
for this reason the disease deserves some  consideration in
this  place.  Formerly AA'hen yelloAv-fever patients Avere
brought to our ports elaborate disinfection of the ships
and of all fomites,  including infected clothing and  linen,
was insisted upon.  The patients Avere isolated with pre-
cautions as elaborate as in the case of smallpox.  At the
present time  infected patients  are isolated  in  screened
rooms and the mosquitoes, in the hold of the ship and
elseAvhere,  are destroyed  by fumigation.   Exposed per-
sons are detained or kept under observation during  the
period of incubation (fiAre  or six days) but all precautions
as regards  infected  clothing,  etc.,  are  disregarded  as
useless.  It is unnecessary  to consider the symptoms of
the disease in detail.  It is  characterized by a  febrile
course Avith a stage of remission, jaundice, A^omiting, and
frequently  by renal complications.   Sometimes there is
Aromiting of  blood,  so-called  "black  vomit."  In  Cuba
and  other  subtropical  countries, the disease is  usually
acquired in infancy which accounts for the immunity of
the native races.   In adults, particularly  in  foreigners,
the mortality is very high.
   Dengue.—Dengue,  or break-bone fever, may be men-
tioned in this connection.   It is also transferred by mos-
quitoes and occurs in epidemic  form in  warm climates.
Its popular name is due  to the  intense headache,  back-
ache, and  general  pains  Avhich  are present  during  the
fever Avhich is short  in duration, and like yellow fever,
has a period of remission.  The mortality is comparatively
slight.  In this  country it  is practically limited to  the
Southern States.

         B. INFECTION  SPREAD  BY FLIES.
   Sleeping  Sickness.—Sleeping  sickness  is  a  disease
indigenous  to  equatorial Africa and is mentioned merely 
           INFECTION SPREAD BY FLEAS        311

as a type of disease transmitted by flies.   In this case
the parasite known as  the "trypanosome," which causes
the disease, is inoculated by the tsetse fly.  This scourge
has for years decimated large parts of Central  Africa,
but recently there has been  discovered a  special  drug
containing arsenic which is very effectual in curbing the
disease.  This affection is characterized by a prolonged
course (months and even years), general mental hebetude
or sleepiness, and a fatal termination.  It has no relation
to lethargic encephalitis, the sleeping disease which has
recently sprung into prominence (see infantile palsy).

         C.  INFECTION SPREAD  BY  TICKS.

  Rocky Mountain  Fever.—Several  diseases  of minor
importance are transmitted  by ticks, for example Texas
fever  and Rocky  Mountain fever.  According to Osier
700 to 800 cases of the latter disease, with 75 to 80 deaths,
occur annually in  the mountainous regions of Montana,
Idaho, Nevada, and Wyoming.  The symptoms of the
disease, including  the  hemorrhagic rash are not unlike
those of typhus fever.   Prophylaxis consists in "dipping
or scouring" tick infested horses and cattle.

         D.  INFECTION  SPREAD  BY  FLEAS.

  The Plague.—The plague is a very fatal infectious dis-
ease, indigenous to the East, which occasionally spreads
to the temperate  zone.  In recent years there  have been
local  outbreaks  in  California, Louisiana, Cuba,  and
South  America, but owing to  vigorous action by the
health authorities the pest has been kept within bounds.
The famous epidemic of this disease known as the " Black
Death" which raged in the  fourteenth century swept
away  a fourth part of the population of  Europe.  Within
the last few  years the  disease has caused  the death of
tens of thousands of people in India, the Philippines, and
elsewhere  in  the  Orient.  It  occurs in  two forms—the
ordinary or  bubonic plague,  characterized by general 
 312   INFECTIOUS AND PARASITIC  DISEASES

 enlargement of the lymphatic  glands with abscess  for-
 mation  (buboes), and the pneumonic form.  Both are
 extremely fatal, the mortality being higher than that of
 any other infectious disease  (90 to  100  per cent.).  The
 causal organism is knoAvn as the "bacillus pestis."   The
 disease appears to be actively contagious in  the  pneu-
 monic form, but is usually conveyed through the agency
 of fleas.   These not only carry the disease from one per-
 son to another but also from rats and other rodents to
 human beings.  The  incubation is from  tAvo to ten days.
  The prophylaxis of  the disease  is largely  concerned
 AA'ith the destruction of infected animals, principally rats
 and squirrels, and of the insect carriers.   The disease is
 therefore controlled in part by general sanitary improve-
 ments, and in particular by a campaign directed against
 vermin.   The difficulty in exterminating rats  is greater
 than anyone  not conversant Avith  conditions in ships,
 wharves, granaries, and public storehouses would suppose.
 The symptoms and course of the disease need not be
 discussed since it is unlikely  that  cases will come under
 observation.

  E. INFECTION SPREAD BY  LICE OR  BED-BUGS.
  Typhus  Fever.—Typhus  fever, also known as ship
 feA'er and jail fever, is a disease of uncertain cause trans-
 ferred  by lice.  At  one time it Avas  almost as  prevalent
 as typhoid fever, and  until the  end  of the first third of
 the  nineteenth century the  two  diseases  were usually
 considered identical.   Dr. Gerhard,  of the Philadelphia
 General Hospital, deserves the credit for having finally
 distinguished them.  Since then  enteric  fever  has  been
 described as typhus  abdominalis or  typhoid fever in
 contradistinction  to typhus exanthematicus or eruptiA'e
 typhus.  "Typhoid" means typhus-like.  Typhus fever
runs a course of  about two  weeks and  is  characterized
by  a high,  continued  fever which begins  abruptly and
ends by crisis.  In both respects it differs  from typhoid
which  begins  and ends gradually,  i. e.,  by  lysis.  In 
    INFECTION SPREAD  BY  LICE OR BED-BUGS  313

 typhus there is  an eruption  which does not  disappear
 (like that of typhoid)  on pressure because it  is hemor-
 rhagic in character.  The points  of resemblance  in the
 two  diseases are  mainly the  stupor,  low  muttering
 delirium, broAvn  tongue,  and  other  so-called  "typhoid"
 symptoms (really symptoms of toxemia).  The  disease is
 readily transmissible, probably  not so much  by direct
 contagion as through the agency  of the  formerly ubiq-
 uitous body louse.  With  improvement  in sanitation
 the  disease  apparently disappeared in this  country  and
 was thought to be  extinct.  In the last few years a mild,
 infectious disease described as "Brill's  disease" has been
 repeatedly  observed in  New York,  Philadelphia,  and
 elsewhere.  This has recently  been shown to be nothing
 more nor less than a mild form of  typhus fever.  A form
 of typhus also persists  in  Mexico.  Recently the disease
 has  reappeared  in epidemic  form in  the Avar-ridden
 countries of Europe, particularly in Russia, Austria, and
 Serbia.  In  Serbia the epidemic was  checked  largely
 through  the heroic efforts of American physicians  and
 nurses.  Prophylaxis in this disease is  strictly in the line
 of impro\red  sanitation—cleanliness, destruction of ver-
 min, "delousing,"  and  prevention of  overcrowding in
 tenements,  lodging-houses, jails,  etc.
  Relapsing Fever.—Relapsing fever is very rare in this
 climate,  but may be mentioned  as an example of  a  dis-
 ease transmitted by  vermin,  in  this instance by lice or
 bed-bugs.  There are several varieties of the disease the
 best known  of which is caused  by an organism  known
 as the spirillum of Obermeier which is found in the blood
 during the paroxysms.  The name of the disease is derived
 from the fact that severe  febrile  attacks, each lasting for
 four or five days,  alternate  with equal periods of well-
 being without fever.
  Trench Fever. — Trench fever first  appeared in  the
British army in France in 1915 and was later studied by
the American Red Cross Commission. "Briefly" (Tileston)
"trench  fever is  characterized by the sudden  onset  of 
314    INFECTIOUS AND  PARASITIC DISEASES

fever, with  dizziness,  headache, backache, and pains in
the legs, Avhich later become localized in the shins.  The
temperature curve  is  often  characteristic,  showing  an
intermission on the  third or fourth day, folloAved after an
interval of a day or tAVO by a second rise.  The final defer-
Aescence takes place at about the eighth day, and is fol-
loAved by one or several relapses at fairly regular intervals.
There  is no mortality."  The  intenal betAveen  relapses
ranges from four to thirteen days.  The disease is probably
caused by a filtrable virus and is certainly transmitted by
lice.   The  prophylaxis is the  same  as that  of  typhus.
The  treatment is similar to that  of mild influenza—rest
in bed, soft diet, phenacetin, salicylates, etc. 
CHAPTER IV.
    INFECTIOUS AND PARASITIC DISEASES-
                     CLASS III.1

Diphtheria.                 I Pneumonia.
Laryngeal  and  Nasal  Diph-   Course of Disease.
    theria.                    Complications.
  Treatment.                   Treatment.
Cerebrospinal Fever.         ! Influenza.
  Treatment.                  Whooping-cough.
                             Prophylaxis and Treatment.

              A. BACTERIAL DISEASES.

  Diphtheria. — The  term diphtheria  is derived from a
Greek word meaning a membrane and  is applied to a dis-
ease  which is  characterized clinically by  membranous
deposits  on the mucous membranes.  These deposits are
commonly seen in the pharynx, larynx, and nose, rarely
on  the conjunctiA'a and on Avound  surfaces.  The causa-
tive organism (the Klebs-Loffler bacillus) is limited to the
membrane and produces a virulent toxin, which is largely
responsible  for the  symptoms of  the disease.  In the
larynx the  membrane in  itself becomes  of importance
because  it may cause fatal obstruction  to respiration.
Before the  discoAcry of the bacillus,  diphtheria of the
larynx was commonly known as membranous  or pseudo-
membranous croup, but these terms are happily becoming
obsolete.  Diphtheria attacks children between one and
five by preference, but older children  and adults are by
no  means exempt.  Doctors  and nurses are notoriously
liable to infection.  This emphasizes  the  fact that the
disease  is  contagious  principally  for  those who come
in close  contact with the  patients and are exposed to
what  is  known as "droplet" infection.  Infection may
                      1 See p. 268. 
316     INFECTIOUS AND PARASITIC DISEASES

also occur through the medium of "carriers" or of objects
soiled  Avith secretions.   "Carriers" are immune  persons
Avho have been exposed to the disease and carry virulent
bacilli in their  throats, or convalescents Avhose  throats
have not been freed from the infection.   There is  prob-
ably no basis for the idea  that  the infection  is  con-
veyed  through the air  in any other manner than I have
mentioned.
  The incubation in diphtheria is brief—one to fiVe days—
and the onset insidious.  The fever is irregular and  only
moderately elevated (lower than in follicular tonsillitis),
and the general symptoms, such as headache and back-
ache, not seA'ere, but the pulse is Aveak and often irregular
and albuminuria almost the rule.  As the disease progresses
prostration becomes marked, but delirium is  not a prom-
inent feature.  Deposit  sare seen on the throat early in
the  disease,  at first  perhaps  on  the  tonsils,  but later
spreading to  the  pillars,  palatal  arches, and pharynx.
Occasionally the membrane  is  confined  to  the  tonsils.
In all  doubtful cases of tonsillitis, therefore, cultures are
imperative.   After four or five days the membrane which
has been extending over the  tonsils and pharynx begins
to loosen and disintegrate, and in a Aveek or two  con-
valescence is Avell advanced.  In patients receiving prompt
treatment with  antitoxin the membrane  clears up  as a
rule more rapidly. Frequently hospital cases present
no membrane after the first day and no fever except the
temporary rise caused by the injection of antitoxin.  In
other cases toxemia is intense and delirium and prostra-
tion extreme; in some the disease extends to the larynx or
to both nose and larynx;  in still  others  heart  failure,
respiratory paralysis, bronchopneumonia, or kidney insuf-
ficiency causes a fatal outcome.
  Laryngeal  and  Nasal  Diphtheria.—In  the  laryngeal
form  the constitutional  symtoms  may be  slight,  but
the  obstructive  symptoms,  although  they  may  show
remissions, do not disappear,  but tend to increase  until
serious  or fatal interference with  respiration  occurs, or 
BACTERIAL DISEASES
317
until  the  loosening and coughing up  of  the  membranes
bring relief.   The  chief  symptoms  of  obstruction are
inspiratory dyspnea  ("pulling") with  retraction of the
interspaces between the ribs, stertor or noisy breathing, and
cyanosis.   Cases in which resort to intubation or trache-
otomy has been necessary are often febrile and are prone
to develop severe bronchitis and bronchopneumonia.  The
nasal form, while occasionally very seAere, is more com-
monly mild  and its  character  might  not be suspected
except for the presence of. the disease in the throat.  Cases
of this kind are likely if unrecognized to act as dangerous
carriers.  Diphtheria of the conjunctiva, while rare, is such
a  serious  danger to eyesight that great care should be
taken to avoid  it,  or if it occurs to administer prompt
treatment.
   In  convalescence the selectiA'e action of the diphtheria
toxin on the heart muscle, the  kidney, and the neiwous
structures  leads  to  characteristic   and  often serious
sequelae.   Endocarditis  is  not  common but the pulse
may  be  slow, weak,  or  irregular  and  the possibility of
sudden heart failure is  to be dreaded until late in conva-
lescence.  Nephritis is suggested by a pasty pallor and its
presence  is confirmed by the urinary examination.   The
nerves Avhich supply the  extrinsic  muscles of the  eye,
the muscles of  the palate and pharynx, the muscles of
respiration, and the muscles of the extremities are all fre-
quently involved.   The throat  paralyses cause difficulty
in swallowing and regurgitation of food through the nose.
   Treatment.—The  prophylactic treatment of diphtheria
is  an interesting  one.  Non-immune  persons,  particu-
larly  children  in  hospitals  or homes Avho  have  been
exposed,  should receive prophylactic  injections  of anti-
toxin, 500 or more units, dependent on age and other
circumstances.   This treatment has been successful in
checking the spread of the malady and  in reducing the
mortality in  these classes of  persons.   Unfortunately
the  immunity  afforded  is   a  passive  or borrowed
one and  does not persist for any length  of time so  that 
318   INFECTIOUS AND PARASITIC DISEASES
recurring epidemics  may require subsequent  injections.
These might  be unobjectionable  except for  the very
rare  occurrence of  anaphylactic shock  and  the  more
common  serum  sickness Avhich  is manifested  by  hives
and other  eruptions.  Recently  less  prompt  but  more
permanent  results have been obtained  by the use  of
a  toxin-antitoxin mixture  (1  c.c. subcutaneously—three
doses).  At  the same  time most of the  objections  to
prophylactic  injections have  been met  by the  intro-
duction  of  the  Schick test1  which  enables us to dis-
tinguish immune from non-immune persons.  The latter
alone  require  protection.  In  diphtheria  a  strict  quar-
antine should be  maintained until  two or more suc-
cessive cultures have been  reported  negative.  Sputum,
nasal and aural discharges  should be collected  and de-
stroyed; all  utensils  should be boiled or othenvise ster-
ilized; food  should be burned; clothing and particularly
handkerchiefs  and  linens should  be   disinfected  by
fumigation, by antiseptic solutions, or by boiling.  The
nurse  and  physician  should   protect themselves  from
infection by avoiding close proximity to the patient when
the  latter  is  coughing.  When  applications are  being
made exposure is unavoidable, but some protection may
be  giAren  by a gauze mask.  A spray for the nose and
throat—1 to 10,000 bichloride  of  mercury—is possibly  of
some prophylactic value against infection.
  The treatment of  diphtheria consists in  the adminis-
tration of adequate  doses of  antitoxin  at  the earliest
possible  moment and  its  repetition Avhen necessary.
Massive  doses sometimes  save life even  in apparently
desperate cases.  The  dosage  ranges  from  10,000 units
upward  according  to  the  age of  the patient  and the
severity  of  the case.   It may be administered subcuta-
neously (back, abdomen), intramuscularly (thigh, buttocks)

  1 A minute amount of diphtheria toxin is injected into, not under, the
skin, by means of a fine hypodermic  needle.  In from  twenty-four to
forty-eight hours a red areola appears in persons who have  no natural
resistance. 
                BACTERIAL DISEASES             319

or—in late cases—intravenously.  The old drug treatment
with calomel or bichloride of mercury is sometimes used in
doubtful cases or in emergencies.   The general treatment
consists of stimulants, diuretics etc., as indicated by the
condition  of the  patients.  Strychnin, caffein,  atropin,
whisky,  and ammonia are  often necessary.  Fresh air
treatment  is valuable in toxic cases.  Local treatment is
not  usually  necessary;  the  best known  application is
Lofner's  solution  which  contains  toluol  and   chloride
of iron.  After preliminary  drying of the  mucous  mem-
brane this  solution  is applied by the aid of cotton swabs.
  In  laryngeal  diphtheria  steam inhalations  (croup
kettle and croup tent), medicated or plain, are of value.
Fig. 57.—O'Dwyer tube, obturator and handle.  (Koplik.)
If  obstruction  is  progressively increasing, as indicated
by  respiratory  distress  and  cyanosis,  intubation  or
tracheotomy  becomes  necessary.   In this  country  the
former operation is always the  method of choice, as it is
safe, bloodless, and  in  the majority of cases effectual.
The operation of intubation consists in the introduction
of a special hollow tube  (O'Dwyer's), of a size suitable to
the age  of  the patient,  into the larynx by  means of  a
curved  instrument called  an  intubator.   This  tube,
which  is usually made of  hard rubber  or gold-plated
metal, maintains a passageAvay of sufficent size to permit
of  easy  respiration.   Cyanosis is  usually  immediately
relieved.  A silk  thread is tied to  the intubation tube 
320   INFECTIOUS AND PARASITIC  DISEASES
on  introduction  and  left  hanging  out of  the mouth.
If difficulty  in  respiration  occurs  within  ten to fifteen
minutes the  tube may be AvithdraAvn by  means of the
thread, otherwise the thread  is cut  and remo\7ed.  Some-
times soft  "piano" wire is  used and allowed  to remain
" permanently."  Otherwise the subsequent removal of the
tube requires a special pair of cur\'ed forceps, known as an
Fig. 58.—Introduction of the tube along the index finger.  (Koplik.)


"extubator."  During the operation of either intubation
or extubation the child should be wrapped in a sheet and
firmly held by the nurse and assistant.   WThen the dyspnea
has permanently disappeared (after two or three days to a
week), the intubation tube may be removed, but it is some-
times necessary to replace  it after removal or after acciden-
tal displacement  (cough).   Sometimes the tube becomes 
BACTERIAL DISEASES             321
clogged and must be removed for cleansing.  A small per-
centage of children—usually of nervous temperament and
ancestry—become chronic "tubers" and  either cannot get
along without the tube or are subject to attacks in which
immediate  intubation is necessary to save  life.
  Cerebrospinal  Fever—Epidemic  cerebrospinal  men-
ingitis (also  knoAvn as cerebrospinal fever and  spotted
~*~   /r.JDt/l<J"
Fig. 59.—Introduction of the tube into the chink of the glottis.  (Koplik.)

fever)  is  due  to  the diplococcus intracellularis menin-
gitidis,  an organism so designated  because it  is found
inside  the pus cells  of  the exudate.   The disease is
endemic in this  country,  sporadic cases occurring from
time to time without any very evident connection with
each other.  Severe  epidemics  also  occur  at  compara-
tively long inter\^als, the most important  one of recent
years being that which  had its chief centers in New
  21 
322    INFECTIOUS AND PARASITIC DISEASES

