Statistics of Five Hundred Cases of Lobar Pneumonia. Notes on Some Interesting Results with the Widal Test. A Case of Pernicious Anaemia with Fatty Heart Occurring During Pregnancy. BY ALFRED MEYER, M.D. Attending Physician to Mount Sinai Hospital, New York ; Visiting Physician to Bedford Sanitarium for Consumptives, Bedford Station, N. Y. [Reprinted from Mount Sinai Hospitax- Reports for 1898.j NEWYtnrK : ' Press of Stettiner Bros., 52-58 Duane St. 1899. STATISTICS OF FIVE HUNDRED CASES OF LOBAR PNEUMONIA. ALFRED MEYER, M.D. ATTENDING PHVSICIAN. The following statistics of 500 lobar pneumonias are culled from all the cases of the primary type that have occurred in the medical service of Mount Sinai Hospital during the ten years ending January 1, 1898. The med- ical service includes 2 adult male wards of about 44 beds, 1 adult female ward of about 24 beds, and a children’s ward of about 26 beds. The children's service includes both sexes up to the age of 14 years. TABLIi I. Casks Treated. Died. Age. Male. Female. Total. Male. Female. Total. Percentage. 4-12 months.... 6 7 13 4 5 9 69.34 1-5 years 22 25 17 3 7 10 21.27 6-10 “ 23 15 38 0 3 3 7.89 11-20 .. 77 27 104 7 4 11 10 57 21-60 *• 90 36 126 5 5 10 7.93 81-10 “ 64 20 84 15 2 17 20 23 41-50 “ 36 16 52 12 7 19 36.53 51-60 “ .. 22 5 27 9 2 11 37.03 61-50 “ 6 0 6 3 0 3 50.00 71-80 “ 2 1 3 0 1 1 33.33 348 152 500 58 36 94 18.88 Total cases, 500. Total deaths, 94. Mortality of series, 18.88 per cent. Youngest casein series, 4 months (died). Oldest “ < ii 77 years (recovered). Twenty-three cases died within forty hours after admission Excluding these, the mortality for series is 14.20 per cent. 2 MOUNT SINAI HOSPITAL REPORTS. A study of this table indicates a rather favorable mor- tality per cent: 94 deaths out of 500 cases = 18.88 per cent. Omitting 23 cases that died within forty hours after admission, the mortality for the series is only 14.20 per cent. Pye-Smith reports a mortality of 25.5 per cent out of 434 cases. Now, as it is well known that for a number of reasons hospital statistics are apt to be un- favorable as compared to those drawn from private practice, our own results, taken exclusively from hospital records, are comparatively more favorable than the figures indicate. As the cases cover a period of ten years, there is less probability of the introduction of certain chance elements that might influence the mortality during a particular year. Aufrech't reaches the conclusion, after a careful study of mortality for sixteen years, and after excluding all variations due to locality, season, individu- ality, and therapeutics, that the varying mortality (his own figures, 6.6-25.3 per cent) is dependent upon the varying virulence of the pneumococcus.1 How large a role in the reduction of our own mortality is played by the fact that our patients do not belong to the drinking class I shall leave undetermined. Mortality according to Age.—A further study of this table shows (last column) a very high mortality under 12 months (9 out of 13 cases = 69.34 per cent), an almost uninterrupted fall in the mortality up to 30 years of age, and then a rise for every decade up to 70 years, which latter gives a mortality of 50 per cent. The mortality is nearly three times greater between 31 and 40 than it is between 21 and 30, and nearly twice as great between 41 and 50 as it is between 31 and 40. All authors agree as to the influence of age on mortality, though fin ir figures vary. Morbidity according to Sex.—Of the 500 cases, 348 were males and 152 were females—he., 69.6 per cent and 30.4 per cent respectively. The difference is mainly due to cases occurring after 10 years of age, and is greater than 1 I refer to this question again in Table IX. MEYER: FIVE HUNDRED CASES OF LOBAR PNEUMONIA. 