York and Boston in 1904 and again in 1905.   As a rule
cases are seen late in the Avinter or in the early spring.
Thus a  small  epidemic occurred in Philadelphia at this
season in 1917.  The disease  is not common in the old
or middle-aged,  but is frequent in infancy,  childhood,
adolescence,  and  in young adult  life.  The  organisms
seem to  enter through the respiratory tract, and  infec-
tion occurs principally, if not  entirely, by  direct contact
either with the patient or with "carriers," as in diphtheria.
Infected  objects  (handkerchiefs, pilloAV cases,  etc.)  may
occasionally  convey the  disease, but  the meningococcus
is  fortunately  very susceptible to drying, sunlight, and
simple disinfectants.
  The disease affects  the delicate membranes  (lepto-
meninges) which  closely invest the brain  and spinal cord.
The furrows, or sulci, on the lateral aspect and  the depres-
sions at  the  base of the brain, as aacII as  the surface of
the spinal cord, are covered with a creamy exudate.  The
cerebrospinal fluid which  surrounds the  spinal cord and
fills  the  ventricles  of the brain is increased  in quantity
and turbid  Avith  pus cells.  The spleen  is enlarged, but
no  other organs  show  any characteristic changes unless
complications haA'e been  present.   In this  it differs from
the secondary forms which are due to  the  pus cocci, the
pneumococcus, the influenza bacillus, the tubercle bacillus,
etc.   In  these forms except the last,  the symptoms are
so similar to the  disease we are describing  that they will
be  merely alluded to  in  their proper sections.  Tuber-
cular meningitis  is different in its manifestation and  on
account  of its great frequency (70 per cent, of all men-
ingitis cases in childhood, Holt), and its terrible mortality
(nearly 100 per cent.), has been described elsewhere (p. 52).
  Epidemic meningitis  is  characterized by a sudden onset,
Avith severe  headache, vomiting, fever,  sensitiveness  to
touch, light,  and sound,  and general rigidity.  Tremor
and convulsions are common.   In typical cases the head
is held stiffly or  draAvn backward, the spine is rigid, the
thighs flexed on  the abdomen, the hands  clenched, and 
BACTERIAL DISEASES
323
the feet extended.  The  patient  generally  lies  on  his
side.  Irritability  is succeeded  by delirium,  stupor, and
finally complete unconsciousness (coma).  As a result of
the loss of appetite  and the mental state  of  the patient,
food is difficult to administer and rapid emaciation occurs,
Bed-sores are  liable to develop because  of the position
and  the poor  nutrition  of the patient.  For  the  same
reason congestion  of the lungs, due to posture, frequently
occurs.   The pulse is at first rapid and Aveak, but may be
slow at the last; the bowels are  constipated.  Intervals
of seeming improAement  occur and the  fever which is at
first high becomes  very  irregular.  Irregular respiration
or Cheyne-Stokes  respiration, with Avhich  Ave are familiar
in nephritis and myocarditis, is also common.  Headache
is a persistent symptom whenever the patient is conscious.
On examination in addition to the posture Ave may notice
inequality of the pupils, herpes  on the lips, and occasion-
ally scattered hemorrhagic spots on the chest and extremi-
ties.  In the Philadelphia epidemic  of 1917 the  spots
(petechia?)  were seldom observed, while  in France  (1918)
they were  a striking feature of the disease.  Cases Avere
even  described in  which hemorrhages  Avere  the only
distinctive evidence of the infection.  If the finger is
drawn sharply across  the  skin  a red  line bordered by
two  white  lines shortly  appears.  If the thigh  is bent
at right angles to the  body it will be found difficult or
impossible to  straighten  the leg on the  thigh.  This
sign is known  as  Kernig's sign and  is  of considerable
diagnostic  importance.   The disease lasts from three to
six weeks or more.  When death occurs it usually results
from  exhaustion  or some complication.   If recovery
ensues there may be a gradual return to normal  condi-
tions, but  only too frequently paralysis,  chronic hydro-
cephalus, or mental impairment  is  the  sad legacy  of
the disease.  There are rapidly fatal  cases which  termi-
nate by death in a few days or hours,  and  cases Avhich
linger  for several  months.  In  the basilar meningitis of
infants  the duration is especially long.  In these cases 
324   INFECTIOUS AND PARASITIC  DISEASES

extreme  retraction  of the head  is the  most noticeable
symptom.  Mild cases also  occur and in these the diag-
nosis may be difficult.
  Of the laboratory  examinations the  most important
is  that  of the  cerebrospinal fluid.  This is increased in
quantity, cloudy in appearance, and  contains  numerous
pus cells and the causative microorganisms.  The fluid is
obtained by  lumbar puncture, an important method of
diagnosis and treatment in this and other diseases.  (See
p. 28.)
  The  prophylaxis  of the  disease consists in a careful
disinfection of  the discharges or  washings from  the ear,
nose,  throat, and mouth, avoidance of direct  exposure
in case of cough, disinfecton  of  clothing and  bedding,
and of  discarded food  and  dishes.   A  nurse who is in
prolonged contact with the  patient should wear  a gown,
for although the danger  of transmitting  the  disease is
slight,  the severity of the affection demands special care.
Persons  Avho have  been  in intimate contact with  the
patient immediately prior to the onset of symptoms should
be kept under obsenation until negative throat cultures
haAre been obtained.
  Treatment.—In a disease  which, untreated, frequently
has a mortality of 75 per cent., treatment had until recently
been more or less hopeless.   Flexner's serum given early
has reduced the mortality to 25 per cent, or less.  Ten to
thirty  mils,  are introduced  by gravity directly into  the
spinal  canal  after  a preliminary removal of an  equal
amount of fluid.  The procedure is repeated once  or twice
daily for several days.   This destroys the micrococci and,
when the changes in the brain and cord have not gone
too far, accomplishes remarkable results.  Serums pre-
pared  for  particular strains of  meningococci   are fre-
quently  e\ren  more effective.  Lumbar puncture is  in
itself  a  useful  therapeutic  measure,  particularly for the
relief   of the  terrible   headache.   Aside from  these
methods medical treatment  is largely one of support and
stimulation.  Good nursing is, however, very essential. 
BACTERIAL  DISEASES
325
The patient must  be frequently turned and  otherwise
cared for  to  avoid congestion of the  lungs  and  bed-
sores.  In  many cases  an air  mattress  is  of  service.
The nose, throat, and mouth require frequent cleansing
with mild antiseptic solutions.  The bladder and bowels
will  also need  attention, as the patients are frequently
unconscious.  Sometimes the nurse will be able to admin-
ister sufficient food in the usual manner—at least the
caloric equivalent of  two quarts of milk and  three  eggs.
At other times it will be necessary to resort to gavage.
This is accomplished  by means of a large catheter and a
funnel.  The catheter is passed through the nose  into the
esophagus; in some instances a stomach tube, passed in
the  usual  Avay, is  preferable.   A pint or more  of  milk
fortified Avith eggs and  milk-sugar may be poured into
the stomach two or three times a day.  In patients who
recover, massage and passive movements will be required,
particularly if there have been any paralyses.
   Pneumonia.—When Ave speak of pneumonia Ave usually
mean lobar or croupous  pneumonia, a malady Avhich  is
caused by the pneumoccocus1 and is noAV regarded as a
general infectious disease Avith its most  prominent mani-
festation in the lungs.   It  is characterized by a  definite
febrile course  and by physical signs indicative of the
typical  pulmonary  lesions.  It  is modified  in many
respects in infancy and old age, in the course of  acute or
chronic complicating diseases, and in alcoholism.  It  is
sometimes difficult to distinguish it from  bronchopneu-
monia (catarrhal or lobular pneumonia) and other irregr
ular types which are not specific infections but may be
caused by a great variety of organisms as well as by the
pneumococcus   (croupous  pneumonia  is rarely  due  to
other organisms).   Croupous pneumonia is common from
late infancy to middle  age, Avhile bronchopneumonia  is
ordinarily most prevalent at the extremes  of life and  in
debilitated persons.  During the great influenza epidemic
  1 Various types of races (Types I, II, III, etc.) of pneumococci are
described which produce corresponding types of disease. 
326    INFECTIOUS AND  PARASITIC DISEASES

of 191S bronchopneumonia  of a very fatal type  attacked
patients  of  all ages—particularl.A- those in the  prime of
life.   Croupous  pneumonia  is  said  to constitute from
1 to 6 per cent, of all diseases and to cause from 9 to 10
per cent, of all deaths.  The mortality of the disease in
private practice is roughly 10 per cent., in general hos-
pitals  about 20  per cent.,  Avhile  in institutions which
receiAre drunkards and subjects of chronic disease in large
numbers it may rise to 50 per cent, or more.  Pneumonia
may therefore  be said to be the most important of  all
acute infectious diseases.  Ordinarily it is not very readily
communicable if  precautions are taken with the sputum,
being on a par in this respect with meningitis.  An undue
susceptibility is as important perhaps as the presence of
the pneumococci  themselves which  are often tolerated by
the healthy throat Avithout apparent harm.  In institu-
tions and elsewhere the disease at times becomes actively
infectious  Avith  deplorable  results.  The  most  recent
explanation for these variations is  that  there are several
distinct races  of  pneumococci  with  varying  degrees  of
virulence and infectiousness.
  At  autopsy in  typical cases  an  entire  lobe is found
consolidated.  The lung contains no air and small excised
pieces sink in water.  The cut surface of the affected lobe
is found  to be of  a deep red color and decidedly  granular
on account of the "croupous" exudate  in the minute air
cells.   If the patient dies in the early stages of the disease
the lobe  may be intensely congested but not solid.  If he
dies very late in the disease the consolidated lobe is gray-
ish in color, and the exudate has begun to soften prelimi-
nary to  absorption.   Only a small part of  the exudate is
ever expectorated.
  The typical signs of pneumonia are caused by  the con-
gestion and consolidation.   Crepitant rales are "sticky"
sounds caused  by the  air  entering  and separating the
walls  of  the congested air cells.  The dulness on percus-
sion is due to the physical  state of the lung.  A similar
"note" may be brought out by tapping a large piece  of 
BACTERIAL  DISEASES
327
meat, while the normal sound has been compared to that
elicited by striking the top of a loaf of bread.   Bronchial
breathing is a sound normally heard over the bronchial
tubes.  In pneumonia this  is "transmitted"  directly to
the ear while the soft, breezy sound normal to the little
air cells is lost because they are completely filled up.  A
dry or fibrinous pleurisy almost uniformly accompanies
the pneumonic consolidation, and is the cause of the severe
pain and  of  the characteristic  rubbing or  scratching
sound  that is often  heard over the diseased  area.  The
pleurisy is usually dry, but in exceptional cases may be
serous  or purulent; in the latter case it consitutes a com-
plication or sequel of some gravity. With convalescence
the consolidated  lung softens and is  rapidly absorbed.
During this stage dulness diminishes and bubbling sounds
are heard  over the  lung.  Sometimes resolution is  long
delayed.   This may frequently justify the suspicion  that
the process is tuberculous rather than pneumonic.  Pneu-
monia  most commonly  affects  the lower lobes but the
upper  lobes are  often  involved in drunkards  and  in the
aged.  In many cases a whole  lung is solidified and in
others  a  large part of both  lungs.  Though  pneumonia
may attack one  lobe after another there is seldom a true
relapse.  I have seen one case only.  Repeated attacks of
pneumonia are, however, very common, as the immunity
which prevents a relapse  appears to be very transitory.
  Course of Disease.—The history  and  course of a typical
case  of pneumonia is somwhat as follows: an  individual
who  may have been in perfect health,  without preceding
coryza or bronchitis, is seized with a violent chill.  This
is frequently attributed to a wetting or to other exposure.
Following this, high fever, rapid respiration,  cough, and
severe  pain in the  affected  side supervene.   The  pain
is  sharp  or stabbing and occurs Avith  respiration.  It is
commonly felt in the chest, but may occasionally  be
referred to  the abdomen and thus give rise to errors in
diagnosis.  The cough is at  first unproductive but later
tenacious,  slightly  blood-tinged  ("rusty")   sputum  is 
32X   INFECTIOUS AND  PARASITIC DISEASES

brought up Avhich adheres  to the lips and is expectorated
with  difficulty.  On microscopic  examination  this  is
found to contain the causative organism.   The fever now
remains  continuously elevated with a  slight morning
remission of little more than  a degree, the respiration is
nearly double its normal frequency (quite out of  propor-
tion to the fever), and the  pulse, which is full and strong,
is increased in proportion to the temperature.  The blood-
pressure  Avhen taken is found  to be well sustained  and the
leukocytes are markedly  increased (leukocytosis).  The
appetite, as in all fevers, is diminished and slight delirium
is present, at least at night.  The skin is flushed and it is
commonly thought  that the  cheek on the affected side
is redder than its fellow.  Fever blisters  (herpes) on the
lips  or nose are an  almost constant finding.  After five
to  nine  days  the  temperature rapidly  falls to  normal
(crisis), the respiration becomes easy, and if the leuko-
cytes are counted a feAv hours later, they are also found
to have  returned to normal.  This  period  of  the  crisis
is usually accompanied by  sweating, chilly sensations, and
a tendency to Aveakness of the pulse, but in simple  cases
no  treatment is required beyond a hot-water bag.  The
patient   should, however,  be  carefully watched  by the
nurse and medical advice immediately sought at the least
untoAvard  symptom.  Sometimes  in otherwise  typical
cases there is a fall of temperature of a temporary nature
just preceding the  crisis  (pseudocrisis).   Coiwalescence
proceeds  rapidly and in another week the  patient may
be  up and about.  The signs of consolidation also dis-
appear with surprising rapidity, but not so quickly as the
symptoms would indicate.
  Failure to develop a high leukocytosis  usually  denotes
a poor resistance and a dubious outcome, or on the  other
hand, a  very mild infection.  Rapid pulse, low blood-
pressure, and blueness indicate a  failing circulation.   A
very full, high-tension  pulse  is sometimes considered an
indication for bleeding; so  also is intense cyanosis.  Exces-
sive pain on respiration is common in extensive  pleurisy 
BACTERIAL  DISEASES             329
or pleuropneumonia.  Brown or "prune-juice" sputum is
found in seA^ere alcoholic pneumonias.  Jaundice is com-
mon in  some epidemics, but does not in itself add to the
gravity  of the case.  Abdominal distention is a condition
that frequently develops and demands assiduous atten-
tion on the part of the nurse and physician.  The urine, as
in all severe fevers, is liable to be scanty and to contain
little albumin.  In pneumonia it is important to maintain
a free secretion for the purpose of eliminating the toxins
as rapidly  and completely as possible.  With high fever
and severe toxemia restlessness  and delirium  are aggra-
vated.  The delirium may be active  or stupor may ensue.
There are  no typical eruptions and  joint swellings occur
only  as complications or sequelae.   The  course  of  the
infection may show Avide  variations from the type.   In
children a  convulsion may replace the chill at the onset.
In  other cases the onset may be insidious and patients
may walk  about  during  the  greater part of the attack.
The fever  may be slight or  in the  aged even absent; it
may pursue an irregular  course and end  by lysis.   In
other cases it may remain at a high  level with severe
general symptoms, or  fresh accessions of fever may mark
the successive involvement of lobes  primarily unaffected.
An irregular fever persisting after the beginning of con-
valescence   usually  points to some complication, most
commonly empyema or tuberculosis.
  Complications.—The possible complications are so mani-
fold that we must limit ourselves to the most important.
In  some cases the course at first simulates pneumonia,
but at  the time of the expected crisis the fever becomes
irregular and all  the symptoms  of  tuberculosis develop.
These cases are  doubtless tuberculous from  the onset,
but it is frequently impossible to  diagnose them except
by their course.   In other cases an irregular feAer persists
and with it the signs of fluid in  the chest are made  out.
A definite  diagnosis of empyema  is  usually made  by
exploratory puncture  and the discovery of pus.   Early
treatment  of empyema by drainage  usually leads to excel- 
330   INFECTIOUS AND PARASITIC DISEASES

lent results, but neglected cases often develop septicemia
and either  die, or  are "operated" late and  recover Avith
deformity of the chest and a crippled lung.  Exploratory
puncture is usually made with a large antitoxin syringe
or with  an aspirator. A small hypodermic  needle Avhich
will suffice for the diagnosis of a serous effusion is liable
to become  obstructed by pus; one of large caliber should
therefore be provided.   If the pus is "loculated" or shut
off in a little  pocket, it may be very difficult to locate
and require repeated punctures,  or even operation if the
diagnosis is practically certain.  A purulent effusion may
also develop in the pericardium, the  sac which surrounds
the heart.  The treatment is similar to that  of empyema,
but the  outlook is much more serious.   Endocarditis,
abscess of the lung, gangrene of the lung, nephritis, menin-
gitis, and arthritis  are a feAv  of  the other complications
that may develop.,  As mentioned at the beginning pneu-
monia may complicate many  acute  and chronic diseases
and be profoundly modified by  them.  It is  one of the
commonest modes of death in the aged and in them the
sign and symptoms are likely to be very obscure.
  Epidemic   Bronchopneumonia. — Bronchopneumonia
and other  non-specific types have been described briefly
under Diseases of the Lungs.  In 1917 and  1918 there
were extensive epidemics  of bronchopneumonia both  in
the military  and   civilian population. As  a rule  the
disease followed measles or influenza but was often seem-
ingly independent.  It was characterized by a high degree
of contagiousness,  extensive pulmonary involvement and
high mortality (50  per cent, and upward).  Both strep-
tococci  (hemolytic)  and pneumococci (as well as other
organisms) were found.  The course of the disease  was
irregular and leukocytosis was absent in most cases.
  Treatment.—The preventive treatment of pneumonia is
simple and consists merely  in  the  disinfection of the
sputum and of  utensils and linen that may  have been
contaminated  by it:  If the disease  shows  an epidemic
tendency, more elaborate disinfection should be carried 
BACTERIAL  DISEASES
331
out,  and  after  convalescence  the usual  cleansing and
airing  of  the  room  or  ward should  be  undertaken.
Pneumonia patients are frequently treated in the wards
with other patients, but it is good practice to keep them
in separate rooms,  both for the protection of susceptible
subjects and the more efficient carrying out of the fresh
air treatment.  This is the practice in the Philadelphia
General Hospital and other large institutions Avhere many
cases are  almost constantly under observation.  During
the pneumonia (postinfluenzal) epidemic of  1918 it was
the rule in military hospitals to isolate patients in tempo-
rary  cubicles improvised  from  sheets.  Gauze masks,
consisting of three of more layers of fine gauze, were also
worn by attendants, both for their own protection and to
prevent them from becoming "carriers."
   Serums and antitoxins  have been used  in pneumonia,
generally  with little success.   Recently  serums prepared
to combat distinct  "types" of pneumococci haA^e been
widely used, with encouraging results.   Some  physicians
employ venesection in robust patients if  they are seen at
the onset.  Quinin and other drugs have also been lauded
as specifics,  but  the majority of  physicians  use a treat-
ment,  AAiiich is  largely expectant ("watchful  Avaiting").
Simple diuretics  (including water) are used to encourage
elimination and stimulants are  administered when needed,
particularly at the  time of the crisis.  Expectorants are
not required in croupous pneumonia,  though they have a
place  in  bronchopneumonia.   Sedatives are  used, AA'hen
other  means fail, to relieve pain  or to check excessive
cough.
   For the pleuritic pain the ice-bag, dry cups, and strap-
ping  are  most   efficient;  poultices,  and  their modern
equivalents  made of clay or chalk and  glycerin, are  less
desirable  on account of  their weight,  inconvenience of
application,  and interference with examinations. Other
applications  less used now than formerly are the local
pack (compresses wet in water and covered  with oiled
silk), the  cotton jacket, the mustard pack, camphorated 
332    INFECTIOUS AND PARASITIC DISEASES

oil, and blisters.  A light Avoolen shirt is probably as effi-
cient as the cotton  jacket and is decidedly more comfort-
able;  frequently nothing but a muslin nightgoAvn is Avorn.
  For  the  distressing  tympanites Avhich often threatens
the patient's life by interfering Avith respiration, the  hot-
Avater bag, turpentine stupes, rectal  tube, and enemas are
used.   A change in diet—omission  of milk—and certain
drugs (such as dilute hydrochloric acid, eserine salicylate)
are also beneficial.
  To  control excessive temperature  and to stimulate the
respiration and the nervous system, sponging and pack-
ing are excellent.   Treatment in the  cold, open air has
much the same effect if the coverings during the febrile
stage  are kept as  light  as  is consistent Avith  comfort.
Hydrotherapy is  hardly practicable in improvised open-
air rooms or Avards but  may  be employed  if there  is  a
Avarm retiring room.  If the patient is treated indoors the
room  must  not merely be A'entilated,  but there must be
an  unlimited  supply of pure, cold air streaming through
it.  In  bronchopneumonia, as seen in the  aged and in
children, on the other hand, the  temperature should  per-
haps be kept up to (55°  and good  ventilation provided.
Other methods Avhich may be mentioned are hot mustard
foot-baths for adults and  full mustard baths for children.
The latter  are used to promote reaction in  cases  Avith
seAere respiratory distress and  cyanosis.   Alternating hot
and cold  baths or  affusions are also  used for the same
purpose.
  It is hardly necessary to insist on absolute rest in  bed,
the use of  the bed-pan and the administration of a liquid
diet A\ith a great abundance of water, lemonade, or simi-
lar beverages.  The excess of fluids  is intended to secure
a  free diuresis and prompt elimination of toxins.  When
convalescence begins,  a  rapid return to  soft  and  solid
diet, largely regulated by the appetite of the patient, is
in order.
  Influenza (Grippe).—Several  diseases  are  probably
confused under the term influenza.   True influenza occurs 
BACTERIAL DISEASES             333
in widespread epidemics which are often Avorld-wide and
are  therefore known  as pandemics.  These  pandemics
occur at comparatively  long intervals (25 to 30 years),
while local epidemics  are of constant occurrence.   The
latter are not always  and perhaps not generally due  to
the same bacterial  cause, but may be brought about by
a variety of organisms, pneumococci, streptococci, etc.
In  their  general symptoms they bear  a  strong resem-
blance to the true  influenza which is doubtless due to a
specific organism (bacillus  of Pfeiffer).  They are  often
distinguished by the terms "grippe," influenza nostras,
or influenzal cold.   The best known epidemic of influenza
(prior to that of 1918) began in Russia in 1889 and within a
few months spread over the whole civilized world.   The
rapidity with which the  disease  spread at first gave rise
to the idea that it was  due to some atmospheric condi-
tion, but  a more  careful consideration  and a study  of
previous epidemics  showed  that  its progress  was not
more rapid than  the  means  of  modern  travel Avould
explain (Osier).  The  epidemic of 1918,  which was asso-
ciated  Avith epidemic (streptococcic) bronchopneumonia,
is  believed to have caused upward of  400,000 deaths
in the United States  during the  months of September,
October and  NoA-ember.  While the epidemic  of 1889-90
was most fatal in debilitated or aged persons, that of 1918
caused  the greatest mortality  in healthy  young adults
(20  to  40).  Pregnant  women were  frequent  victims.
The disease is very contagious and few people  seem to be
immune.  It is probably communicated by direct contact.
The disease  affects primarily  the  respiratory system,
but  nervous  and  gastro-intestinal forms are described
in which  the principal  stress seems to  fall upon those
systems.
  The  disease  begins  suddenly  and  is attended  AAith
symptoms of extreme prostration,  severe  headache, back-
ache, and aching in the limbs.  There is moderate fever
and  some increase  in  the  rapidity of the pulse.  With
these symptoms there is sneezing, cough, coryza, injection 
334    INFECTIOUS AND PARASITIC DISEASES

of the conjunctiva, and in the gastro-intestinal form, vomit-
ing or diarrhea.  In the course of a feAV days, in uncompli-
cated cases, the symptoms subside and convalescence be-
gins.  In spite of the apparent mildness of the disease recov-
ery of health and strength is often slow.  Complications
are frequent, particularly bronchopneumonia, myocardial
weakness, nephritis, meningitis, and mental disturbances.
  Treatment as a  rule is largely  hygienic.  The patient
should be  kept  strictly in bed and protected from cold,
to which patients with this disease are peculiarly sensi-
tive.  On this account it is Avell to  use a flannel nightgown
or to place the patient  in blankets.   The  diet should
be liquid in the  febrile stages and  afterward as nutritious
as the condition of the  patient's stomach will  permit.
The pains in the acute stages  may be relieved by the use
of hot-Avater bags or other local applications, and by the
administration  of  salicylates, phenacetin,  and  codein.
These remedies  are to be used Avith caution in  the weak
and debilitated.  If it were practicable, isolation would be
advisable in all cases, but in  widespread epidemics this is
usually impossible, and it must suffice to guard the young,
the infirm, and  the aged  as far as possible from contact
with affected persons.   That isolation may be effectual is
proved  by the  fact that prisons  and  other  institutions
have  frequently escaped  infection, even  in Avidespread
epidemics.
  Whooping-cough.—Whooping-cough or pertussis, is an
infectious disease of early childhood, although adults and
particularly the aged are occasionally attacked.  It  is
probably due  to a bacillus described by Bordet.  This
organism is found in the plugs of mucus which the patients
spit up after a paroxysm.  The disease is actively conta-
gious and  is acquired by close contact with a case in the
acute stage, rarely, if ever, through a third person.   It is
easy  to imagine that the  atmosphere  surrounding the
patient may be surcharged with suspended droplets after a
"kink."  The incubation is from one to two weeks.  There
are no distinctive pathological changes in the organs. 
BACTERIAL  DISEASES
335
  After a Aveek or  two of apparently simple  bronchitis,
which may be accompanied by slight fever and associated
symptoms, the cough  becomes spasmodic  and soon de-
velops  its typical character.  This second or paroxysmal
stage may last for  a  month or more.  The  paroxysms
may only be  occasional or they may be very frequent
throughout the day and night.   In typical cases  a child
gives a series of spasmodic coughs in the intervals of which
he is unable to take a full  breath.  The  face becomes
congested and bluish and the eyes prominent.  Children
often run to their mothers or nurses as if for protection.
At the culmination of  the attack the child takes a deep
inspiration which is accompanied  by the  characteristic
whoop.   When the attacks are frequent exhaustion may
be pronounced, particularly  as the  child always vomits
whatever food may be  in its  stomach at the time.  This
paroxysmal stage is succeeded by a stage of decline last-
ing tAvo Aveeks or longer.   During this  period the cough
usually retains some spasmodic element.  The total dura-
tion of the disease is not  often less than a month or six
weeks and it may last  for many months if conditions are
unfavorable.   Recovery is more prompt in the  spring and
summer  when the child  can remain constantly in the
open air.  The diagnosis in mild cases in which the whoop
is  poorly marked is at times difficult  and may  depend
on the history of exposure.  While the disease in itself
is  not  serious, its complications make it one of the most
fatal affections of infancy.   Hemorrhage is one of the
most frequent complications. This may take  the form
of nosebleed, it may be subconjunctival, the Avhole white
of the  eye becoming of a  deep red color, or it may occur
in the membranes of the brain.  The last is a most serious
form and may occasion a paralysis (monoplegia) whose
extent  and distribution will depend on the size and situa-
tion of the blood-clot.  I recall a case in which paralysis of
one  arm  was due to this  cause.   Bronchitis and  brocho-
pneumonia are the most fatal complications and are all
too common in young children.  Vomiting and emaciation 
330   INFECTIOUS AND PARASITIC DISEASES

have been mentioned.   Convulsions may also complicate
pertussis and may be a cause of death.
  Prophylaxis  and  Treatment. — Children  attacked  by
whooping-cough should be isolated at once, as the dis-
ease is  contagious  from  the  beginning.   Quarantine
should be maintained at least until the end of the paroxys-
mal stage.   The  child,  hoAvever, should not be kept  in
the house, but  should be allowed to go out of doors and
only restricted  as regards its association Avith susceptible
children, that is, those who have not had  the disease.
The treatment  consists  in keeping the child  as much  as
possible in the fresh air and  in maintaining the nutri-
tion.  When practicable, city children should be sent  to
the country  but in winter time the  fresh-air treatment
should not be pushed to an extreme on account  of the
susceptibility of these patients to pneumonia.  The child
should be protected by light woolen clothing or under-
clothing  as  in  other catarrhal affections.  Some  physi-
cians find a tight abdominal belt of  benefit in limiting
the paroxyms.  Vaccines are now being employed both
in prophylaxis  and  treatment.  Medicinal treatment  is
almost wholly sedative  and should be confined  to those
cases  in which the number of paroxysms is excessive.
Drugs such  as antipyrin, bromides, and monobromate  of
camphor are types of those ordinarily employed. 
CHAPTER  V.
    INFECTIOUS  AND PARASITIC DISEASES-
                       CLASS III.

         A.  BACTERIAL DISEASES  (Continued).

                               Incipient  Tuberculosis of the
                                Lungs.
                               Chronic Fibroid Phthisis.
                               Chronic Ulcerative Tuberculosis.
                               Prophylaxis of Tuberculosis.
                               Treatment of Tuberculosis.
                             Leprosy.

            TUBERCULOSIS  AND LEPROSY.

   Tuberculosis.—Tuberculosis  may be regarded  as  the
 most important  of the chronic infections.   It affects not
 only man, but many species of animals.   In the  human
 subject, practically every organ and tissue  of the body
 may  be  involved.   It  is  therefore of  importance  in
 every  department  of medicine,  but from the  purely
 "medical" point of view pulmonary tuberculosis occupies
 the place of  chief importance.   The symptoms of tuber-
 culosis are produced by the action of the tubercle bacillus
 and its toxins. In advanced cases of tuberculosis, whether
 of the lungs or of other organs, secondary infection as Ave
 shall  see is  frequently responsible for the high fever,
 sweats,  and chills often  regarded as peculiarly character-
 istic of  tuberculosis itself.   These secondary  invaders
are the ordinary pus organisms, the pneumococcus, and
perhaps the influenza bacillus.  Tavo varieties of tubercle
bacilli are found  in human beings:  the human  type and
the bovine type.  These seem to be more or less distinct
the one from the other  and  possess special predilections
     22
Tuberculosis.
  Distribution of Tuberculosis in
   the Body.
  Glandular Tuberculosis.
  Miliary Tuberculosis.
  Galloping Consumption. 
338    INFECTIOUS AND PARASITIC DISEASES

for certain structures.   The human type is the one com-
monly found in tuberculosis of the lungs and is communi-
cated from person to person.  The bovine type is ingested
with the food and  particularly  with milk, and probably
gives rise to most of the glandular tuberculosis in children.
  Tuberculosis is probably rarely, if ever, hereditary; the
prevalence of the disease in certain families is more rea-
sonably accounted for by the inheritance of a frail consti-
tution and by exposure to infection in childhood.   Dis-
semination of the tubercle bacillus is principally due to
the sputum  and to other  discharges  given  off  by the
affected patient.  As a rule the disease is  acquired by
very intimate association since the bacilli  do not  long
survive the effects of light and  drying.  Nevertheless the
danger of  dust should never be  ignored.  Tubercle bacilli
are also  eliminated in the urine  and feces.   Another
source of  infection is from the milk and meat of tubercu-
lous cows, and  although this is not as important as  it
was once believed to be, nevertheless meat should always
be Avell cooked and milk for children should be obtained
from  tuberculin-tested   herds  (pasteurization,  however,
kills the tubercle bacillus).   It  seems possible that many
infections  may  take  place  in   childhood and afterward
remain latent until some intercurrent disease or  chain of
circumstances overcomes the immunity which the patient
has acquired.  A large  proportion of  all  adults harbor
tubercular lesions,  however slight, in  some part of the
body.  These, as a rule, are walled  off completely, but
suffice to  induce a certain degree of  immunity  and to
protect the patient from ordinary  minimum  amounts of
infected material.  Before taking  up  pulmonary  tuber-
culosis in its various aspects, a brief  summary of the other
forms that tuberculosis may assume is in order.
  Distribution of Tuberculosis in the Body .—Respiratory
tuberculosis includes tuberculosis of the  pleura, and tuber-
culosis of the lungs.  Gastro-intestinal tuberculosis occurs
principally in the form of tuberculous ulcers in the small
intestine.   Occasionally the cecum  is affected, leading to 
TUBERCULOSIS AND LEPROSY        339
the formation of a tumor-like mass.  Tuberculosis of the
intestine is frequently, but by no means invariably, asso-
ciated with  intractable  diarrhea.  It  is  commonly  a
sequence of advanced pulmonary  tuberculosis.  In intes-
tinal  as well as in  miliary tuberculosis  tubercles are
frequently found in the liver.  Tuberculosis of the peri-
toneum is a common variety and one that is often suscep-
tible  to cure by operative interference.   Tuberculosis  of
the kidney is a  common manifestation, one kidney being
usually more diseased than  the other.  It may be asso-
ciated with  stone.  Bladder  tuberculosis  is also found  in
these cases.  Tuberculosis  of the ovary is  a common
starting-point for tuberculous peritonitis in women, while
tuberculosis of  the  testicle and epididymis is frequently
responsible for miliary tuberculosis (meningitis) in men.
  Tuberculosis  of the  bones and joints  is common  in
childhood.  In the  large joints it is known as ."white
swelling."  Pott's disease (tuberculosis of the  spine) and
hip disease belong to this group.  In these cases the bone
frequently breaks  down with  the formation of "cold
abscesses" (e. g., psoas abscess).  Glandular tuberculosis
is most frequently observed  in childhood and  attacks by
preference the glands of the neck.   The infection in many
cases makes its way throught the tonsils (disputed). The
glands,  Avhich are at first discrete tend to fuse  together
as  the  disease  progresses,  to undergo cheesy degenera-
tion,  and finally to  break  down  and suppurate.  This
condition accounts for most of the irregular and ragged
scars seen in the necks of  adults.  At  the present day
serious  scarring is prevented by .r-ray treatment  or ex-
cision.  Tuberculosis of  the bronchial   and  mesenteric
glands is less readily diagnosed.  The former may be a
cause of obscure coughs in childhood.   In the abdomen
the condition is knowm  as  "tabes mesenterica."  These
lesions  of  the  bones,  joints, and  glands, Avere formerly
spoken  of as scrofula.  They are discussed in works on
surgery.  The  heart and  blood\ressels are infrequently
attacked  by tuberculosis.   Tuberculous  pericarditis   is, 
340    INFECTIOUS AND PARASITIC DISEASES

however,  not uncommon and  is often  associated with
tuberculosis of the pleura and peritoneum.   Tuberculosis
of the nervous system  is commonly manifested  in  the
form  of tubercular meningitis.  Tuberculosis of the skin
occurs in two principal forms: the anatomical Avart which
is due to  accidental inoculation  in  the  performance  of
autopsies, etc., and lupus.  The latter is an extremely dis-
figuring and  mutilating disease of the skin which pursues
a decidedly chronic course.
  The following forms of tuberculosis Avill be considered
in more  detail in  this  section:  miliary  tuberculosis,
phthisis florida, incipient pulmonary tuberculosis, chronic
fibroid phthisis, and chronic ulcerative tuberculosis of the
lungs.
  Miliary Tuberculosis.—Miliary tuberculosis  is a form of
tuberculosis in Avhich tubercles  are  distributed not only
throughout the  lungs,  but  through  practically every
organ of  the body.  As  a  rule  the  distribution of the
disease throughout the system follows the breaking down
of some old latent focus Avith  invasion of the bloodvessels
or lymphatics.  Sometimes a bronchial lymphatic gland
will open into a small bloodvessel and the  patient who
has hitherto had feAv or no symptoms, Avill suddenly show
evidence of severe infection.  Old cases  of  hip  disease
or Pott's  disease,  which may have been latent for many
years, may  suddenly develop  signs  of  miliary  tuber-
culosis (meningitis)  and terminate fatally  within  a few
weeks.  The term "miliary" is applied to this condition
because the infection is so rapid that the tubercles as a
rule do not progress beyond the miliary stage, and appear
as pinhead-sized  to pea-sized gray  or  yellow  nodules,
scattered through  all the organs.   The symptoms depend
largely upon the distribution of  the  tubercles.  If these
involve the meninges at the base of the brain, the  symp-
toms  are predominantly those of meningitis.  In the ordi-
nary form  the lungs and  other viscera are involved early
in the disease while the meningitis is  a late development.
The  individual lesions are  so minute that the ordinary 
TUBERCULOSIS AND LEPROSY         341
methods of physical examination may give no  definite
information, the only signs being those of bronchitis.
  The  general  course  of  the  disease  resembles very
closely that of typhoid fever, and frequently it is impos-
sible  for many  Aveeks to distinguish  the  two infections.
In miliary tuberculosis the  mind is usually clear  and  the
temperature shows decided  daily variations.  The pulse
is  often more rapid than  Ave would  expect in  typhoid
fever.   In  the earlier stages the laboratory examinations
employed by  the physician are of  little assistance except
the Widal  reaction and  blood cultures.  These if persist-
ently negative exclude typhoid.
  Galloping Consumption.—Another form  of rapidly fatal
tuberculosis  is  phthisis florida  or "galloping consump-
tion."  This begins suddenly with all the symptoms of
ordinary pneumonia.  Frequently the patient may have
been in failing health prior to the onset of the acute dis-
ease.   At the end  of  a Aveek or ten days the so-called
pneumonia  does not clear up, the temperature is  persist-
ent and irregular; and in time, signs of cavity formation
and the expectoration  of  sputum  containing  tubercle
bacilli confirm the  diagnosis.  These patients usually die
in a few months, although it is possible for the disease to
assume a more chronic form.
  Incipient Tuberculosis  of the Lungs.—This is not a dis-
tinct form of the disease, but the early stage of the chronic
ulcerative type.   If the presence of beginning disease at
the apex  is  recognized  sufficiently early, patients may
recover complete health if treated by fresh air, rest, and
proper  feeding.   These  measures  will be  discussed  in
detail  below.  The  suspicion  of  tuberculosis  should be
awakened by a persistent cough,  even of slight degree,
loss of Aveight, digestive disturbances, or anemia without
obvious cause.  Suspicion in these  cases will be strength-
ened if the temperature is found to show a slight  evening
rise.
  Chronic Fibroid Phthisis.—In patients who reco\er from
tuberculosis, the focus  of disease is surrounded by con- 
342   INFECTIOUS AND  PARASITIC DISEASES

nectiA'e tissue and the actual lesion itself may be converted
into a calcareous or chalky nodule.  In persons with more
extensive  invohement but with a high degree  of  resist-
ance,  fibroid induration of a  whole  lobe  or  lung may
occur.   This may limit the spread of  the disease, but
does not bring about complete recoAery or latency.  In
these  cases chronic bronchitis  persists for ten  or twenty
years  or longer.   A large part of the lobe or lung may be
involved by the tuberculous process  and  many of the
bronchial  tubes may be  dilated (bronchiectasis)  as  a
result of  the  chronic cough.  The chest  is frequently
deformed  by the partial collapse of the  affected portions
of the lung.  The patients become emaciated and finally
die, either from  the progress of the disease itself or, more
commonly, from some complicating or intercurrent con-
dition.
  Chronic   Ulcerative  Tuberculosis.—Chronic  ulcerative
phthisis is the ordinary form of  pulmonary tuberculosis.
It is  characterized by more or less  extensive  areas of
consolidation in  the lung, which tend to break down with
the formation of pus-containing  cavities.  As a rule the
pleura which overlies the  diseased lung is  affected, and
after  a number of  attacks  of acute  pleurisy  the lung
becomes more or  less generally  adherent.  Occasionally
a cavity ruptures into the  pleura, and  air, or air and pus
fills that sac (pneumothorax or pyopneumothorax).
  The destructive process in the lungs  is prone to involve
the smaller blooodvessels and occasionally a large artery
may be exposed.   As a consequence  slight or massive
hemorrhages are one of the commonest features of the
disease  and may occur at all  stages.   The hemorrhage,
as a rule, does not prove  fatal.  In the more  advanced
cases  there is a strong tendency to involvement of the
larynx.  In cases in which  the larynx  is primarily or
principally involved, the course is usually rapidly down-
ward.  Tuberculous ulceration of the small intestine is
also a common complication  in advanced cases.  This
is not invariably  attended by distinctive symptoms, so 
TUBERCULOSIS AND LEPROSY        343
that the diagnosis is often in doubt.   Anemia is an early
manifestation of the disease and  is characterized  by a
disproportionate reduction in the coloring matter of the
blood, so that the pallor of the patient suggests a greater
reduction in  the blood  count  than is  found to  exist.
Night-sweats  and  hectic  fever,  which  have  long  been
considered as characteristic  of tuberculous infection, are
to be  attributed to secondary infection with  other bac-
teria.  As  long as the process is purely tuberculous the
diurnal  variations  in temperature  are  comparatively
slight.  One of the benefits  of the open-air  treatment is
that  it tends to minimize secondary infection and thus
to prevent  the development of  the typical  hectic  stage.
  The Prophylaxis of  Tuberculosis.—The  prophylaxis  of
tuberculosis in its widest sense would include  almost the
whole domain of preventive medicine, as tuberculosis is
fa Adored by almost all  unhygienic conditions: overcrowd-
ing, lack of sun and fresh air, lack of cleanliness, insuffi-
cient and improper food, lack  of exercise in the open air,
etc.  It has been found  that  the incidence of  tubercu-
losis  is considerably greater in  certain houses in  which
sunlight and A^entilation are  particularly defective.   With
the  clearing  up  of  the slums  in some modern  cities
the  death-rate  from tuberculosis has rapidly diminished.
Persons who are predisposed to  tuberculosis, not to men-
tion others, should be housed in buildings freely exposed
to  fresh air and sunlight and  free from dampness.   The
food should be of a nourishing quality and should include
an  adequate amount of fat and protein.
  Treatment of Tuberculosis.—The treatment of pulmonary
tuberculosis consists essentially  in rest,  fresh  air, and an
abundant supply of nourishing  food.  Climate, exercise,
tuberculin,  and drugs  occupy an  important but secondary
position.
  Consumptives Avere formerly  advised to go  into  the
open,  and  live a  life of active exertion—riding  horse-
back,  camping, tramping, etc.   According to our present
ideas  this treatment  was bad and suited only  to  a few 
344     INFECTIOUS  AND PARASITIC  DISEASES

exceptional cases.   At present patients with feA'er or rapid
pulse are kept absolutely at rest in bed.   When the acute
symptoms disappear greater activity is  gradually  per-
mitted and finally a certain amount of work is prescribed.
This  is systematically increased and the patient is  not
considered fit for discharge until  he is  able to perform
his usual work Avithout unusual fatigue. In some instances
work is prescribed with the idea of causing a slight febrile
reaction (auto-inoculation  with the tuberculous toxin).
  Fresh air is a very important agent in the treatment of
this  disease.   Where it is  possible, a Avell-screened sleep-
ing porch  or tent should be arranged in the yard or on
a roof or balcony.   When the weather conditions permit
(that is, rain  or snow) the shelter should be completely
opened at  least on tAvo sides so as to allow a free circula-
tion  of fresh air.  Tents closely battened are worse than
ordinary rooms.  Cold, dry air is undoubtely more bene-
cial than Avarm  or damp air, except perhaps in tubercu-
lous  laryngitis, but this should not deter the patient from
taking full advantage of the best that is available.
  Climatic treatment  is not so popular  now  as formerly
because the undoubted  advantages of altitude and dry
air,  etc.,  are  in many cases counterbalanced by the
inability to procure good  food, and  by unsuitable quar-
ters,  homesickness, etc.   Most  of  the   advantages  of
distant  climates may be  obtained  near home—in the
country,  mountains, state  or  national forests, or at the
seashore.   Sea air is especially valuable for those who are
suffering Avith the glandular and bone lesions ("scrofula").
  The most  convenient  diet and  the  one  ordinarily
employed  consists largely  of milk and eggs.   Patients at
partial rest may be given three quarts of milk a  day
corresponding  to two thousand calories, half a dozen eggs
representing nearly five hundred calories, and  a substan-
tial meal making up the total to three thousand.  Very
often four or five  thousand calories a day are adminis-
tered, but  the advisability of excessive hypernutrition is
being questioned.   More difficult to arrange but perhaps 
TUBERCULOSIS AND  LEPROSY         345
Fig. 60.—Outside sleeping room.  (T. S. Carrington.)
preferable is a diet made up of ordinary articles of food
without  large quantities of milk  and eggs.  The object
to be kept in view is  the  maintenance of  nutrition and 
346   INFECTIOUS AND  PARASITIC DISEASES

increase  in AA'eight  up to normal standards.   Allowance
must always  be made for the loss of a certain amount of
fat when active exercise is resumed.
  Tuberculin treatment consists  in the repeated injection
of minimum  doses of tubercular toxins obtained by grind-
ing and suspending killed tubercle bacilli.  When tuber-
culin Avas first introduced, many years ago, comparatively
large doses were employed  Avith results Avhich in most
cases Avere far from happy.   This led to its abandonment
except for diagnosis.  The injection of a moderately large
dose of  tuberculin in  a person or animal possessing a
focus of infection anywhere in the body causes a sharp
febrile reaction.  This is  constantly used  in  the  case of
cattle in order to diagnose the presence of the infection.
In human beings it is employed for the same purpose, but
less often than formerly,  on account of the discoAcry of
less troublesome modes of applying the test.  Von Pirquet
discovered that  if  a little tuberculin  was rubbed  into
an abrasion  on the arm, a  local reaction, Avith  redness
and  slight swelling, Avould appear in  a day or tAvo  if
the patient  Avere infected Avith  tuberculosis.   Calmette
employed a similar reaction in the conjunctiva, but this
is now little employed  on acccount of the possible danger
of injury to the eyes.  The diagnostic value of these and
several  similar  methods  is impaired  by  the  fact that
the majority of  adults have tuberculous  foci, latent or
otherwise, somewhere  in  the body.  They are, however,
of great  use  in children.  This  leads to the modern use
of tuberculin for treatment,  Avhich consists in the use of
Aery minute  doses  administered  hypodermically at suit-
able intervals OA'er a long period of time.  The  dose is
gradually augmented as the patient's tolerance is increased.
Each injection is adjusted to call forth a minimum reac-
tion.   In this manner the patient develops a  resistance
to the tubercular toxins which may enable him to oArer-
come and localize  the  infection.   The effect of  large
doses is to overwhelm the defensive forces of the body and
to facilitate  the  rapid progress of the disease. Patients 
TUBERCULOSIS AND LEPROSY        347
with active tuberculosis who indulge in excessive  exer-
cise  probably  absorb  similar  poisons  from  their  own
diseased tissues  and so encourage the progress of the
disease.
  The medicinal treatment of tuberculosis  is disappoint-
ing.   Innumerable drugs have been proposed as specifics,
but none of them has held a permanent place except cod-
liver  oil and perhaps  creosote.   The former  is to be
regarded purely  as  a food.   The latter administered in
small doses may  relieve both dyspepsia and  bronchitis.
Enormous doses of creosote were formerly prescribed, but
these are now  little used.  Iodin preparations of  various
kinds are credited  by some with curative  properties;
they  are frequently administered by inunction.  Other
drugs are used symptomatically, e. g., codein for excessive
cough, nux vomica for  anorexia, iron for anemia, etc.
  These and other methods of treatment may be carried
out in the patient's home or in a sanatorium.  A  short
residence in a well-regulated institution  is often of  great
benefit  in  instilling into  the patient the importance of
a careful and systematic carrying out of all the details
of the  treatment.  Patients who  cannot command the
necessary facilities for  open-air treatment  at  home can
remain  Avith benefit in such an institution during the
whole course of treatment.  Sanatoria are  also valuable
as refuges for advanced cases, at the same time securing a
certain degree of comfort for the patients and protecting
the general public from infection.
  Leprosy.—The  disease  that  Ave  noAV  call  leprosy is
probably not identical with that  described in the Old
Testament,  which,  according to  the best authorities,
included other  skin  conditions, and particulary psoriasis.
The  disease prevails  extensively  in tropical countries
and sporadically in  northern latitudes.  In this country
there  are local foci of disease in the Northwest, whither
it  has been  brought by  Scandinavian immigrants, and
in Louisiana.  It is  also prevalent in HaAvaii and the
Philippines.   The leper colony in  the  former place is 
348     INFECTIOUS  AND  PARASITIC DISEASES
pIG 6j_—Anesthetic leprosy with mutilating results.   (From a photo-
       graph of a leper in the Sandwich Islands.)  (Ormsby.)

particularly famous.   The disease  is due to an organism
which in many respects resembles the tubercle  bacillus,
and is  probably transmitted in a similar manner.1  The

  1 Some authorities suspect that the bed-bug is  responsible  for the
transference of this disease. 
            TUBERCULOSIS AND LEPROSY         349

popular exaggerated dread  of contagion is unwarranted,
as physicians, priests "sisters," etc., have  lived for years
in comparatively close contact with cases without ac-
quiring the disease; not all  have been so fortunate.  Its
contagiousness is probably  on a par with that of tuber-
culosis.  Leprosy occurs  in two forms,  which are, how-
ever  frequently  combined. The  nodular form begins
as red spots  in  the  skin,  from which  nodules develop
particularly  about the  face, knees,  and  elbows.  The
lumpy appearance in the  face has given  rise to the desig-
nation of "lion-faced."  In the other type nodules occur
in and along the nerves, causing  in the beginning pain
and  later anesthesia.   As a  result of interference with the
nerves the fingers and toes slough off and deep intract-
able ulcers occur.  The disease  is extremely chronic  and
apparently incurable.  Death may result, however, from
some complication or intercurrent disease. 
CHAPTER VI.
INFECTIOUS AND  PARASITIC1  DISEASES-
                   CLASS III.
B. DISEASES  OF UNCERTAIN OR UNKNOWN
                CAUSATION.
Infantile Paralysis.
Follicular  Tonsillitis   and
   Quinsy.
  Treatment.
Glandular Fever.
Rheumatic Fever.
  Course.
  Diagnosis and Prognosis.
  Treatment.
Mumps.
Measles.
  Prophylaxis and Treatment.
German Measles.
Scarlet Ffver.
  Course.
  Prophylaxis and Treatment.
Smallpox or Variola.
Vaccinia.
ClIICKEN-POX.
  Infantile Paralysis.—Acute poliomyelitis has only come
into  prominence as an epidemic disease in the last twelve
to fifteen years, first in the Scandinavian countries, later
in other parts of  Europe and America.  Prior  to  that
time sporadic  cases had attracted attention almost solely
on account of the  paralytic phenomena, the symptoms
suggestive  of infection being  usually so mild as to escape
observation.   As time has gone on, however,  epidemics
have increased in  severity—culminating in that  of 1916
in New  York and neighboring States—and the infec-
tious  features have come more  and  more  into  promi-
nence.   As an evidence of this change of Aiewpoint  the
paralyses  are  now regarded  as  frequent  complications
rather than essential or invariable accompaniments of the
disease.
  About eight years ago the disease was reproduced experi-
mentally in monkeys  by the inoculation material from
patients dead  of the disease.  Since that time the virus 
       DISEASES OF UNCERTAIN CAUSATION    351

has been successfully cultivated on artificial media.  The
causative organism, like the unknown agents which cause
vaccinia  and rabies, are so minute that  they are invisible
under the ordinary microscope and readily pass the finest
filters.  The virus is easily destroyed  by ordinary  anti-
septics—e.  g.,  1 per  cent, peroxide of hydrogen or 1 per
cent,  menthol  in oil—but like  vaccine virus resists the
action of glycerin  (Rosenau).  The infectious  agent is
found on the mucous membranes of the nose and throat
and of the  gastro-intestinal  tract, as Avell as in various
internal  organs and  in the tissues of the  central nervous
system.  The infection is probably disseminated  by the
discharges from the nose and  throat, though the  agency
of  insects   (stable  fly)  cannot  be excluded.  Healthy
"contacts," abortive and convalescent cases seem to play
a  part  in  disseminating the infection.   The  principal
pathological lesions  are  found  in  the  ganglion  (motor)
cells of the spinal cord—hence poliomyelitis.  The  disease
usually  attacks infants or young children though adults
are occasionally attacked.
   Symptoms.—In typical cases of poliomyelitis the course
of the disease  is sharply divided into  two stages  (com-
pared to the  humps of a dromedary  by Draper) sepa-
rated by a  longer or shorter interval  (a  few hours to a
few days) of apparent health.   In  some cases the symp-
toms  remit but do not  disappear.  In  abortive cases
the first stage  alone  is present.  Such  cases can  only
be  recognized  in the  course  of an epidemic.   In other
cases the onset is with the nervous symptoms of the second
stage.  The symptoms of the first stage are not char-
acteristic.   Usually there is  slight fever,  flushed cheeks,
heaviness, coated  tongue, constipation, or there may be
local symptoms; sore-throat, cough, vomiting, or diarrhea.
The symptoms of the second "hump" are related  to the
nervous system: fever, headache, irritability, convulsions,
hyperesthesia, tenderness and rigidity of the back (" spine
sign"), altered reflexes, muscular weakness, and paralyses.
Facial palsy is common  and so are irregular paralyses 
352    INFECTIOUS AND PARASITIC DISEASES

of the extremities.  In fatal cases paralysis of the respira-
tory muscles is common.  The acute symptoms are often
of short duration but the paralyses persist,  though  the
ultimate loss of power is much less than Avould be expected
at first.  The muscles permanently  paralyzed  undergo
atrophy.  One attack of the disease gives a  high degree
of immunity.
  Recently  a new disease has appeared  in  Europe and
America which some authorities  consider a cerebral form
of poliomyelitis, Avhile others believe it a sequel of influenza.
Adults are chiefly affected.  The most striking symptoms
are headache, vertigo, lethargy (stupor), and  progressive
paralyses of the structures supplied  by the cranial nerves
with resulting ptosis, double vision, immobility of face, etc.
The disease has been called lethargic or epidemic encepha-
litis.   Acute infectious  polyneuritis is still another new
disease belonging to the same group  in which there are
extensiAe paralyses of the face and extremities but without
wasting as in infantile paralysis.
  Treatment.—Prophylaxis should be principally directed
to the disinfection of discharges from the nose and throat
and to the isolation of contacts and convalescents.  Dis-
infection of  urine and feces, destruction of food remnants
and careful screening against flies should also be practised,
in short all  the precautions  that would be employed in
the acute exanthemata.  Nurses  and other contacts may
spray the nose and throat with peroxide solution, one part
to tAVO of water.
  The management of the first stage is the same as that of
any mild fever.  In the  second stage early and repeated
lumbar puncture is a valuable diagnostic (increase of cells)
and   therapeutic  measure.  Immune  serum,  obtained
from  persons Avho have passed through an attack of the
disease, is frequently injected into the spinal  canal after
lumbar puncture and in some cases seems to have a favor-
able   effect.   Occasionally severe headache,  respiratory
distress, etc., may follow such an injection.  Under these
circumstances the physician should be immediately sum- 
       DISEASES OF UNCERTAIN  CAUSATION    353

moned and needles  made  ready  for  lumbar  puncture.
Other methods  of treatment,  including the  injection  of
adrenalin chloride, are at present sirf) judice.
  After  the  acute  stage has  passed the physician Avill
make use  of  measures designed  to  restore the greatest
possible  degree of  function to  the paralyzed muscles.
These  include strychnin,  massage,  passive  moAements,
gymnastic exercises, electricity, and  hydrotherapy  (salt
baths).   Among the poor  the mother may be  taught
to use massage and  employ suitable  movements, but in
the Avell-to-do this task will  fall to the nurse or masseuse.
Faradic  (electric) stimulation  is  often of great  use  in
restoring the affected muscles.  Occasionally the galvanic
current may be required.  In the later stages, Avhen com-
plete atrophy has occurred,  orthopedic procedures are in
order.   In a general  Avay these include the use of various
forms of apparatus and operations.   In the last few years
surgeons haAe been successful in restoring  partial or com-
plete use  of paralyzed  limbs  by  the  transplantation  of
tendons.   This  is possible because not all the muscles of
a part are affected.
  Follicular  Tonsillitis and  Quinsy.—Acute  tonsillitis is
an  infection AA'hich is probaly  due to a modified  strepto-
coccus, similar  to or identical with  that which  causes
acute  articular rheumatism.   The  close relation Avhich
exists betAveen recurring follicular tonsillitis and rheuma-
tism is a medical truism.  The various  forms  of tonsillitis
may be  due to distinct microorganisms, or to microorgan-
isms of  the same kind but of Ararying A'irulence (strepto-
cocci) .   The marked variations in the severity of the dis-
ease and particularly in its communicability are sufficient
evidence of this statement.  Most cases are only slightly
contagious, Avhile others deserve the designation of epidemic
or septic sore-throat  (the pharynx is  also inAolved).
  Tonsillitis is  of three general types, features of all of
Avhich may be, and usually are, combined in individual
cases.   In one  type  the "pits" (follicles,  lacunae,  crypts)
in  the  tonsils  are  primarily  involved.   They are  filled
      23 
354   INFECTIOUS AND  PARASITIC DISEASES

with a yelloAvish-Avhite exudate which may be limited to
them or may spread over the whole surface of the tonsil.
Unlike the membrane of diphtheria it  does not spread
beyond  the tonsil  and is  easily  detached Avith  a probe
or applicator.  In a second  type (parenchymatous) the
tonsil is diffusely swrollen and infiltrated, Avhile in a third,
quinsy, the inflammation invohes the tissues Avhich sur-
round the  tonsil  and usually terminates  in suppuration.
In almost all cases of any severity the pharynx is more or
less inflamed.
  Ordinary follicular or  lacunar tonsillitis begins Avith
severe headache,  backache,  and general pains  in the
limbs. There may be a decided initial chill.  The tem-
perature  rises immediately to 102° to 104° and the  pulse
is rapid, full, and strong.  The throat may not be sore at
first but is usually slightly reddened.  By the second day
the follicular deposits are Avell marked.  The involvement
is bilateral. In severe cases there is local pain, which may
be referred to the ears, and difficulty in swallowing solids.
After tAvo  or three days to a week the temperature falls
by crisis and the patient rapidly  recovers.  In the paren-
chymatous type the local symptoms are more pronounced.
The follicles are not especially involved, but there may be
small abscesses in the substance of the tonsil or tonsils.
  Quinsy (suppurative  tonsillitis) is a much  more dis-
tressing affection.  It may complicate or follow  an ordi-
nary attack of acute tonsillitis or it may arise indepen-
dently.   The  local  symptoms are  similar to those  of
tonsillitis  but are much more  marked.  The swelling of
the affected parts together with  the profuse secretion of
mucus and saliva causes considerable  interference with
breathing.  The  patient is usually unable to  take solid
food and even  the swallowing of  liquids causes great dis-
tress. Some persons can hardly open the mouth on account
of the swelling of the tissues and glands about the  angle
of the jaw.  Unlike follicular tonsillitis  the  disease is
unilateral,  or one tonsil after the other is involved.  The
temperature  is moderate  but  irregular  and  disappears 
       DISEASES OF UNCERTAIN CAUSATION    355

when the abscess has opened, whether spontaneously  or
following  incision.  The duration  is  indefinite—a  week
more or less.
  Treatment.—Cases of acute follicular tonsillitis require,
as a  rule, very little  local treatment beyond the  usual
toilet of the mouth and teeth.  An alkaline spray is useful
to rid the  tonsils  and  throat of  mucus.   Internally a
preliminary saline folloAved by salicylates, or  a  solution
of potassium chlorate and chloride of iron suffices in most
cases.  If the initial  pain  and headache  are very severe
acetphenetidin (phenacetin) or some similar  drug is indi-
cated. An ice-bag  or hot  applications  externally are
grateful to many patients.  In quinsy more active local
treatment is  required.  A free use  of alkaline sprays,
gargles, and mouth Avashes aids the patient in  getting rid
of the large quantities of mucus.  When suppuration has
occurred early, incision into the peritonsillar tissue shortens
the attack.
  Persons Avho have  had repeated attackes  of tonsillitis
and quinsy may exhibit glands which are pitted Avith deep
unhealthy follicles and deformed by scar tissue.  In these
cases operation may remove cryptic  (hidden) infections
Avhich are responsible for acute (rheumatic)  or chronic
articular disease (arthritis deformans).
  Glandular Fever.—Glandular fe\er is an  acute febrile
affection,  occasionally seen in children, which is character-
ized by fever of short duration, mild, constitutional symp-
toms and general glandular swelling.   Very  little, if any,
treatment is necessary.
  Rheumatic  Fever.—Rheumatic  fever, which is  also
known as acute articular or inflammatory  rheumatism,
is an  infectious disease  of  uncertain causation.   It  is
probably  due  to streptococci  which  have acquired  a
special predilection for the  joints and other serous surfaces
(endocardium, pericardium,  pleura).   Prolonged growth
in the crypts of the tonsils or in other hidden places seems
to modify the  streptoccoci  so that  they  attack  these
special structures and lose their power to produce general 
^»
356    INFECTIOUS AND PARASITIC DISEASES

inflammatory conditions.  This  hypothesis  is Avorthy of
mention, because  it may explain the frequent incidence
of rheumatism in persons Avho have been repeated victims
of follicular tonsillitis.   Although the disease is infectious
and is present in epidemic proportions in the late Avinter
and early spring,  Ave do not know enough  of  its trans-
mission to take any precautionary measures, aside from the
avoidence of  undue exposure to  wet  and cold, and  the
effectual treatment of attacks of sore-throat and tonsillitis
(including excision  of the tonsils  in many cases).   I Iuiac
frequently  seen  rheumatic persons greatly  benefited by
the latter procedure.
   "Rheumatism"   attacks  children  and  young  adults
by preference  but frequently recurs in later life.   Primary
rheumatic attacks  in middle-aged and old persons seem
to be mild  and  atypical in  their manifestations.  They
are frequently simulated by the various forms of arthritis
which  are so  common  at that age period.   Males (par-
ticularly coachmen, drivers,  carters,  longshoremen, etc.)
seem to be more liable  than  females  on account of their
greater exposure to the elements.  Cold, moist climates
and damp and badly heated houses also predispose to the
disease (England).  Certain families also consider them-
seh'es  rheumatic, though here there is much uncertainty
on account of the failure to distinguish gout, rheumatisms,
arthritis, muscular  "rheumatism," etc.
   Course.—Rheumatic fever usually begins suddenly after
a chilling or thorough Averting.  I remember  sleeping in a
long-unoccupied, chill, "spare-chamber" at a farm house
where  I visited  in  childhood  and waking in  the morning
Avith joints so SAVollen and tender that I was barely able
to craAvl doAvn to the heated part of the house.  Untreated
the disease  lingers for  an indefinite period, usually of
several weeks and  is  accompanied by irregular, but not
very high  feAer and by SAveats.  The  large joints are
successiAely  imrolved,  shoulders, elboAvs,  wrists,  knees,
ankles, hips,  and  occasionally  smaller  joints.   When
new joints are invoh'ed those first affected tend to clear 
DISEASES OF  UNCERTAIN CAUSATION    357
up and Avhen the  disease is  over  no permanent changes
remain.  The affected joints are  red,  swollen, hot,  and
exquisitely tender.  The most characteristic feature of the
disease is its tendency to injure the heart.  It may attack
the lining  membrane leaflets and valves (endocardium),
the heart muscle  (myocardium), or the covering of the
heart (pericardium).  If the valves are principally affected
we  speak  of endocarditis,  if the  pericardium,  of  peri-
carditis,  if  all the structures  of  the heart, of  carditis.
The advent of  cardiac mischief,  as the English phrase
it, is detected by a  rise in pulse  and respiration  rate,
the development of a cardiac murmur,  and later  by  car-
diac enlargement.   Pericarditis is recognized by its special
physical signs, to-and-fro rub, etc.   Pleurisy, pneumonia,
cerebral  symptoms, and  A'ery high temperature are other
complications of rheumatism. Sometimes joint  symptoms
are associated Avith purpura as described under  Purpura
Rheumatica.
  Diagnosis and Prognosis.—Rheumatism is in itself rarely
fatal,  but  as it is the most frequent  cause  of  chronic
Aah'ular heart disease its ultimate consequences  are Aery
serious in  many  cases.  The forms of Aalvular  disease
have been described in Part III.  The close association of
rheumatism with chorea (St. Vitus' dance) may  be referred
to in this connection.  It is questionable Avhether  there is
any such condition as chronic rheumatism  in the sense of
a direct sequence to the acute disease.  Cases so described
are forms of mild  arthritis or inflammation of  the joints,
due to a variety of causes.  Some of them  are mild forms
of rheumatoid arthritis, others  have nothing more behind
them than  flat-feet for example. Acute articular  rheuma-
tism may be confused with gout, Avith the  acute forms or
stages  of rheumatoid  arthritis, AAith infectious  arthritis
(particularly gonorrheal arthritis), etc.
  Treatment.—Patients with rheumatism should  sleep in
flannel pajamas or nightdresses or  between blankets.  If
cardiac complications ensue prolonged rest  in bed may
become necessary.  The diet in the febrile period should 
358    INFECTIOUS AND  PARASITIC DISEASES

be largely fluid Avith cereal additions, but later a simple
but abundant diet should be gi\'en.   This should include
green vegetables, eggs, and a moderate amount of meat,
as these patients are usually  emaciated and anemic  and
require an abundance of  nutritious  foods  rich  in iron.
Many physicians, however, Avould limit  the  meat more
strictly than I have indicated.
  The medicinal treatment of rheumatism is  simple  and
satisfactory.   It consists  of  suitable doses  of  salicylic
acid or some  of its  derivatives.  Alkalies are also used,
either  separately  or in  combination Avith  salicylates,
and  recently  vaccines  have  been  employed by  some
clinicians.  The local treatment is more important from
the nurse's standpoint. If no local medication is employed
the joints may be wrapped in cotton-wool and in severe
cases splinted.  The  feet should  be protected by a cradle
(as pressure is not only  painful but  in protracted cases
may lead to "pointed toe" deformity).  A cotton pad
should also be placed beneath the tendo  Achillis to pre-
vent pressure on the  heels which  is likely to cause necrosis
and ulceration.  A great  variety of local applications are
employed such as lead water and laudanum, saturated
solution  of Epsom  salt,  diluted alcohol, oil  of winter-
green, medicated ointments, etc.  When the swelling and
stiffness of the joints are persistent, massage and baking
are often of use.
  Mumps.—Mumps  (epidemic parotitis) is an infectious
disease Avhich attacks children and young adults particu-
larly.
  The disease  is more prevalent in the spring and autumn
months than at other seasons.  The incubation  is long,
from  two  to  three  weeks.  The disease is  contagious
from the appearance of the first symptoms.   The causal
organism  is not known:  it is thought by some  authors
to be  a diplococcus.   As a rule  the disease is very mild,
beginning with a slight soreness of the throat, which is
soon followed by enlargement  of first  one, and then  the
other  parotid gland.  The swelling is  just  below  the 
       DISEASES OF  UNCERTAIN CAUSATION    359

ear and overlaps the angle of the jaw, which serves to
distinguish it, as a rule, from simple lymphatic  enlarge-
ments, which are beloAv the border of the maxilla.  The
swelling is accompanied by slight fever and malaise which,
however, last only a few days, while the swelling persists
from a week to ten days; the lymphatic glands of the neck
as well as the smaller  salivary glands  are also frequently
swollen.   More rarely  distant  glandular   organs  are
attacked: breasts,  ovaries, testicles,  thyroids, and pan-
creas.  None of  these complications  are common except
orchitis (inflammation of the testicles),  which occurs in
epidemic form in boarding schools and military barracks.
   To prevent  the  spread of  mumps, it is necessary to
isolate the patient for two weeks from the beginning of the
symptoms or for one week after the disappearance of the
swelling.  As a rule no general treatment is necessary,
local cold or hot-water compresses, lead water  and lauda-
num, or  a  simple dressing  of cotton being  all that is
required.  During the first few days a liquid diet is usually
acceptable on account of the difficulty in swallowing.
   Measles  (Morbilli,  Rubeola). — Measles is an acute
infectious disease characterized  by catarrhal symptoms,
fever, and later, a diffuse, patchy eruption.  It is doubt-
less due to microorganisms,  but none have as yet been
discovered.   It is  found in  all climates,  in  both sexes,
and at all ages, but most frequently in children, as their
elders have often been protected by previous attacks.  In
isolated places (e. g., Alaska) where the population has not
been  protected by attacks in childhood, very fatal epi-
demics have occurred  in adults.  Similar epidemics have
also occurred in mobilization camps where large numbers
of unprotected recruits are gathered.  One attack gives
protection in the large majority of cases and physicians
seldom see two attacks in the same person, although such
a history is  often given by patients.  In  such instances
other infections have, as a rule, been mistaken  for measles.
The disease is infectious from the first catarrhal symptoms
and is transmitted  directly  from patient  to  patient, 
360    INFECTIOUS AND PARASITIC DISEASES

rarely  by second persons  or infected objects.  The infec-
tion  seems to be principally contained in the discharge
from the eyes, nose, and ears, seldom if at all, in the
scales.   It is extremely actiA'c, but does not stand drying
or other unfavorable influences.  Infection is  therefore
not air-borne except Avithin short range, as from coughing
and sneezing.  The period of incubation beforethe appear-
ance of the first symptoms is usually ten days, and before
the appearance of the eruption, tAvo Aveeks.
  The   disease  begins  Avith  catarrhal  symptoms   and
fever.  The eyes are red, and  bright light is unpleasant
to the  patient. There is coryza (running  from the nose),
hoarseness, sneezing, cough, and often looseness of the
bowels.  The  inside  of the  mouth  is  red and  swollen,
and  very early  in  the  disease Avhite spots with a red
border, no larger than a pin-head, are seen on the inside
of .the  cheek.   These are  known as  Koplik's  spots  and
although  difficult to distinguish are  diagnostic  of the
disease.  After about four days there is frequently  a
remission of a day  or tAvo in the fever and other symp-
toms on account of which  the patient might be considered
convalescent,  but Avith  the appearance of the eruption
the fever again rises (see  Fig. 49).  The eruption  usually
appears first in the  edges  of the hair, or on the forehead,
or beloAv the ears,  and  then spreads to the face, limbs,
and trunk.  It is even seen on the palms and soles.  It
consists of little elevated  red spots like minute pimples,
grouped in irregular patches with white  skin  between,
giving  the patient  a splotchy  appearance very different
from the uniform  blush  of  scarlet  fever.  The  general
symptoms  continue and the feA'er may be high, but  in a
few days it rapidly falls and convalescence begins.   During
the stage of convalescence desquamation of fine scales
occurs  (lasting for a Aveek or a little more), and the patient,
barring  complications,  rapidly  recovers  appetite   and
strength.   Numerous complications  occur  in measles
Bronchopneumonia is the most important and is  respon-
sible for the large mortality of this  disease in infants or 
        DISEASES OF UNCERTAIN CAUSATION    361

 unprotected adults.  Bronchitis and tuberculosis are also
 common  respiratory  complications,  the  former  being
 serious from its liability to terminate in pneumonia.  Other
 sequels are defects of vision, deafness, and chronic enlarge-
 ment of glands.  The frequency of the latter complications
 can be much diminished by proper care of the mouth, nose,
 ears, and eyes.
  ^ There are many variations in the course of the disease.
 The feAer and catarrhal  symptoms may be very marked
 or almost  absent while the eruption may resemble that of
 other infections or be simulated by them in turn.  Drug
 and  other accidental rashes may also cause confusion.
 Combinations with diphtheria, scarlet  fever, and  other
 infections  are not rare.  The prognosis is largely deter-
 mined by  these and the previously named  complications.
 Uncomplicated measles is  not  a serious disease  but  the
 frequency of  bronchopneumonia and of  other grave com-
 plications  makes it one of the most fatal of all infections.
 It is therefore not to be regarded lightly, especially in
 undernourished or frail infants.
  Prophylaxis and Treatment.—Prevention is very difficult.
 Notification,  quarantine,  and other public measures  are
 of little avail since the most infectious period has usually
 passed before the  diagnosis is certain.   In some places
 all regulation has been given up as useless, but  it seems
 wiser to attempt to guard, as far as possible,  children
 unprotected by a previous attack, and to disregard others.
 In hospitals and homes the patients  should be isolated
 in Avell-ventilated rooms with the bed so placed that the
 light does  not strike the  eyes.   The  nasal and other
 discharges  should be disinfected as well as utensils and
 clothing exposed   to  contamination.    The  attendants
 should wear goAvns and caps  and  disinfect their hands
 and  faces  before leaving  the room.   Quarantine should
 be maintained for "ten  clays  after the appearance of
 the rash and until all discharges from the nose, ears, and
throat have disappeared and until all cough has ceased."
The  scales  are not important, but their diffusion should be 
362   INFECTIOUS AND PARASITIC DISEASES

limited by the use of ointments and the usual antiseptic
bath at the end of the illness.
  Treatment is largely symptomatic.  The patient should
be kept in bed from the first and a fluid diet administered
during the fever.  As soon as the feA'er  has disappeared
soft diet may be gi\'en and later  solids.  As said before
the eyes should be protected without limiting the ventila-
tion.  As in all  infections water may be  given freely.
Tepid baths are used  for high fever, restlessness, and
insomnia.  The mouth should be kept clean by the usual
measures; spraying or  douching of the nose and throat
will usually be approved by  the  physician.  The  bron-
chitis may require local stimulating  applications to the
chest such  as  camphorated  oil or mustard  paste.   If
pneumonia  develops  open-air treatment will be useful.
If the rash does  not "come  out" promptly it has been
a time-honored practice to bring  it out with hot  baths
(mustard), etc.
  German Measles (Rubella, Roseola).—German measles
is a very mild infection resembling in some respects both
scarlet fever and measles, but entirely distinct from either.
The incubation may be as long  as three weeks, although
usually  it is between two and three.  Adults and older
children are more frequently affected than young children.
Like measles it has a period of invasion with catarrhal
symptoms, but these are so mild that they are frequently
overlooked.  A general  glandular enlargement is more  or
less distinctive of the disease.  This enlargement persists
during the  rash but disappears in convalescence.   The
rash appears after several days, first on the face and later
on the body, and finally on the  limbs.  At first there are
red spots similar to those of measles but  not elevated.
On the  chest and  elsewhere they may coalesce and form
a uniform  rash,  difficult to distinguish  from  that  of
scarlet fever.  The eruption is peculiar, however, in that
different stages are present at the same time in different
parts of the body.  The eruption disappears in a few days
and  the patient  is  convalescent.   The  temperature 
       DISEASES OF  UNCERTAIN CAUSATION    363

seldom rises above 100°.  There are no complications, as
a rule, and no mortality.   The treatment is practically
nil, although  the patient  should  be kept in the  house
during the height of the disease.   Partial quarantine  is
probably  sufficient.   The  disease is infectious  on  close
contact, but is seldom carried by a third party.
  Scarlet Fever.—This disease is much  less widespread
than  measles, being largely restricted  to the temperate
zone.   It attacks only a small portion of those who are
exposed  to infection.  It  occurs  in epidemic  form and
attacks  principally   young  children.   The  infectious
material is present in the  discharges from the nose, ears,
and throat (or from suppurating glands), and possibly
in  the  desquamating skin  during  early convalescence.
The infection, according  to tradition, is very resistant
and clings to  clothing,  infected  rooms, etc., for  a long
period.   However in the  late influenza  emergency old
scarlet feA^er Avards, after  ordinary cleaning and airing,
AA'ere  utilized  for influenza  cases  Avithout any  resulting
cross  infection.   It  can  probably be carried by a  third
person and such  persons (carriers) may harbor the infect-
ing organism in their throats.  The  causal microorganism
is unknoAvn but is  probably a  modified form  of the
streptococcus.  The incubation is snort, rarely over  seven
days, and usually only two or three days. The disease is
infectious from the very  beginning, but as the rash comes
out within twenty-four hours, dissemination from failure
to recognize the infection is less probable  than in measles.
The first symptoms  are vomiting or convulsions,  head-
ache, and sore-throat. The face is flushed, but the erup-
tion appears first on the neck and chest and then spreads
downward involving the limbs last.  There is no real erup-
tion on the face, but the  pallor of the skin around the
mouth in contrast to the  red flush of the cheeks is striking.
The eruption  itself is made up of minute red points not
at all raised and all blending together in a uniform red
blush.  On the  extremities it is  sometimes patchy and
may  be  mistaken for measles.  Typical cases with asso- 
 364   INFECTIOUS  AND PARASITIC DISEASES

 ciated  symptoms are  easily recognized,  but  slight or
 atypical cases are difficult to distinguish from a multitude
 of  other similar  rashes.  These rashes are  the bugbear
 of  hospital interns  and  others  who are charged  with
 the duty of excluding infectious disease, and at the same
 time are not expected to exclude or mistake other condi-
 tions.   In  addition  to measles,  German measles,  and
 eA^en smallpox, all of which may closely simulate scarlet
 fever,  there are deceptive rashes due to food  infections,
 to serum injections, to drugs, and even to enemas.  Drug
 rashes due to belladonna,  quinin, sodium salicylate,  and
 copaiba are Avell knoAvn.
  Course.—The period  of  invasion lasts, as  a  rule, only
 twenty-four  hours  and is characterized  by  headache,
 vomiting, sore-throat, feA^er, and rapid pulse.  At the  end
 of tAventy-four hours  the rash begins to appear and lasts
 about  four  days  when  it is succeeded by desquamation
 which  may last for six or seven Aveeks.  The  latter varies
 in character from a fine  powder-like deposit to large sheets
 of skin Avhich may form  perfect casts of hands or feet.
 In  mild cases in winch  the patients are seen in the later
 stages  of the disease the  diagnosis can often  be made
 from the character of the desquamation. The fever rises ,
 rapidly AAith the  onset, maintains  its height during  the
 acme  of the disease, and falls  rapidly, though not by
 crisis,  Avith  the disappearance of the rash.   The normal
 temperature  is reached about  the seventh day.   The
 pulse  is at first out  of  proportion  to the fever and this
 is  regarded as a characteristic symptom.   It may be
 noticeable  in  the earliest stages  only.  The  throat is
 almost  ahvays red,  swollen, and  covered with mucus.
 In  bad cases ulceration  and membrane formation  are
seen.   A mixed infection with diphtheria is not unusual.
With the inflammation of the throat there is an associated
enlargement of the glands of the  neck.  The  tongue is
at first hea\ily coated with white, but at the time of  the
appearance  of the eruption the  papillae become red and
SAvollen and project through the white, giving the tongue a 
       DISEASES OF UNCERTAIN CAUSATION    365

strawberry-like appearance.  A few days later after the
coating has disappeared the tongue is red and the papillae
prominent, so  that the  organ looks like  a  raspberry.
The term  "strawberry tongue" is frequently  applied to
either  or  both of  these  appearances.   Evidently the
enlarged red papillae are the characteristic features.   With
these more typical  symptoms are  associated the  usual
Fig. 62.—Desquamation in scarlet fever.  (Welch and Schamberg.)
concomitant phenomena of fever: thirst, loss of appetite,
gastro-intestinal derangements, scanty urine of dark color,
mild delirium, occasionally convulsions  at onset, etc.
  The final stage of desquamation  or convalescence  is
perhaps the one requiring the most care,  for while the
patient may feel almost well, it  is during this time that
the  most  serious  complications  occur.   Endocarditis,
otitis  media,   diphtheria,  rhinitis,  bronchopneumonia, 
366    INFECTIOUS AND PARASITIC DISEASES

arthritis, nephritis, and  relapse are the most important.
Of these nephritis is the  most characteristic and the most
to be dreaded.  The nasal and aural infections are impor-
tant from the point of  vieAv of prophylaxis, as the dis-
charges are  prone to convey the  disease and to prolong
the period of infectivity.  The onset of nephritis should
be immediately  revealed by routine examination of the
urine.   The usual symptoms are: headache, convulsions,
nausea, vomiting, high pulse tension (high blood-pressure),
edema, scanty, smoky urine, etc.  Nephritis often does
not occur until the third wreek of  convalescence or  later.
Diphtheria  is common after scarlet fever,  especially  in
institutions, but if it is recognized promptly and  treated
AAith antitoxin the mortality is not so high as  might be
expected. Middle-ear disease is a prolific cause of deafness,
but here again early treatment produces good results.
  As in other infections there are several types described:
mild, or trivial cases,  simple cases covered by the above
general description, toxic or malignant cases in Avhich the
symptoms are intense and death supervenes in a few hours
or days, and septic cases in  which the throat symptoms,
swelling, exudation, ulceration, and  glandular  enlarge-
ment are in  the ascendant.  The last type  requires active
local  treatment.   Scarlet fever, uncomplicated, is  more
fatal than measles,  but  is not so important a cause  of
death on account of its restricted distribution.  The com-
plications are greatly feared  rather  for  their ultimate
results than on account of the immediate danger.
  Prophylaxis and  Treatment.—Prophylactic measures are
of more importance  in scarlet fever  than in measles,
both  on account  of the severity of  the infection  and
because there is a much better chance of  preventing the
spread of the disease  (possibility  of early diagnosis and
general unsusceptibility).  The health officer does not have
to contend, as in the case of measles, with the fatalistic idea
that infection is sooner or later inevitable, and that efforts
at prevention are useless.  On the other  hand, there  is
no specific protective measure comparable to Araccination 
PLATE  VI
Smallpox (Typical Distribution).
Notice the eruption on  face is crusting while the remainder is at
                     its height.  (Knowles.) 
 
       DISEASES OF UNCERTAIN. CAUSATION    367

in smallpox.  In view of these facts the patient should
be rigidly quarantined with an attendant, and the quaran-
tine maintained for five or  six weeks from  the onset  (in
New York thirty days).  The general details have already
been described.  Contacts after receiving a disinfectant
bath and donning clean clothing  should  not associate
with children for a week at least, i. e., until the period
of incubation has passed  (in  Philadelphia  two weeks).
The patient should be frequently anointed with ointment,
with or  without antiseptics, in order  to  limit the  dis-
semination  of  scales,  and  the  nose and  throat  should
receive  attention.  Slight desquamation  need not be a
bar to raising the quarantine, but aural  or nasal discharge
is of more importance.  Some authorities (Ker) advise that
discharged patients should  avoid intimate contact (kiss-
ing, etc.), with susceptible  persons for a long period of
time.
  To a certain extent the treatment is also of a preventive
nature so far as the patient is  concerned.   Flannel night
clothing  and blankets instead  of sheets should be used,
and rest  in bed continued for  two weeks during con-
valescence,  as  a precaution against nephritis and joint
complications.   For  the same  reason the febrile diet of
milk should be adhered to until late  in convalescence.
To this fruit, breads,  cereals, vegetables, and eggs may
be added.  Meat, fish, and fowl should be excluded until
the danger  of  nephritis  is well over.   The toilet of the
mouth, nose, and throat is most important for  the avoid-
ance of  aural  and respiratory complications.  In case
of nephritis the usual measures (see Acute  Nephritis) to
secure elimination will be in order.  Serums and vaccines
have been used in scarlet fever but are not much in vogue.
Drug treatment is purely symptomatic.
  Smallpox  or  Variola.-—In  former  times  smallpox was a
scourge almost  as common as measles is now, and like the
latter disease attacked children  principally.   It Avas very
fatal and even those who recoA'-ered were frequently disfig-
ured by excessive scarring.   At the present time owing to 
36S   INFECTIOUS AND  PARASITIC DISEASES

the efficiency of A'accination, it is a relatiwiy rare all'ec-
tion; during seA'enteen years of practice,  the writer has
encountered only two or three cases.  Many cases moreover
are modified by A'accination and are  Aery mild (varioloid).
Small  epidemics   ^cur  from  time  to time,  principally
in unprotected persons or in adults who have outgrown
their  childhood immunity  (from primary vaccination).
In countries where reAaccination  is systematically prac-
tised the disease is almost non-existent.  On the other
hand, Avhere the scruples  of  individuals are  allowed to
defeat  the purpose  of vaccination  hnvs, serious epidemics
have occurred.  The causative organism of smallpox has
not yet been discoA'ered, but recent  reports indicate that
the solution of the problem may not be long delayed.  In
the pustular stage  ordinary pus organisms occur as  sec-
ondary imaders.
  After an incubation  of about twelve days the disease
sets in suddenly AAith high fever, loss of appetite, sleepless-
ness, delirium, severe headache and  backache, chills, and
perhaps nausea  and vomiting.   Sometimes a  diffuse rash
occurs Avhich may mislead the physician and suggest scarlet
fever or other infections.   With  the  appearance of the
eruption on the third day  the  "initial" feA'er disappears.
The stage of remission lasts about four days.  The erup-
tion appears  as little  reddish,  "shot-like" elevations
or papules about the wrists and in  the edge  of the hair.
The face, forearms, and Avrists show the most  profuse
eruption Avhile the  chest and  abdomen may be almost
or entirely free.  After a  day or a day and  a half, the
papules become vesicles (blisters) filled Avith  clear fluid.
This gradually becomes milky and finally, about the sixth
day of  the disease, the vesicles are  converted into "um-
bilicated" pustules.   Finally  the pustules  rupture  and
form  crusts which separate after a period  of Aveeks to
leave the characteristic pitted scars.   During the pustular
stage there is  a secondary irregular  feArer which varies
in degree and duration in accordance with  the profuseness
of the  eruption.  In mild cases or in varioloid there may 
        DISEASES OF UNCERTAIN CAUSATION    369

be only a few pustules on the face or wrists, while in the
confluent or severe types the  face may  be a mass of
pustules blended  together by  inflamed and edematous
skin.  In such  cases the secondary fever may  be  high
and its associated symptoms severe.    he severest  form
is hemorrhagic  or black smallpox.   Complications are
not  common, the most  frequent being  conjunctivitis.
otitis, and affections of the respiratory tract.  Mild cases
are difficult to diagnose and  are responsible for the  wide
diffusion  of  the disease.   For  this reason  chicken-pox
cases, especially in adults, are  always viewed with sus-
picion when variola is epidemic.   Chicken-pox  is often
seen on the body while smallpox, as we have seen, usually
spares the trunk.
  Vaccination renders the prophylaxis  of smallpox com-
paratively simple.   Affected persons are always removed
to  special hospitals  where  the strictest  quarantine is
exercised  (isolation for at least two weeks).  The infected
quarters, clothing,  etc., are disinfected and those who have
been exposed are vaccinated.  When the disease is preva-
lent all who have not been recently  vaccinated  should
undergo the  operation again.  Otherwise vaccination in
infancy and again on entering school is probably sufficient.
Even after an attack of the disease itself immunity tends
to become less with time, although a  certain resistance
may always persist.
  Vaccinia.—Vaccinia  is a  disease of  cattle (a similar
affection is found in horses) which manifests itself as pus-
tules on the udders.   The local  and constitutional symp-
toms are of a very mild character, but Jenner found that
milkmaids and  others who  had  acquired the  infection
in their work were immune  to  smallpox.  Prior to this
discovery it  was  customary to  inoculate people with
actual smallpox  virus to gain immunity from the ravages
of the pest.   Jenner  was thus able to test the efficacy of
vaccination by inoculation and to confirm his observations.
From that time inoculation, which had sometimes been
fatal and was always liable to spread the disease by con-
     24 
370    INFECTIOUS AND PARASITIC DISEASES

tagion, Avas replaced by this neAV and practically harmless
method.  In Jenner's time, and  cacu doAvn to the last
quarter of the nineteenth century, it Avas customary  to
take the  scab  from a healthy child and  preserve it for
future vaccinations.  While this Avas on the Avhole a satis-
factory plan  it  occasionally  led to  unfortunate  conse-
quences  on account  of  the simultaneous inoculation  of
other diseases, particularly of syphilis.  HoAvever, objec-
tions based on this score are no longer valid, as humanized
lymph is not used at the present time.  At present lymph
is obtained by inoculating  the udders of healthy calves.
The pulp  so obtained is mixed  Avith glycerin  and kept
until free from contaminating organisms.   The calves are
killed and examined for  tuberculosis or other disease and
the A'accine is tested for freedom from tetanus.  Serious
infections due to the lymph itself are now of the rarest
occurrence, although a vaccination Avound, like any scratch
if carelessly treated, may serve as an avenue of entrance
for some chance infection such as erysipelas.  The nature
of \raccinia was long unknown; at the present time there
is little reason to doubt  that it is a mild form of variola
which has been robbed of its virulence  and contagiousness
by passage through an extremely resistant animal.  This
produces a permanent change in the virus without depriv-
ing it of its specific protective power against smallpox.
   In persons  who have been vaccinated  and are  still
immune re vaccination does not "take," but on the second
day a small area  of redness appears Avhich indicates their
immunity. It is similar to the von Pirquet reaction, which
is employed in the diagnosis of tuberculosis. In susceptible
persons, on the other hand,  nothing is seen until the third
or fourth  day, when a papule appears.  On the fifth day
Aresiculation occurs  and  this is  in turn succeeded by
pustulation, crusting, and scarring.  The total duration  is
three or four weeks.  Mild constitutional symptoms may
be present for  a  day or tAvo with local  induration  and
swelling.  More severe reactions are usually due to mixed
infection with pus organisms. These seldom prove serious 
       DISEASES OF  UNCERTAIN CAUSATION   371

and are treated on general antiseptic principles.  Enlarge-
ment of the neighboring lymphatic glands is the rule.  The
site of vaccination is not important; it is usually practised
on the arm near the insertion of the deltoid or on the
outer side of the leg near the head of the fibula, the choice
being determined  by the  freedom of these regions from
movement.
  Chicken-pox.—Chicken-pox or  A-aricella  is one of the
least serious of all  the infections  and  one that rarely
requires  treatment.   As  already stated it is  of  most
importance on account of its resemblance to varioloid.
The incubation is approximately two weeks and the erup-
tion may be the first and only symptom, although  slight
fever for two or three days is the  rule.   The eruption,
unlike  that of smallpox, is chieflv confined to the trunk,
but a few vesicles appear  on the  face also.  The eruption
comes  out in crops,  first as papules and then as vesicles.
The vesicles  dry to  crusts,  but  occasional ones form
pustules, and presumably  give rise to the characteristic
scars Avith which almost  all  persons are marked.   The
irregularity of the  eruption and  its  situation usually
suffice  to distinguish it from  varioloid, but at times the
most experienced are puzzled.  On  account of the conta-
gious character of the disease children should be isolated
for at least twelve days and until the crusts have separated.
Other children of the family should be kept  from school. 
CHAPTER VII.
INFECTIOUS AND PARASITIC DISEASES-
                    CLASS IV.1
Typhoid or Enteric Fever.
  Course of the Disease.
  Complications and Sequelae of
   Typhoid.
  Treatment of Typhoid Fever.
  Diet in Typhoid Fever.
  Hydiotherapy.
Malta Fever.
Cholera.
DyseDtery, Bacillary and Amebic.
              BACTERIAL  INFECTIONS.

  Typhoid or Enteric Fever.—The name typhoid ("typhus
like")' recalls the confusion that formerly existed between
this  disease (typhus abdominalis) and the now rare jail
or ship fever (typhus exanthematicus) which we usually
designate simply as typhus.  Our German patients, on
the  other hand,  when they  speak  of  an attack  of
"typhus" usually mean enteric fever.   Typhoid fever
is caused by the bacillus typhosus and is characterized
pathologically: by ulceration in the lower part of the small
intestine, by enlargement of the spleen, and  by degener-
ative changes in the heart, liver, and other organs; clini-
cally: by a prolonged febrile course (commonly three to
six weeks), an eruption of rose spots, bronchitis, diarrhea,
delirium,  stupor, and exhaustion.
  The  characteristic  ulcers  involve  the  thin areas of
tonsil-like tissue known as  Peyer's patches,  which  are
situated  in the last few feet of  the ileum just before it
enters the large bowel.  At  first they are merely swollen,
but about the third week of the disease they begin to
ulcerate and present a ragged appearance.  The ulcera-
tion  may involve small  bloodvessels, causing serious or
1 See p. 269. 
BACTERIAL INFECTIONS
373
fatal hemorrhage, or the bowel may be perforated with
the production  of  peritonitis.  The spleen is large and
soft and can usually be readily felt during life.
  The typhoid bacilli are found not only in the intestinal
ulcers  but in many other organs and tissues and even in
the rose  spots.  They are readily cultivated  from  the
blood  early in the disease so that blood  cultures form
one of the earliest  and most reliable means of diagnosis.
At the end of a week or ten days certain substances  are
found  in the blood which have the power, when brought
  Fig. 63.—Ileum from a case of typhoid fever, showing ulceration of
solitary follicles (b) and of a small Peyer's patch (a).  (Adami and
McCrae.)

into contact with  active  living typhoid  bacilli in pure
culture, of checking their movements and causing them
to clump.  This is the  basis of the valuable and diag-
nostic Widal reaction.  Material for this test is obtained
by puncturing the  finger and collecting a little blood in
a narrow tube which is drawn out at the ends to permit
sealing by heat.  Another method is to catch a few drops
of blood on a piece of glazed paper or on a glass slide.   If
this method is employed the blood should be thoroughly
dried before it is sent to the laboratory. 
374   INFECTIOUS AND PARASITIC  DISEASES

  Many obscure epidemics, particularly in institutions,
haA'e  been traced to  carriers.  When these persons are
employed in the kitchen the danger is of course increased.
Lettuce  and  other "truck" A'egetables are  frequently
fertilized with "night  soil" and this may lead to obscure
sporadic or epidemic  outbreaks.   Oysters  are open  to
contamination on account of the custom of "fattening"
them in fresh  AA'ater  (often contaminated with  seAvage)
Fig. 64.—Positive AA'idal test showing clumping of bacilli (magnified)
                        (Simon.)
after their remoA^al from the salt Avater.  Flies have also
been convicted of carrying typhoid bacilli  from infected
discharges to the food  (from "latrine"  to  "mess-tent").
I have considered these less frequent causes in order  to
call attention to their importance in many cases, but I
do not mean to undervalue the most prolific source  of
typhoid  infection,  namely,  drinking  Avater.   Wells and
springs in the country are very often badly placed and
open  to  contamination  from  surface drainage or from 
BACTERIAL INFECTIONS
375
underground communication with  sources of pollution.
City supplies  are  open to  more  gross defilement from
sewers and streams, etc.  Tardy efforts are being made
to minimize these  conditions and  the large cities of the
Eastern States have recently spent scores  of millions in
either filtering bad water or in bringing pure water from
a great distance. Frequently chlorinated lime is employed
to purify water supplies,  but  usually  as an accessory
measure.  In  most cities the disease is decreasing, but
it still maintains its hold in the country.   Its frequent
occurrence and prolonged course make it the most impor-
tant of  acute infections both  for the nurse and the
physician.
   Course of  the Disease.—There are a great many varia-
tions in the  course of typhoid cases, some of which will be
described beloAv.  The following  sketch  will serve to
illustrate the  course of an ordinary case  unmodified by
treatment (see Fig. 51).  The incubation is on the average
ten days.  The symptoms  at first are indefinite: "gener-
ally out of sorts," loss of appetite, headache, diarrhea,
abdominal pain, cough, slight chills, gradually increasing
fever, etc.   Nosebleed is common, but  not so invariable
as commonly thought.  Constipation is almost as frequent
at this stage as diarrhea.  At the end of a  week the tem-
perature has climbed to 102°, 103°, or 104° and the patient
has usually succumbed and gone to bed.  The next week
or two are characterized by many of the same symptoms
in an  aggraA-ated  degree.   The fever is  high and  con-
tinuous with a slight morning remission.   Hydrotherapy
has little or only a temporary effect on the temperature.
The pulse is relatively sIoav but soft and dicrotic.   (See
pages 82 and 83.)  Rose spots  appear  On the abdomen,
chest,  and shoulders.  Headache  is replaced by  stupor
and delirium.  The tongue if  not persistently  treated
becomes dry and  brown and the  teeth are covered  with
dry brown  deposits knoAvn as  "sordes."   Diarrhea  may
be severe with stools  of a "pea  soup" consistency and
musty odor.  In  the  third week, or in prolonged cases 
376    INFECTIOUS AND PARASITIC DISEASES

perhaps in the fourth or fifth AAeek, the morning temper-
ature begins to shoAV very marked remissions and reacts
readily to measures adopted to  lower  it.  This period
corresponds to that of ulceration  in the bowel, and per-
foration or  hemorrhage  is  to be dreaded.  Stupor and
delirium  continue  and  emaciation and  Aveakness  are
progressiAe.  Bronchitis which  is  often marked  in  the
early stages is replaced by congestion in  the dependent
portions of the lungs.   In the fourth or  final A\reek  of
feAer, the temperature gradually descends to normal, the
patient's mind becomes active, the appetite returns, and
a rather tedious convalescence begins.  This is liable to
be marred by the recrudescence of fever from constipa-
tion,  oA'erfeeding,  or  other slight causes,  by relapse, in
which the Avhole course of the disease is repeated, usually
in an abbreviated and  milder  form, but occasionally with
greater seAerity, or by one  of the many  unfortunate
sequels.
   Occasional cases occur  Avith  symptoms  resembling
typhoid in which a Widal reaction fails to appear.  These
are frequently due to  organisms  allied  to the typhoid
bacillus, but differing from it  in some respects.  Paraty-
phoid is the most common of these fevers.   Colon bacillus
infection may also  produce a similar train of symptoms,
but it  is more likely to invade  the genito-urinary tract,
inducing pyelitis, etc.
  The mode of onset and course of the disease may show
many A'ariations.  Some cases are so mild  in their onset
or the patients  are so  insensible to  suffering that they
continue on  their feet for the first  week or two  of the
disease.  These  cases are knoAvn as "walking typhoid."
The  prognosis is usually more serious than  that  of the
ordinary disease.  Other  cases  pursue an exceptionally
mild and  abbreviated  course.  Atypical modes  of onset
are those AAith acute nephritis  and uremia, with croupous
pneumonia, with violent delirium, or with seAere chills.
  Complications  and Sequelae of Typhoid.—The complica-
tions and  sequelae of typhoid  are legion.   Some of them 
BACTERIAL INFECTIONS
377
 consist merely in an exaggeration of ordinary symptoms
 of the disease such as bronchitis and diarrhea.  It will
 save time, however, to take them up systematically.
   Mild  delirum  and  mental hebetude,  as  mentioned
 above, are almost invariable symptoms of the disease;
 occasional  cases  are  marked from  the onset by wild
 maniacal delirium.  More characteristic is  a low mutter-
 ing delirium associated with picking at the  bedclothes or
 at imaginary objects, twitching of the tendons (subsultus),
 dry,  brown tongue,  sordes on  the  teeth,  general  mus-
 cular  relaxation  (slipping  down  in the bed), and incon-
 tinence  of urine  and  feces.  When these  symptoms of
 extreme prostration  ("typhoid state") develop in other
 diseases they  are sometimes described as  "typhoid,"
 irrespectiAe  of the presence or absence of  enteric fever
 (for example "typhoid pneumonia").  This  is often  a
 source of  confusion in history taking.  Thanks to  good
 nursing  and the stimulation of  the nervous, cardio-
 vascular, and respiratory  systems  by  cold baths, these
 symptoms are seldom seen in typhoid  at the present
 day.   Insanity due either  to intoxication or exhaustion,
 is not an  unusual sequel of the disease. As  previously
 stated  (page 30)  the  prognosis is  usually  favorable for
 ultimate recoAery.  Neuritis with paralysis occurs occa-
 sionally as a sequel.   It is  common, however, for patients
 to suffer from hyperesthesia of the  extremities, "tender
 toes."
   More or less profound anemia is a  natural sequel of so
 severe a disease.   This is of the secondary type, i. e., the
 coloring matter of the blood suffers  more  than the  cell
 count.  During  the  fever the  leukocytes are reduced
 in number  (leukopenia);  if  inflammatory complications
 occur  this  characteristic  leukopenia  is replaced  by a
 leukocytosis.
  Valvular heart disease is not common, but myocardial
AA'eakness is the rule  in seAere cases.  In convalescence
patients  sometimes  have  a  rapid, but more often an
extremely slow, soft pulse.   One  of the common compli- 
378   INFECTIOUS AND PARASITIC DISEASES

cations  of the disease  is phlebitis; this almost always
affects the left femoral vein and causes at first moderate
pain (avoid rubbing or massage in suspicious cases), and
later marked  swelling (edema.)  of the extremity.  It is
identical in symptoms and treatment Avith that seen after
childbirth (milk leg).
  Bronchitis is one of the ordinary symptoms of typhoid
fever and is only to be  regarded as a complication when
it is excessive in  degree, or AA'hen  it extends to the finer
bronchioles or al\Teoli  (bronchopneumonia).  In  seAere
cases there is almost always passive  congestion at  the
bases of  the  lungs reA-ealed  by dulness and fine rales
("moist" or  bubbling  sounds on auscultation).   The
patient's position should be changed from time to time
to ob\iate this condition so far as  possible.  Croupous
pneumonia may complicate the disease  at the onset, as
already mentioned,  or later during its course.
  Loss  of appetite  is more or  less  constant in all  seArere
cases during the  febrile stage, but in  convalescence  the
appetite is inordinately  great.  Gaseous  distention of the
abdomen or tympanites  is  often a  serious complica-
tion.  Sometimes it appears to be due  to the diet (milk),
although it may be due in part to a toxic paralysis of the
boAAel Avail.  Diarrhea is a regular symptom of the dis-
ease, but Avhen excessiAc is a very serious complication.
Constipation is common in convalescence;  sometimes the
accumulation of feces is so great as to require removal by
instrumental means (e.  g., by handle of a spoon).   The
most serious and fatal complications of typhoid are hem-
orrhage and perforation, both of which  occur as  a rule in
the later weeks of the disease.  The onset of hemorrhage
is suggested by a sudden fall in the temperature, rapid,
feeble pulse, increasing pallor, etc., and is confirmed by
the appearance of blood in the stools.   This may appear
as large clots  or the  stools may present a tarry appear-
ance.  In the presence of hemorrhage the patient should
be  kept absolutely quiet  and if there is any mental or
physical agitation a hypodermic of morphin (gr. I) should 
BACTERIAL INFECTIONS           379
be administered.  Many physicians will not allow even a
bed-pan to be used  for fear that the added exertion may
renew the hemorrhage.  The foot of the bed should be
raised and an ice-bag applied to the  abdomen.   In an
emergency the nurse should treat the patient along these
lines, but should  omit  administering medicine by the
mouth or boAvel unless specifically ordered.   Astringents
by the mouth, although of doubtful efficacy, are  some-
times used by the physician.  Gelatin may be given freely
by the mouth to favor clotting; its employment by sub-
cutaneous injection has  proved  too  hazardous (tetanus)
and  painful to encourage its further use.   Calcium lac-
tate  by the mouth and blood serum  administered subcu-
taneously are hoav extensively used  to promote clotting.
Perforation of the intestine occurs  in  the lower part of
the small intestines, rarely in the large, and results from
deep ulceration, excessive  distention, etc.  The cure of
this  otherwise fatal complication by operation depends
upon early diagnosis.  The accident is  suggested by a
sudden fall in the temperature,  an increased rapidity of
the pulse, sudden pain, or increased tenderness and rigid-
ity of  the abdomen, etc.   Any  symptoms in the least
degree suggestive should be immediately reported  to the
physician.  Sudden seAere pain  in the lower abdomen is
A'ery characteristic,  but is often masked by the apathetic
state of the patient.   The patient should be kept abso-
lutely  quiet  and the  pain relieved if necessary  by an
ice-bag.
  Inflammation  of the gall-bladder  is a common compli-
cation  or sequel of  typhoid fever.   The bile is a Aery
faA'orable culture medium for typhoid bacilli  and they
have been found in the gall-bladder years after infection.
The  complication is important rather  as a cause of gall-
bladder disease than on  account of any acute symptoms
during, the typhoid  attack.  In typhoid "carriers" the
bacilli frequently come from an infected gall-bladder.
  Albuminuria is Aery common in the  course of this dis-
ease  and severe nephritis occasionally occurs. I  have 
380    INFECTIOUS AND PARASITIC DISEASES

seen patients die with uremic symptoms at the height of
a typhoid attack.  Typhoid bacilli are almost constantly
found in the urine and if they persist into conA'alescence
the  patient becomes  a  source  of  danger  to  others
("carriers").
  Joint affections are  not common  as complications  or
sequels of typhoid  but occasionally occur.   The spine is
frequently affected, causing  chronic pain  and rigidity
("typhoid spine").   Periostitis of the tibia  and other
bones is not very unusual.  Of the skin complications the
most troublesome is furunculosis.  When a single case
exists in a ward the infection is very liable  to spread  to
others.   Careless bathing and sponging are  frequently
responsible  for the  transference of  the  infection  from
patient to patient.
  Treatment.—Prophylactic Treatment.—The stools and
urine should be disinfected by the addition of equal parts
of 5 per cent, carbolic, milk of lime, 3 per cent, chlorinated
lime, 10 per cent, formalin solution, etc.  After thoroughly
mixing  the A'essels should be allowed to  stand for some
time  before being emptied.   In  some  large  hospitals
double-jacketed receiArers are provided for sterilization by
live steam.  Bedding,  clothing, etc., should be soaked  in
carbolic or placed immediately in a boiler for sterilization
by  heat.  Gauze and cotton  used  for  cleansing  the
mouth, etc., should  be  burned.  The patient's dishes
should be kept separate from those of the household and
should be sterilized at the end of the case or after each
feeding according to circumstances.  The room  or ward
should be well screened and infected objects should  be
immediately covered in order  to prevent access of flies.
Nurses  and attendants should scrub their  hands thor-
oughly  before  eating.  Carelessness   in  this  respect  is
probably the cause  of  the undue frequency of  typhoid
among nurses and orderlies.  Antityphoid vaccination  is
now  being used as an additional prophylactic,  but the
security against infection thus afforded does not excuse
carelessness in preventive treatment.   The prophylaxis  of 
BACTERIAL INFECTIONS
381
typhoid in the hospital is simplified when the patient can
be treated in special wards.
  The patient suffering from typhoid should be  kept  at
absolute rest.  This  necessitates the use of the bed-pan
and urinal.   A soft but firm mattress is sufficient in the
majority of  cases but  with severe emaciation  or a ten-
dency to bed-sores an  air- or Avater-bed is preferable  or
even  essential.   Sometimes bony prominences may  be
protected by rubber or cotton rings.  On account of the
danger of bed-sores and of "hypostatic"  congestion of the
lungs  the patient  should  not be permitted to rest con-
stantly on  the  back,  but should be turned  frequently
from side to  side.   The back and buttocks" should be fre-
quently cleansed, sponged  with alcohol, and thoroughly
powdered.   (Compound stearate of zinc or talcum pow-
der.)   These precautions are particularly essential if the
patient is incontinent.   In many cases  it is necessary  to
support the  bedclothing on a cradle to protect the toes
(if  tender)  from  pressure.  In  men and children  it  is
usually best to cut the hair closely, but in women frequent
and thorough combing and  brushing  may obviate the
necessity of this measure.  An ice-cap applied to the head
is  grateful in cases with severe  headache;  it should  be
loosely filled so as to conform to the shape of the head
and must be water-tight.   Some physicians apply to the
abdomen an ice-bag, a coil Avith running cold  water,  or
ice compresses.   If the latter are used the patient AA'ill
need  to be Avell protected Avith water-proof linen or silk.
Special attention should be given to.  the care  of the
mouth, teeth, and tongue  Avhich should be rinsed after
every feeding, and cleaned with pledgets of cotton, moist-
ened in a mild antiseptic solution AAith or without glycerin.1
A  dry, brown, fissured tongue and teeth heavily  coated
Avith sordes are usually due to defective nursing as much
as to the condition of the patient.

  1 Equal parts of a saturated solution of boric acid and glycerin, to
which a little lemon juice may be added.  Liquid petrolatum is useful
for moistening the lips. 
382    INFECTIOUS AND PARASITIC DISEASES

  Diet.—The  traditional  diet in typhoid consists of milk
with the occasional addition of broth, beef-juice, and egg-
AA'ater.  This  regimen  (e. g.,  a  glass milk e\erv tAvo
hours  for  ten feedings) seldom yields more than fifteen
hundred calories and  frequently  much less, about eight
hundred, if broth  is given alternately Avith milk.  The
advantages of this diet are the sense of security Avhich it
gives against  hemorrhage  and perforation, its simplicity,
and  its ease of digestion.   Its chief disadAantages are the
marked  loss  of  nutrition, the  tendency  to  meteorisin
(distention),  and  the impossibility  of  satisfying  the
patient's appetite as coiiAaleseence approaches.   Disturb-
ances due  to  milk diet are sometimes attributable  to an
impure supply (high bacterial "count")  and not to the
milk in  itself.  FeAv physicians hoav adhere to this rigid
dietary throughout.   RaAv or  soft-boiled  eggs,  junket,
corn-starch, and  other semisolid foods  are  commonly
added as  convalescence approaches.  Other physicians,
Avhile employing a diet Avhich is largely  liquid (milk),
increase its caloric value  enormously by the addition of
milk-sugar, cream, eggs, cereals, etc. (up to five thousand
or six thousand calories).   The aim is to furnish sufficient
food to maintain completely the nutrition of the body,
in spite of the additional drain  upon it resulting from
infection.  A  diet  sheet  prepared for  the purpose  of
facilitating the prescription of such a diet is sIioavii in the
chapter  on Metabolism.  A  third  method of  dieting
admits the free use of  semisolid or even solid food to suit
the appetite of the patient; this treatment originated in
Russia  and the  good  results obtained have showTn  the
fallacy of some of the older theories.  The nurse should
of course folloAv  the method  of dieting  favored by the
physician  in  attendance.  WhateAer the diet, Avater,
lemonade, and other fluids should be offered to the patient
at frequent intervals to promote a free excretion of toxins.
  Hydrotherapy.—Hydrotherapy occupies a very promi-
nent place  in the  treatment of  typhoid.  It  has  been
found that the application of cold water not only reduces 
BACTERIAL  INFECTIONS
383
the temperature temporarily but has  a most  stimulat-
ing effect on  the nervous system, lessening stupor and
delirium and indirectly improving the appetite, etc.  The
circulation in the skin is also improved,  breathing is deep-
ened, and the kidney secretion is increased.  Cold water
may be  applied  in many ways,  but is most frequently
employed in the form of full cold baths, Avet packs,  or
sponges.  The full or Brand bath  is  by far the most
effectual method of treatment.   In hospitals it is usual
to giAe a bath every three hours, when the  temperature
reaches a certain height  (e.  g.,  103°).   Most physicians
do not giAre more than three or four baths a day and none
at night.  The general condition of the  patient is a better
indication for the use of hydrotherapy than the tempera-
ture alone,  but in Avard work some routine  procedure  is
necessary as a basis and may be modified to suit indi-
vidual cases.  In mild cases or in the presence of compli-
cations Avhich forbid the use  of the full  bath, sponges and
wet packs may be employed for a similar end.  If there  is
danger of hemorrhage or perforation  tub baths are contra-
indicated, largely on account of the necessary disturbance
to the patient.
  Drugs.—The drug treatment of typhoid is almost entirely
symptomatic.   Many physicians place  faith in  an initial
dose of calomel, but during the course of the disease purga-
tives should be avoided (this opinion is by no means univer-
sally held).  Many antiseptic and antipyretic drugs haAe
been employed from time to time, but no general agree-
ment has been reached as to the value of any one in par-
ticular.  Salol is perhaps most frequently used.   Whisky
was formerly given as a routine  in the course of typhoid,
because it Avas thought  to  serve  both as a food and  a
stimulant.  As Ave have seen, it serves the former purpose
only AA'hen given in small quantities, while its stimulating
properties are  entirely  denied in many  quarters.  It  is
now used for special indications only.
  Malta Fever.—This disease is so rare in t his country that
it  requires only brief mention.   It occurs principally in 
384    INFECTIOUS AND PARASITIC DISEASES

the countries bordering on the Mediterranean and partic-
ularly at Malta.  It is due to a bacillus AA'hich is found in
the milk of infected goats and is acquired by using milk
or milk products derived from this animal.  The prophy-
laxis  is therefore evident.  It  is  characterized  by fever
AA'hich resembles  that  of mild typhoid fever, but differs
from  it in that it relapses or recurs, time after time, often
for many months (hence the name undulant or AvaAe-like
fe\rer).  The mortality is low but the treatment is very
unsatisfactory.  Change of climate is  the most effectual
measure.
  Cholera.—Cholera Asiatica is due to  the " comma bacil-
lus" (spirillum) of Koch and  is disseminated by drinking-
Avater in much the same  manner  as typhoid feA'er.  Its
natural habitat is the tropics A\'hence it spreads to  the
temperate zone in epidemic form, when faulty hygiene or
a Aulnerable Avater  supply affords  it an opportunity.  It
is uoav many years since it has invaded the United States,
although many cases have been brought to New York
from  infected  ports.   In  1892,  for example, during  the
Hamburg  epidemic,  many  cases  were  discovered  on
incoming vessels but by  rigid  quarantine  measures, of
Avhich the  writer was, by the way, an innocent victim,
the disease  was excluded.  In Arabia, India, etc., the dis-
ease  is endemic and is spread by the  annual pilgrimages
to Mecca and to other shrines.   It frequently extends
northward into Russia in the direction of the trade routes
and  usually  finds hygienic conditions favorable  to its
spread in epidemic  form.   The disease is also prevalent
in our oAvn tropical  possessions, at  Manila and elsewhere.
  The incubation is brief, from two to five days,  and is
followed by diarrhea.  The stools at first resemble  those
of ordinary enteritis,  but soon become  very  frequent,
thin,  and Avatery ("rice-water stools").   Severe vomiting
and cramps in the muscles of the  abdomen and legs  are
a prominent feature.  The extremities are cold and blue
and greatly shrunken  from the excessive loss of  fluid.
Collapse rapidly ensues.  Suppression  of urine is usual. 
BACTERIAL INFECTIONS           385
Death may follow in a few hours or days, or reaction may
occur and the patient gradually regain health and strength.
Exhaustion or complications may claim victims in the
late stages.  In the Hamburg epidemic the mortality was
approximately 50 per cent.
  Cholera nostras (morbus)  and cholera  infantum, which
attack adults and infants respectively, are severe forms of
diarrhea with almost  identical  symptoms.  They  occur
in temperate climates in the summer months.  They may
be very fatal but do not become epidemic.
  In England affected ships are fumigated,  those  ill of
the disease are isolated, and  those who have been exposed
are allowed to proceed to their own homes, but are kept
under observation until the end of the period of incuba-
tion.  In this country a much more rigid quarantine is
necessary,  because  cases  cannot be adequately treated
and supervised after they have once entered the country,
on  account of  the  lack of  a centralized department of
health.  During the course  of an epidemic, protection is
obtained by boiling the water and by eating cooked food
only.  Prophylactic inoculation has also been used during
epidemics.
  The treatment of cholera consists in irrigation of the
bowels with tannic acid or other astringent solutions, large
intravenous saline injections, and symptomatic measures.
  Dysentery, Bacillary and Amebic.—There are two prin-
cipal types of dysentery:  one due to the bacillus dysen-
teriae and related organisms, the other  to an animal or
protozoan parasite,  the ameba dysenteriae.  The former
is the common  cause of acute dysentery, both in the
temperate and in the tropical zones; it is also a factor in
many of the summer diarrheas of infancy and may cause
chronic dysentery.  The ameba is responsible for a small
portion of the acute and for much of the chronic dysen-
tery of the tropics  and it frequently gives rise to liver
abscesses.  Americans  and Europeans Avhose work carries
them to the tropics are  frequently invalided  home  on
account of the latter form of  the disease.
      25 
3S(i    INFECTIOUS  AND PARASITIC  DISEASES

  The typical symptoms of dysentery are the passage of
frequent  small  stools, consisting largely of  mucus and
blood  Avith painful straining  (rectal  tenesmus).  These
symptoms distinguish it from ordinary enteritis, in Avhich
the stools are thin and fecal  in character, and mucus and
blood, if present at all, are intimately mixed.   In enteritis,
pain is either absent or colicky in its nature and is felt
about  the navel.  In cholera defecation is usually pain-
less.  Acute dysentery may be mild and of brief  dura-
tion, but  usually  the movements are frequent and fever
and constitutional symptoms marked.   E\Ten  acute forms
tend  to  become  subacute  and  to  persist  indefinitely.
Emaciation and anemia are progressive and  the patient,
if untreated, may eventually  perish from exhaustion  or
inteicurrent  complications.  Perforation of  the bowel,
peritonitis, hemorrhage, liver  abscess,  and arthritis may
be mentioned  as complications  likely  to occur.   After
recovery there is frequently  a marked  liability to recur-
rence from quite trivial causes, such as unsuitable diet  or
change of temperature.   Persistent cases are often relieved
by remoAral to a cold climate.
  The  prophylaxis is practically the  same  as that  of
typhoid  and  cholera.  Improved  sanitation  has  made
dysentery of minor importance in modern armies, at least
in the  temperate zone, although as late  as the Civil War
it was a most serious  cause of invalidism and death.
  In both forms of dysentery, especially if chronic, medi-
cated fluids  containing tannic acid,  nitrate of silver,
quinin, etc., are used  to irrigate the loAver bowel.  In the
bacillary type bismuth  and similar drugs Avith opium are
frequently employed, while in the amebic form ipecac  or
emetin Avhich is deriAred from it,  is administered in large
doses with remarkably good results.  Abscess  of the liver
is treated  by incision and  drainage usually, Avith  good
success. 
CHAPTER VIII.
INFECTIOUS AND  PARASITIC  DISEASES-
            CLASS IV  (Continued).
Intestinal  and Visceral  Par-
   asites.
  (1) Threadworms.
      Treatment.
    Round or Lumbricoid AVorms.
   Hookworms and Hookworm
     Disease.
   The Trichina and Trichinosis.
(2) Tapeworms.
   Echinococcus Disease.
       INTESTINAL AND VISCERAL PARASITES.

  The more  highly organized parasites which prey upon
man do not often give rise to the reactions in the human
organism  which we are accustomed to see in bacterial
infections, e. g., fever and  associated symptoms.  It is a
matter of convenience, hoAveAer, to consider these so-called
infestations in this  connection, because  of a certain simi-
larity in modes of  propagation and  prophylaxis.  Para-
sites of all kinds and particularly intestinal parasites are
far more  common  in the tropics than in the temperate
zone; Ave  can refer only  to  the  more  common varieties
obseiwed  in this latitude.
   1. Threadworms.—Of the  general class of roundworms
the most familiar   is  the threadworm (oxyuris vermi-
cularis) which  is so commonly  found  in the rectum of
children.  These Avorms are Aery small, from one-fifth to
two-fifths of an inch in length, and have a habit of wan-
dering out of the rectum particularly at night and laying
their eggs.  In girls they may enter the vagina. The eggs
therefore  are not ordinarily  found in the stools.  Their
migrations may give rise to irritation, itching, and scratch-
ing.   In children Avith susceptible nervous  system  they
occasion muscular tAvitching, disturbed  sleep, and similar 
388   INFECTIOUS AND  PARASITIC DISEASES

manifestations.  Reinfection may occur by the introduc-
tion of the eggs into the mouth.   Other children  acquire
the infection by direct  contact or from green vegetables
or from other food that may have been contaminated by
fecal matter  (fertilizer).
  Treatment.—Cleanliness is important to avoid infection
and  reinfection.  Migrations of the  Avorms (e. g., to the
vagina) are sometimes preAented by placing a  ring of
mercury  ointment about  the anus.  The parasites are
removed by flushing the Ioavci- bowel Avith simple salt or
Avith some medicated  solution.  An infusion  of  quassia
made by pouring a quart of water on one or tAvo ounces
of the chips is the most popular remedy.
  Fig.  65.—1. Oxyuris vermicularis:  a, male; b, female; natural size.
                 2. Magnified.  (Simon.)

  The  "Roundworm." —  The   common   roundworm
(ascaris lumbricoides) is a much larger parasite, measuring
from  six to sixteen inches in length.  It is more at home
in the upper part of the small intestine, but occasionally
wanders into the appendix, gall ducts, stomach,  and even
larynx. The symptoms are ordinarily  extremely vague:
picking at  the nose,  grinding of the  teeth,  and even con-
vulsions are  attributed to  the presence of  this parasite. 
INTESTINAL AND VISCERAL PARASITES  389
The diagnosis is made by finding the eggs in the stools.
Under the microscope the eggs, with their rough envelope,
are quite distinctive.  Treatment is usually by santonin.
It is given  in one-half- to two-grain doses, combined with
calomel.  The  patient should fast  for some time before
treatment  is begun  and subsequently a purgative should
be administered.
«~k  68
«».—
  Fig. 66.—New World male hookworm. Natural size.  (Stiles.)
  Fig. 67.—New World female hookworm.  Natural size.  (Stiles.)
  Fig. 68.—The same, enlarged to show the position of the anus (a)
and the vulva (v).  (Stiles.)
  Hookworms and Hookworm  Disease.—This disease,
until a few years ago considered to be rare, has come to
be recognized as one  of the most  common  and serious
maladies of the Southern States.  It  is almost universal
in Porto Rico and has been a subject  for extensive inves-
tigation  by the govermnent authorities since our recent
conquest of the island.  The New World variety (Necator 
 390   INFECTIOUS AND PARASITIC DISEASES

 Americanus)  is about twice as  large  as the  ordinary
 threadAvorm.  It is possessed of minute teeth  by which
 it attaches itself firmly to the inside of the intestine.  Its
 eggs are discharged  in the stools, but infection  does not
 appear to enter, as a rule, by the mouth.  The eggs develop
 in  the soil  and the lame  gain access  to the  body  by
 burroAving through the skin,  causing inflammatory symp-
 toms known as "ground-itch" in  those who go barefoot.
 Once Avithin the body, the  parasites make their Avay  by
 devious paths into the intestines.
   The disease may produce  no  symptoms, but as a rule
 it causes intense anemia accompanied by a deathly pallor
 and extreme  lassitude,  so  that  the  parasite has been
 humorously called the germ of laziness.  The  infection
 may proA'e fatal.
   The prophylactic treatment consists in proper  sanitary
 arrangements (Avell-arranged outhouses,  drains,  etc.), to
 prevent the contamination of the  soil by fecal discharges
 and in the  wearing of shoes and  stockings.  Where the
 country  is  extensively infected, as in  Porto Rico, the
 stools of suspected persons should be examined to confirm
 the diagnosis  and  treatment administered in accordance
 with the findings.  This is both for the advantage of the
 patient and  for the good of the community.
   The curative treatment consists in the  administration
 of thymol, chenopodium,  or  other vermifuges in suitable
 doses, preceded by fasting and saline purgatiAes  and fol-
 lowed by  reneAved purgation.
   The Trichina and  Trichinosis.—The  trichina  spiralis
 is a minute  intestinal worm which is ordinarily found in
 hogs but is  occasionally seen in  man.  The female Avorm
 deposits the embryos in the  intestinal wall so that they
 immediately reach the lymph or  bloodvessels and  by these
 paths reach  the muscles  all over the body, Avhere they
 develop into larvae and become  encapsulated.  In this
 state they remain dormant indefinitely, but if the uncooked
flesh containing the larvae is eaten the larvie develop into
 the intestine into  the  full-grown worm,  and the cycle 
      INTESTINAL AND  VISCERAL PARASITES   391

begins anew in the new host.  In human beings infection
usually results from eating smoked, imperfectly cooked,
or raw ham (after the German fashion).
 Fig. 69.—Trichinella spiralis in muscle, greatly magnified.  (Simon.)

  The ingestion  of  the infectious food at first induces
few  or no  symptoms  (sometimes mild gastro-enteritis)
but at the end of one or tAvo Aveeks the migration of the
embryos into the muscles causes severe pains, high fever,
and  a train of  symptoms  not unlike  those of  typhoid. 
392   INFECTIOUS AND PARASITIC DISEASES

Quite commonly  there  is edema of the eyelids.  These
symptoms—fever, severe muscle pains, and  edema—in a
person Avho admits indulgence  in  nuv  or  insufficiently
cooked pork,  are very  suggestive  of  trichinosis.   If  in
addition, examination of the blood shoAvs a leukocytosis
Avith an unusual proportion of certain Avhite blood cells
knoAAn as eosinophiles, the diagnosis is practically certain.
In sections of muscle, if such can be  obtained, the trichina
may be seen under the microscope.   There is no treatment
other than measures directed to relieve the sufferings  of
the patient.   The  preventive treatment is evident;  no
pork except that which is known to  be thoroughly cooked
should be eaten.
  2. Tapeworms.—Of the many varieties of tapeworms
only one is common in the eastern United States. This is
the beef tapeAVorm (tenia mediocanellata). This worm, like
the others  of  this group, consists of a chain of flattened
segments and a head.  The head is a little larger than
that of a large pin  and  is attached to  the mucous mem-
brane of the  intestine by  four  suckers.   The  segments
near the head, in which  situation growth  takes place, are
small and elongated, but toward the free extremity they
increase in size and become more nearly square.  The
fully developed segments are as large  as the thumb-nail
and  if held up to  the  light show a finely branched  or
tree-like uterus with an opening at  one side.  From time
to time short  sections,  consisting  of ripe segments, are
detached and are seen in the stools.  The worm may reach
a great length, as much as twenty-five feet
  In spite  of its great size this parasite causes extremely
indefinite symptoms.  There may be vague digestive and
nervous  disturbances.   It  is usually  diagnosed by the
finding of  the segments in the movements,  or by detect-
ing  the eggs  in the stools  by microscopic  examination.
In the ox the parasite is found in the muscles in the larval
stage (cysticercus).   Infection may be prevented by eat-
ing only Avell-cooked meat, and avoiding beef and sausage
Avhich have merely been smoked or dried. 
      INTESTINAL AND VISCERAL PARASITES   393

  The pork tapeworm (tenia solium)  is very similar to
the beef tapeAVorm.   The head is armed with  hooklets
Fig. 70.—Tenia saginata: a, natural size; b, head, much enlarged; c, ova,
                  much enlarged.  (Simon.)
as well as suqkers,  the uterus is  not so finely divided,
and the length of the Avorm is somewhat less.  It is found 
394    INFECTIOUS AND PARASITIC DISEASES

in countries AA'here pork is eaten in a more or less uncooked
condition.  Self-infection may  occur,  but  the  pig is the
usual intermediate  host.
  The fish tapeAvorm, or bothriocephalus  latus, is  com-
mon in countries in Avhich fish forms an important part
of the  diet,  and especially in  Scandinavia.   Imported
cases are not unusual in this country.  This Avorm is ca en
longer than the beef tapeAvorm,  the segments are broad
and  short, and  the  uterus resembles  a rosette.   This  is
a much more serious infestation than those  previously
described, as it  frequently leads  to a very  high degree of
anemia resembling  the pernicious type.
  Echinococcus  Disease.—Tenia  echinococcus  is a small
tapeworm found in dogs, which occurs in the larval form
(hydatids) in man, particularly in the viscera.   The larva1
deAeloping in the  tissues or organs  produce enormous
cysts filled  Avith smaller "daughter" cysts.   The  cysts
contain characteristic booklets.    The liver  and spleen are
the organs usually involved.  The disease is rare here but
common in South America.
  TapeAvorms are  treated  by   fasting, purgation,  and
vermifuges.   The Aermifuges in common use  are the
oleoresin  of  aspidium (male fern)  and the  tannate of
pelletierin  (from pomegranate).   Pumpkin  seeds  are
sometimes used. Echinococcus cysts Avhen large  enough
to be diagnosed Avith certainty  should be incised  and
drained. 
INDEX.
Abscess, brain, 60
    treatment of, 60
  of liver, 190
    in dysentery, 385
Achylia, 166
Actinomycosis, 297
Acromegaly, 79
Acute tonsillitis, 353
Addison's disease,  79
Adenoids, 120,  121, 122
  treatment, 122
"Air hunger," 114
Albumin in  urine, 220
Alcohol, 250
  fuel value of, 250
  wood, 253
    effects of, 254
Alcoholic cirrhosis of liver, 187
  neuritis, 45
Alcoholism,  250
  acute, 251
  chronic, 252
    complications, 252
    delirium tremens,  252
    treatment, 252
Allen's   treatment in  diabetes
  mellitus, 207, 208
Ameba dysenterise, 385
Amebic dysentery, 385
Anemia, 66
  pernicious, 68
    treatment, 68
  secondary, 67
  splenic, 69
Anesthesia,  23
Aneurysm, 90
  symptoms, 90
  treatment, 91
Angina pectoris, 97
    treatment, 98
  Vincent's, 145
Animal diseases in man, 293
Anorexia, 137
Anthrax, 296
  bacillus, 296
  symptoms of, 296
  treatment of, 297
Antimony poisoning, 258
Antitoxin, 275, 278
  diphtheria, 276
  tetanus, 276
Aphasia, 22
Aphonia, 114
Apoplexy, 57
Appendicitis,  180
  acute,  181
    catarrhal, 181
    gangrenous, 181
    suppurative, 181
  chronic, LSI
    catarrhal, 181
    obliterative, 181
  symptoms,  181
  treatment of, 182
Arsenic poisoning, 258
Arteriosclerosis, S7
  treatment of, 89
Arthritis, acute, 239
  chronic, 239
    treatment of,  244
  deformans,  217, 240
  gonococcus, 291
  gonorrheal,  243, 291
  infectious, 237, 243
  irritative, 239
  monarticular, 241
  rheumatoid, 242
  syphilitic, 244 
39(3
INDEX
Arthritis, traumatic, 239
  tuberculous, 243
  villous, 240
Arthropathies, nervous, 244
Articular rheumatism, 239, 240
    acute,  355
Ascaris lumbricoides, 388
Ascending  infection  of urinary
  passages, 225
Ascites, 191
  treatment of,  192
Aseptic nursing, 274
Asiatic cholera,  384
Aspiration  of chest, 135
Asthma,  129
  treatment, 130
Ataxia, 26
  locomotor, 50
Atheroma,  88
Atonic constipation, 173
Atony of stomach,  160
Atrophic cirrhosis of liver,  187
Atrophy,  progressive muscular,
  47
Atropin poisoning,  259
Auto-intoxication, 257

               B
Bacillary dysentery, 385
Bacteria and parasites, ameba
       dysenteriae, 385
    anthrax bacillus, 296
    ascaris lumbricoides, 388
    bacillus of Bordet, 334
       dysenterise, 385
       mallei, 297
       of Malta  fever, 383
       pestis, 312
       tetani, 293
       typhosus, 372
    bothriocephalus latus, 394
    comma bacillus,  384
    diplococcus intracellularis
       meningitidis, 321
    filaria  sanguinis hominis, 309
    influenza bacillus, 332
    Klebs-Loffler bacillus, 315
    micrococcus gonorrhese,  291
    necator americanus, 389
    oxyurjs vermicularis, 387
    Plasmodium falciparum,  306
       malaria;,  306
Bacteria and  parasites,  plasmo-
      dium vivax, 305
    pneumococcus, 325
    pyogenic bacteria, 2S5, 2SS
    ray fungus, 297
    spirillum of Obermaier, 313
    streptococcus pyogenes, 28S
    tenia echinococcus, 394
      mediocanellata  or   sagi-
         nata, 392,  393
      solium, 393
    treponema pallidum, 300, 301
    trichina spiralis, 391
    trypanosome, 311
  •  tubercle bacillus, 337
Bacterial diseases of Class III,
      315, 337
    Class IV, 372
Baniny test, 23
Bed-bugs, infection disseminated
  by, 312
Belching, 138
Bell's palsy, 43
Benedict test in diabetes mellitus,
  210
Beriberi, 215
Bile passages, diseases of, 183, 184
Binet test, 33
Black death, 311
Blood, color of, 63
  counting, 64
  cultures, 287
    'technic of, 287
  diseases of, 63
    general consideration,  63
Blood-pressure, 84
  in nephritis,  223
Bloodvessels, diseases of, 81, 87
Bones, diseases of, 237, 239
Bothriocephalus latus, 394
Brain abscess, 60
  tumors, 60
Break-bone fever, 310
Bright's disease, 231
Brill's disease,  313
Bronchitis, 124
  chronic,  125
  treatment, 125
Bronchopneumonia, 127, 325, 330
  epidemic, 330
  in measles, 360
  in whooping-cough, 335
Bubonic plague, 311 
INDEX
397
               c

 Caisson disease, 249
 Calories, 197
   in diet, 200
 Cancer.  See Carcinoma.
 Carcinoma of esophagus, 150
   of gall-bladder,  191
   of intestine, 179
   of liver,  191
   of peritoneum, 193
   of stomach, 158
 Carriers, 265, 316, 374
 Casts in urine, 222
 Catarrh, chronic gastric, 152
 Catarrhal enteritis, 169
   jaundice, 185
   pneumonia, 127
 Catheterization, 223
 Cerebrospinal fever, 321
   meningitis, 321
     epidemic, 321
     Flexner's serum in, 324
     influenzal, 322
     pneumococcic, 322
     pyogenic, 322
     secondary forms, 322
     symptoms of, 322
     treatment of,  324
     tuberculous, 322, 340
   syphilis, 53
     treatment of,  54
 Chagres fever, 307
 Chest, aspiration of, 135
 Cheyne-Stokes   respiration,
       114, 323
     in nephritis, 223
 Chicken-pox, 371
   varioloid and, 371
 Chlorosis, 67
   treatment, 67
 Cholelithiasis, 185
 Cholera,  384
   asiatica,  384
   infantum, 170, 385
   morbus, 170, 385
   nostras, 385
   prophylaxis of, 385
   treatment of, 385
Chorea, 39
Choreiform movements, 26
Chyluria, 309
Cjrrhosjs of liver, 187
  Cocain habit, 255
  Colic, 138
    gall-stone, 186
  Cough, 114
  Coma, 21
  Comma bacillus, 384
  Communicable diseases, 264, 270
  Confusion, 21
  Confusional insanity, 30
  Congestion of liver, 191
  Congestive chills, 309
  Constipation, 139
    chronic, 173
      atonic, 173
      spasmodic, 173
      treatment of, 175
  Consumption, 341
    galloping, 341
  Contagious diseases, 263
  Contractures, 25
  Convulsions, 25
    epileptic, 38
    infantile, 37
      treatment, 38
    uremic, 223
  Crescents, malarial, 307
  Cretinism, 76
  Crises, 51
  Croup, membranous, 123
    spasmodic, 123
  Croupous pneumonia, 325
  Cyanosis, 86
  Cyst of kidney, 230
  Cysticercus, 392
i, Cystitis,  226
    symptoms of, 226
    treatment of, 227
  Cystoscope, 224
               D

Delirium, 21
  tremens, 252
Dementia, 31
  precox,  31
  senile, 31
Dengue, 310
Descending infection  of  urinary
  passages, 225
Diabetes insipidus, 211
  mellitus, 205
    Benedict test, 210 
398
INDEX
Diabetes mellitus, causes of, 206
     diet of, 208-211
     symptoms of, 206
     treatment of, 206
       Allen's, 207, 208
Diaphragmatic pleurisy, 131
Diarrhea, 139, 168
  in adults, 170
  fermentative, 169
  infantile,  169
  treatment of, 171
  in t\'phoid fever, 376
Diet, calories  of, 200
  in chronic gastritis, 153, 154
  in diabetes, 208-211
  in nephritis, 234
  in typhoid fever, 378
Digestive tract, diseases of, 137
     general  consideration,  137,
       144
Digitalis, 109
Dilatation of heart, 98
  of stomach, 160
Diphtheria, 315
  antitoxin, 276
  conjunctival, 317
  laryngeal, 316
  nasal,  316
  paralysis in, 317
  symptoms of, 316
  treatment of, 317
     antitoxin  in, 318
     intubation in, 319-321
     tracheotomy in, 319
Diplococcus intracellularis  men-
  ingitidis, 321
Disinfection, 272
Disseminated  sclerosis, 50
Diverticulitis, 182
Droplet infection, 274
Dropsy,  86
Dry pleurisy,  131
Ductless glands, diseases of, 73
Duodenal tube, Einhorn's, 142
Duodenum,  ulcer of, 156
Dysentery, 385
  abscess of liver in, 386
  amebic, 385
  bacillary,  385
  prophylaxis of, 386
  symptoms of, 386
  treatment of, 386
Dyspepsia, gall-stone, 186
Dyspepsia, nervous,  106
  reflex,  106
  symptomatic, 166
Dysphagia, 138, 14S
Dyspnea, 86, 107,  114
E
Echinococcus disease, 394
Edema in nephritis, 223
  pulmonary, 129
Einhorn's duodenal tube,  142
Elephantiasis, 309
Embolism, 92
  cerebral, 57
Emphysema, 130
Empyema, 132
  in pneumonia, 329
Encephalitis, lethargic, 352
Endocarditis, acute,  101
  chorea and, 39, 40
  chronic,  104
  gonococcus, 291
  malignant, 103
  rheumatic, 357
  treatment of, prophylactic, 100
Enteric fever, 312, 372
Enteritis, 168
  catarrhal, 169
  diet in, 172
Enteroclysis, 66, 142
Enterocolitis,  169
Enuresis, 224
  treatment of, 225
Epidemic bronchopneumonia, 330
  parotitis, 358
  poliomyelitis, 350
Epilepsy, 38
  treatment, 39
Epistaxis, 115
  packing posterior nares for, 116
Erysipelas, 288
  symptoms of, 289
  treatment of, 290
Esophagus, cancer of, 150
  diseases of,  148
  stricture of, 148
    hemorrhage of, 150
    malignant, 150
    simple, 149
    spasmodic, 149
    syphilitic, 149 
INDEX
399
Esophagus,  stricture  of,
    ment of, 150
  tumors of, 148, 149
Exophthalmic goiter, 76
               F

Facial palsy, 43
Fainting, 86
Famine edema, 203
Farcy, 297
Feeble-minded, the, 32
Feeding, rectal,  143
Fermentative diarrhea, 169
Fever, 278
  classification of, 279
  continued, 280
  diet of,  284, 382
  hectic, 281
  hydrotherapy in, 283, 382
  intermittent, 280, 306
  onset of, 279
  recording of, 282
  remittent,  280, 307
  symptoms of, 278
  treatment of,  283
  trench,  313
  types of, 279
Fibroid tuberculosis, chronic, 341
Filaria sanguinis hominis, 309
Filariasis, 309
Fissures, 180
Fistulas, 180
Fleas, infection disseminated by,
  311
Flies,  infection  disseminated by,
  310
Follicular tonsillitis, 353
Food poisoning, 257
  stuffs, 196
  values,  197
Fractional test-meals, 142
Fulness and distress,  138
Functional  diseases  of  nervous
  system, 33

                G

Gall-bladder,  cancer of, 191
Gall-stone colic, 186
  disease, 185
     treatment of,  186
,- Gall-stone dyspepsia, 186
  Gangrene, 206.  See Diabetes.
    and noma, 145
    pulmonary, 129
      and erysipelas, 290
      and Raynaud's disease, 24
  Gangrenous stomatitis, 145
  Gas, mustard, 260
    war, 260
  Gastralgia, 138
  Gastric pain, 138
  Gastritis, acute, 151
      treatment of,  152
    chronic, 152
      diet of, 154
      treatment of,  153
  Gastro-enteritis, 151
  Gastroptosis, 162
  Gavage, 325
  German measles, 362
  Glanders, 297
  Glands, ductless, diseases of, 73
    lymphatic, diseases of, 73
  Glandular enlargement in meas-
      les, 361
    tuberculosis, 339
  Goiter, exophthalmic, 76
      treatment, 78
    simple, 75
  Gonococcus arthritis, 291
      treatment of,  292
    endocarditis, 291
    infection, 291
    rheumatism, 291
    septicemia, 291
    vaccine,  293
    vaginitis, 291
  Gonorrheal.  See Gonococcus.
  Gout,  212
    treatment, 213
  Grippe, 332
  Ground-itch, 266,  390
  Gummata, 301

                 H

  Hay-fever, 119
  Headache, 22
  Heart, dilatation of, 98
    diseases of, 97
      causation of,  100
      valvular, 101
    hypertrophy of, 98 
400
INDEX
Heart, insufficiency of, 99
    treatment of,  107
  soldier's, 98
Heartburn, 138
Heat, disease due to, 247
  effects of, 24?
  exhaustion, 248
Heberden's nodes,  240
Hematemesis,  139
Hemiplegia, 55
Hemophilia, 72
  treatment, 72
Hemorrhage, cerebral,  57
  subdural, 59
    treatment, 59
  in tuberculosis, 342
  in typhoid fever, 378
Hemorrhoids,  179
  external, 179
  internal, 180
Hernia, 176
Heroin habit, 254
Herpes, 47
  in pneumonia, 328
  zoster, 47
    treatment, 49
Hodgkin's disease, 71
Hookworm disease, 389
Hospital quarantine, 273
Hydatid cysts, 394
Hydrocephalus, 59
  chronic, 60
Hydropericardium, 96
Hydrophobia,  298
Hydropneumo thorax, 133
Hydrotherapy  in  typhoid  fever,
  382
Hydrothorax,  133
Hyperacidity,  166
Hyperesthesia, 23
Hypertrophic  cirrhosis of liver,
  188
Hypertrophy of heart, 98
Hypodermoclysis,  65
Hypostatic pneumonia, 128
Hysteria, 35
  treatment, 37
Idiots, 32
Immunity,  274, 277
Immunity, infections  affording,
      275
    without, 275
Inanition, 203
Incipient tuberculosis, 341
Incontinence of urine, 224
Incubation, period of, 271
    maximum, 271
Industrial poisoning, 256, 258
Infantile convulsions, 37
  paralysis,  350
    etiology of, 351
    prophylaxis in, 352
    symptoms of,  351
    transmission of, 351
    treatment of, 352
  scurvy, 214
Infantilism,  79
Infarct, pulmonary, 129
Infarction, 92
Infections, 263
  due to pyogenic bacteria, 285,
    288
  transmission of,  264
    by air, 266
    by carriers, animal, 265
      human, 265
    by contact, direct, 264
      indirect, 264
    by drinking-water, 264
    by food, 264, 265
    by intermediate hosts,  265
    by soil,  266
Infectious diseases, 263, 285
    classification of, 266
      Class I, 266, 285
        characteristics, 266, 285
        prophylaxis, general, 266
      Class II, 266
        characteristics, 266, 305
        prophylaxis, general, 268
        transmission, 267
          by fleas, 267, 311
          by flies, 267, 310
          by lice and bed-bugs,
            268, 312
          by mosquitoes,  267,
            307
          by ticks, 267, 311
      Class III, 268, 315, 337
         bacterial, 268,  315, 337
         characteristics, 268, 315
         prophylaxis, general, 268.T 
INDEX
401
Infectious diseases,  classification
         of, Class III, uncertain
         causation, 268, 350
      Class IV, 269, 372
         characteristics,  269, 372
         prophylaxis, general, 269
         transmission by  inter-
           mediate  hosts,   269,
           387
         by intestinal discharges,
           269, 374
    immunity in, 274
    incubation of, 271
    isolation of,  271
    quarantine in, 273
Inflammatory rheumatism, 355
Influenza, 332
  bacillus, 333
  nostras, 333
  symptoms of, 333
  treatment of, 334
Insanity, 30
  confusional, 30
Insolation, 247
Insomnia, 20
Insufficiency, cardiac, 99
    symptoms of, 99
    treatment, 107
      medicinal,  109
Interstitial nephritis, 233
Intestinal parasites,  387
  tuberculosis, 339
Intestine, carcinoma of,  179
    treatment of, 179
  diseases of, 168
  obstruction of,  176
    symptoms of, 177
  strangulation of, 176,  177
  tumors of, 178
    treatment of, 179
Intravenous infusion, 66
Intubation, operation of, 319-321
Intussusception,  176
Isolation, 272
  period of, 271
Jail fever, 312
Jaundice, 184
  catarrhal, 185
  causes of, 184
      26
Joints, diseases of, 237, 239
  tuberculosis of, 339
Kernig's sign, 323
Kidneys, abscess of, 230
  cyst of, 230
  diseases of, 219, 224
  functional tests of, 222
  general considerations, 219
  movable, 230
  stone in, 230
  tumors of, 229
Klebs-Loffler bacillus, 315
Lacunar tonsillitis, 353
Laryngeal diphtheria, 316
Laryngismus stridulus, 123
Laryngitis, acute, 123
    treatment, 123
  chronic, 123
Lavage, 139
Lead colic, 256
  neuritis, 45
  palsy, 256
  poisoning, 256
    treatment, 257
Leprosy, 337, 347
Lethargic encephalitis, 352
Leukoma, 69
  tremment, 70
Leukoplakia, 146
Lice, infection disseminated by
  312
Liver, abscess of, 190
    in dysentery, 386
  cancer of, 191
  cirrhosis of, 187
    alcoholic, 187
    atrophic, 187
    hypertrophic, 188
    portal,  187
    prognosis of, 189
    symptoms of, 188
    syphilitic, 188
    treatment of, 189
  congestion of, 191
  diseases of, 183, 184 
402                        INDEX
Liver, gin-drinker's, 187
Lobar pneumonia, 325
Lobular pneumonia, 127
Lockjaw, 294
Locomotor ataxia, 50
    treatment, 52
Lues.  See Syphilis.
Lumbago, 238
Lumbar puncture, 28, 324
Lumpy jaw, 297
Lungs, diseases of, 113, 127
Lymphatics, diseases of, 73
Lyssa, 298
              M

Malaria, 305
  estivo-autumnal, 306, 308
  etiology of, 305
  malignant, 309
  parasite of, 307
    development of, 307
  prophylaxis of, 307
  quartan, 306
  quotidian, 306
  symptoms of, 308
  tertian, 305, 30S
  treatment of, 308
  varieties of, 305
Malignant pustule, 296
Malnutrition, 203
Malta fever,  383
Mania, 31
Measles, 359
  bronchopneumonia in, 361
  German, 302
  glandular enlargement in, 361
  noma in, 145
  prophylaxis of, 361
  symptoms of,  360
  treatment of, 361
Melancholia, 31
Membranous croup, 123
Meningitis, 54
  cerebrospinal, 55, 321
  influenzal, 322
  pneumococcic, 55, 322
  pyogenic, 322
  secondary, 322
  syphilitic, 54
  tubercular, 54
Mental deficiency, 32
Mental diseases, 17, 30
Mercurial stomatitis,  145
Metabolism, diseases of, 195, 201
  principles of, 195
Micrococcus gonorrheas, 291
Miliary tuberculosis, 340
Milk, certified, 172
  pasteurized, 173
  pure, prophylactic value of, 172
  sterilized, 173
Morbilli, 359
Morons, 32
Morphin habit, 254
Mosquitoes,  infection  dissemi-
  nated by, 305
Motor tracts,  19
Mountain sickness, 250
Mouth, diseases of, 145
    treatment, 148
Movable kidney, 230
    treatment, 230
Mucous patches, 146
Multiple neuritis, 45
  sclerosis, 50
Mumps, 358
  orchitis in, 359
Murmurs, 87
Muscles, diseases of, 237
Muscular rheumatism, 237
Mustard gas, 260
    effects of, 260
Myalgia, 217, 237
  treatment, 238
Myelitis, 49
  symptoms, 49
  treatment, 49
Myocarditis, 101
Myositis, 237
Myxedema, 76
               N

Nasal diphtheria, 316
Nauheim baths, 110
Xecator americanus, 389
Nephritis, 231
  acute, 233
  blood-pressure in, 223
  Chevne-Stokes respiration in,
    223
  chronic, 233
    interstitial, 233 
INDEX                        403
Nephritis,  chronic  parenchyma-
    tous, 233
  edema in, 223
  in scarlet fever, 366
  treatment of, 234
  trench, 233
Nervous diseases, 17
    organic,  43
    symptoms and signs of, 20
        anesthesia, 23
        aphasia, 22
        ataxia, 26
        choreiform  movements,
           26
         coma, 21
        confusion, 21
        contractures, 25
        convulsions, 25
        delirium, 21
        headache, 22
        hyperesthesia, 23
        insomnia, 20
         pain, 23
        paralysis, 24
        reflexes, 26
        spasticity, 25
        special senses, 27
        sphincter  disturbances,
           24
        stupor, 21
        tremors, 26
        trophic  disturbances, 24
        vasomotor disturbances,
           24
        vertigo, 23
  dyspepsia,  166
  system, functional  diseases of,
    33
Neuralgia,  41
  treatment,  42
Neurasthenia, 33
  treatment,  35
Neuritis, 43
  alcoholic, 45
  facial, 42
  lead,  45
  multiple, 45
    treatment, 46
  pressure, 44
  toxic, 45
Neurocirculatory asthenia, 98
Neurons, 18
Neuroses of stomach, motor, 167
Neuroses of stomach,  secretory,
       166
    sensory, 165
Nitrate of silver poisoning, 25.9
Noma, 145
Nystagmus, 50
Obesity, 201
  treatment, 202.
Obstruction of intestines,  176
Opisthotonos, 25
Opium habit, 254
    treatment of, 255
  poisoning, 254
Orchitis in mumps, 359
Organic diseases of nervous sys-
  tem, 43
Orthopnea, 86
Osteo-arthritis, 240
Osteo-arthropathy,   pulmonary,
  244
Osteomalacia, 215
Oxyuris vermicularis, 387
Pain, 23
  gastric, 138
  precordial, 97
Pancreas, diseases of, 183
Pancreatitis, 183
Paralysis, 24
  agitans, 40
  cerebral, 55
  facial, 43
  infantile, 350
  lead,  45
  pressure, 44
  in whooping-cough, 335
Paranoia, 32
Parasites, 387
  intestinal, 387
  visceral, 387, 390, 394
Parasitic diseases, 263, 387
Parasyphilitic diseases, 300
Paregoric habit, 254
Parenchymatous nephritis, 233
Paresis, 50, 300
  general, 53 
404
INDEX
 Paresis, treatment of, 53
 Parotitis, 147
   epidemic, 358
 Pellagra, 217
 Perforation in typhoid fever, 378
 Pericarditis, 93
   adhesive, 94
   fibrinous, 94
   rheumatic, 357
   symptoms of, 95
   treatment, 95
   tuberculous, 339
   with effusion, 94
 Pericardium, diseases of, 81, 93
 Peritoneum, cancer of, 193
   diseases of, 137, 183,  191
   tuberculosis of, 339
   tumors of, 193
 Peritonitis,  193
   acute purulent, 193
   chronic,  193
 Pernicious anemia, OS
    transfusion in, 68
 Pertussis, 334
 Phagocytosis, 276
 Pharyngeal  diphtheria, 316
 Pharyngitis, 120
 Phosphorus poisoning, 258
 Phthisis, 340, 341
   fibroid, 340, 341
   florida, 340, 341
   ulcerative, 342
 Physical causes, diseases due to,
   247
 Piles, 179
 Plague, 311
   bubonic, 311
   pneumonic, 312
 Plasmodium falciparum, 306
   malariae, 306
   vivax, 305
Pleura, diseases of, 113, 131
Pleurisy, 131
   diaphragmatic, 131
   dry, 131
   purulent,  132
   treatment of, 134
   with effusion, 131
Pleurodynia, 237
Pneumococcic meningitis,  55
Pneumococcus, 325
Pneumonia, 325
   catarrhal, 127
 Pneumonia, complication of, 329
   course of, 327
   empyema in, 329
   etiology of, 325
   herpes in, 32S
   hypostatic, 128
   lobar, 325
   lobular,  127
   pathology of, 320
   plague, 325
   signs of, 326
   treatment of, 330
    fresh air in, 332
 Pneumothorax, 132
 Poison gas, 260
 Poisoning, antimony, 258
   arsenic, 258
   atropin,  259
   food, 257
   habit, 254
   industrial, 256, 258
   lead,  250
   mercury, 258
   nitrate of silver, 259
   opium, 254
   phosphorus, 258
   ptomaine, 257
   strychnin, 259
   wood alcohol, 253
 Poisons, 250
   diseases due to, 247
 Poliomyelitis, acute,  47, 350
   chronic, 47
   epidemic, 350
    symptoms of, 351
    treatment of, 352
Polycythemia, 69
Portal cirrhosis of liver, 187
Pott's disease, 339, 340
Pressure paralysis, 44
Protoclysis, 143
Protozoan infections, 299
Psychasthenia, 32
Ptomaine poisoning,  257
Pulmonary edema, 129
   gangrene, 129
   infarct,  129
  tuberculosis, 342
Pulsations, 87
Pulse, 81
   capillary, 87
   celerity, 82
   rate, 82 
INDEX
405
Pulse rhythm, 83
  size, 82
  tension, 82
  tracings, 85
Purpura, 71
  hemorrhagica, 72
  rheumatic, 71, 357
Pyelitis, 227
  treatment of, 228
Pyemia, 285
  symptoms of, 286
Pyloric stenosis, 160
Pyogenic bacteria, 285, 288
     infection due to,  285, 288
Pyopneumothorax, 133
Pyorrhea alveolaris,  146
Pyrosis, 138
Quarantine, 273
  absolute, 273
  cubicles, 274
  hospital, 273
  partial, 273
  special, 273
Quinsy, 354, 355
Rheumatic fever, course of, 356
    diagnosis of, 357
    endocarditis in, 357
    heart in, 357
    pericarditis in, 357
    purpura in, 357
    treatment of, 357
  purpura, 71
Rheumatism. »See"also Rheumatic
    fever.
  articular, acute, 239, 355
    chronic, 240
  chorea and, 39
  gonococcus, 291
  gonorrheal, 243, 291
  inflammatory, 355
  intercostal, 237
  muscular, 237
  syphilitic, 244
  tonsillitis and, 356
Rheumatoid arthritis, 242
Rickets, 213
  treatment, 214
Roman fever, 307
Roseola, 362
Roundworm, 387, 388
Rubella, 362
Rubeola, 359
Rabies, 298
  treatment of, 299
Railroad spine, 34
Ray fungus, 297
Rectal feeding, 143
Rectum, stricture of, 179
Reflexes, 26
Rehfuss' fractional method,  142
Relapsing fever, 313
Reportable diseases, 270
Respiratory   disease,   physical
           signs of, 116
         bronchial breathing, 117
         dulness, 117
         frictions,  117
         rales, 117
  movements, 113
Rhinitis, acute, 117
     treatment, 118
  chronic,  119
Rheumatic fever, 355
St. Vitus' dance, 39
Salivary glands, diseases of, 145
Salvarsan and neosalvarsan, 304
    administration of, 304
Scarlet fever, 363
    convalescence in, 365
    course of, 364
    desquamation in, 365
    nephritis in, 366
    prophylaxis   and treatment
      of, 366
Sclerosis, disseminated, 50
  multiple, 50
  spinal, 50
Scrofula, 339
Scurvy, 214
  infantile, 215
  treatment, 215
Senile dementia, 31
Sensory tracts, 19
Septicemia, 285 
400
INDEX
Septicemia, gonococcus, 291
  symptoms of, 280
  treatment of, 288
  varieties of, 287
Serositis, multiple, 193
Shell shock, 34
Ship fever, 312
Sleeping sickness, 310
Smallpox, 367
  symptoms of, 368
  vaccination in, 369
Soldier's heart, 98
Spasmodic constipation,  174
  croup, 123
Spasticity, 25
Special senses, 27
Sphincter disturbances, 24
Spinal sclerosis,  50
Spirillum of Obermeier, 313
Spondylitis deformans, 241
Spotted fever, 321
Sputum, 115
  staining of, 115
Stenosis, pyloric, 160
    congenital hypertrophic, 161
    treatment of, 161
Stomach, atony of, 160
  cancer of, 158
  dilatation of, 160
  diseases of, 151
    functional, 165
    organic, 151
  secretory disturbances of,
  ulcer of, 154
Stomatitis, 145
  gangrenous, 145
  mercurial, 145
  simple, 145
  ulcerative,  145
Stone, 228
  inbladder, 228
  in kidney, 228
  treatment,  229
Strangulation, intestinal, 176
Strawberry tongue, 365
Streptococcus pyogenes, 288
Stricture of esophagus, 148
  of rectum,  179
Stroke, 55
Strychnin poisoning, 259
Stupor, 21
Subacidity, 166
Sugar in urine, 221
Sunstroke, 247
  symptoms of, 248
  treatment of, 219
Suppurative tonsillitis, 354
Syncope, 86
Syphilis, 299
  acquired,  299
  cerebrospinal, 53
  congenital, 299
  diseases due  to,  301
  primary, 300
    lesions of,  300
  prophylaxis of, 303
  secondary, 301
  symptoms of, 302
  tertiary, 300, 301
  treatment of, 303
    iodides in, 304
    mercury in, 304
    salvarsan in, 304
  virulence of, 302*
  Wassermann reaction in, 302
Syphilitic arthritis, 244
  cirrhosis of liver, 188
  rheumatism, 24:5
                  T

    Tabes, 50, 300
      mesenterica, 339
    Tapeworm, 392
100   beef, 392
      fish, 394
      pork, 393
    Teething,  147
    Tenia echinococcus, 394
      mediocanellata, 392
      saginata (beef tapeworm), 393
      solium,  393
    Test breakfast, 141
      meals,  141
        fractional, 142
    Tetanus, 293
      antitoxin, 270
      symptoms of, 294
      treatment of, 295
    Thermometry, 281
    Threadworm, 387
    Thrills, 87
    Thrombosis, 92
      cerebral, 57
    Thrush, 145 
INDEX
407
Thymus, diseases of, 78
Ticks, infection disseminated by,
  311
Tongue, appearance of,  146
  diseases of, 145
  strawberry, 365
Tonsillar diphtheria, 316
Tonsillitis, 120
  acute, 353
  chorea and, 39
  chronic, 355
  follicular, 353
  operation in, 355
  parenchymatous, 353
  rheumatism and, 355
  suppurative, 354
  treatment of, 355
Toxemia,  285
  symptoms of, 286
Toxic neuritis, 45
Tracts, motor and sensory, 19
Transfusion of blood, 65, 68
Transmissible diseases, 264
Transmission of infections, 264
Traumatic arthritis, 239
Tremors, 26
Trench fever, 313
  •nephritis, 233
Treponema pallidum, 300, 301
Trichina spiralis, 390
Trichinosis, 390
Trophic disturbances, 24
Trypanosome, 311
Tubercle bacillus, 337
     bovine type, 338
     human type, 337, 338
Tubercular meningitis, 54
Tuberculin, 346
  test, 346
  treatment, 346
Tuberculosis, 337
  acute, 341
  diet in, 344
  distribution of, in body, 338
  exercise in, 344
  fibroid, chronic, 341
  fresh air in, 344
  glandular, 337
  hereditary, 338
  incipient, 341
  latent, 338
  miliary,  340
     case of, 340
Tuberculosis, miliary,  course of,
    341
  prophylaxis of, 343
  treatment of, 343
    tuberculin, 346
  ulcerative, chronic, 342
      case of, 342
      signs  and symptoms of,
         343
Tuberculous arthritis, 243
Tumors of brain, 60
  of esophagus,  148, 149
  of gall-bladder, 191
  of intestines, 178
  of kidney,  229
  of liver, 183
  of lung, 131
  of peritoneum, 193
Typhoid fever, 372
     complications and sequelae of,
           376
         cardiovascular, 377
         diarrhea, 378
         gastro-intestinal, 378
         hemorrhage, 378
         joint, 380
         nervous, 377
         perforation, 378
         renal, 379
         respiratory, 378
     course of, 375
     dissemination of, 374
     pathology of, 372
     treatment of, 380
      • diet in, 382
      hydrotherapy in, 382
     varieties of, 376
     Widal reaction in,  373, 376
  spine, 380
  vaccine, 277
Typhus abdominalis, 312, 372
  exanthematicus, 312
  fever, 312
  Mexican, 313
  typhoid and, 312
              U

Ulcer of duodenum, 154, 156
  of stomach,  154, 155
    complications of, 156
    hemorrhage in, 156 
408
INDEX
Ulcer of stomach,  perforation in,
      156
    symptoms of,  156
    treatment of,  157
Ulcerative stomatitis, 145
  tuberculosis, chronic, 342
Undulant fever, 384
Upper air passages, diseases  of,
  113, 117
Uremia, 231
Uric acid, 212
Urinary  passages,  diseases  of,
      219-235
    infection of, ascending,  225
      descending, 225
Urine, 219
  albumin in, 221
  casts in, 221
  incontinence of,  224
  sugar in, 221
Vaccines, 270
  gonococcus, 293
  typhoid, 277
Vaccinia, 369
  symptoms of, 370
Vaginitis, gonococcus, 291
Valve lesions, aortic, 105
    individual, 104
    mitral, 105
    multiple, 106
Valvular heart disease, 101
Varicella, 371
Variola, 367
Varioloid, 368
Vasomotor disturbances, 21
Venesection,  108
Vertigo, 23
Vincent's angina, 145
Virus, 277
  anthrax, 277
  rabies, 27S, 298
  vaccine, 278
Visceral parasites, 387, 390, 394
Volvulus,  176, 177
Vomiting, 139
              W

War gas, 260
Wassermann reaction, 302
AVater brash,  138
Weil's disease, 184
Whooping-cough, 334
    bronchopneumonia in, 335
    paralysis in, 335
    prophylaxis of, 336
    symptoms of, 335
    treatment of, 336
Widal reaction, 276, 373, 376
\\roolsorters'  disease, 296
Vellow fever, 309
    prophylaxis of, 310
Yperite gas, 260 
 
 
 
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