3 can be accounted for by the disproportion in the size of the male and female services, which is about 2 to 1. Our result agrees with the general verdict that men are more liable to pneumonia than women. Aufrecht seems to think it still uncertain whether sex plays any role in the causation of pneumonia, but presents figures which seem to indicate a prevalence three and one-half times greater among men than women. Mortality according to .Sex.—There were 36 deaths out of 152 female cases=23.6S per cent; there were 58 deaths out of 318 male cases=16.66 per cent—a proportion that agrees almost exactly with that given by Juergensen in Ziemssen's “Encyclopaedia,” who says that “pneumonia is, caster is paribus, a more dangerous affection in the female than in the male sex in the ratio of 3 to 2.” TABLE 11. (a) TABLE IL (A) Guises. Lyses. Day. Male. Female Total. No of days. No of cases. 5lh 6 5 11 9 days... . 1 6th 2 3 •r> 10 “ .... 3 7th 42 11 53 12 “ .... 3 8th 18 3 21 13 “ .... 3 9th 29 5 34 2 weeks... 4 10th.. . 13 6 19 2* “ ••• 19 llth 11 3 14 3 •• ... 12 12th 4 3 7 4 “ ... 1 1 13th 2 2 4 5 “ ... 1 2 weeks 2 4 6 6 “ ... 3 2* “ 14 3 17 7 “ ... 2 3 “ 4 1 5 8 “ ... 1 4 “ 4 0 4 f.3 Total 151 49 200 Showing average duration of pyrexia. Out of 263 cases there were 63 lyses and 200 crises. Of 200 crises 79 fell on even days, 121 on odd days. In this table all cases are considered as having defer- vesced by crisis in which the temperature fell from 103° or over to normal within forty-eight hours. This may 4 MOUNT SINAI HOSPITAL REPORTS. appear as an arbitrary classification, but I believe it has at least this to recommend it, that it is a compromise between the twenty-four hour limit allowed by some and the seventy-two hour limit allowed by others. Out of 263 cases with complete histories, there were 200 crises—that is, a little more than 75 per cent of the cases. Aufrecht gives a smaller percentage, 57.5 per cent out of 1,501 cases. The proportion on the even and odd days respectively was: Even days 39.5 Odd “ 60.5 Juergensen’s figures are: Even days 38.7 Odd “ 61.3 The closeness of the two sets of figures is striking. The Average Duration, estimated from the beginning of the disease to the cessation of fever, was: For 200 crisis cases, 10 days. “ 63 lysis “ 22 “ “ 263 “ 13 “ The most frequent duration was about a week—125 cases ended between the fifth and ninth days inclusive = 47.53 per cent. MEYER: FIVE HUNDRED CASES OF LOBAR PNEUMONIA 5 Right Lung. Site Left Lung. Lobe. Right upper. | Right lower. S u (£ oJ 3 'd a Entire 9 2 £ U £ Right bilobar. Total right lung. Left upper. Left lower. Entire left lung. Involving | both lungs. Total left tUD P p Total both lungs. Sex. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F M. f. M. F. Male and female. 4-12 mos 1 1 0 0 0 0 0 2 0 0 1 3 1 0 0 0 0 1 1 0 1 1 Right upper.. .. 46 1- 5 yrs 2 2 4 4 0 0 1 2 0 0 7 8 2 4 4 2 3 5 2 4 9 11 Right lower 76 6-10 “ .. ') 6 3 1 (1 0 1 0 0 0 6 1 2 2 4 4 1 1 0 1 7 7 Right middle .. 3 11-20 “ .. 6 i 12 5 0 0 6 2 5 1 29 9 2 0 11 4 7 0 6 0 20 4 Entire right lung. 51 21-80 “ .. 8 3 14 5 0 1 13 2 4 1 39 12 6 3 18 5 9 5 11 4 33 13 Two lobes, right lung. 24 31-40 “ . 7 3 5 8 2 0 6 1 6 2 26 14 5 4 19 4 9 1 9 5 33 9 Left upper 36 41-50 “ .. 3 1 8 2 0 0 6 2 2 1 19 6 3 0 11 6 2 1 5 4 16 7 Left lower 102 51-60 “ .. 3 1 3 1 0 0 5 0 1 0 12 2 1 1 7 1 0 0 4 1 8 2 Entire left lung.. 45 61-70 “ .. 0 0 l 0 0 0 1 0 1 0 3 0 0 0 1 0 0 0 1 0 1 0 Total lobes 383 71-80 “ .. 2 0 0 0 (I 0 1 0 0 0 3 0 0 0 1 0 0 0 0 0 1 0 Bilateral pneu- monia. 58 Total. .. 34 12 50 26 2 1 40 11 19 5 145 55 22 14 76 26 31 14 39 19 129 54 Total cases 325 In this series o1 383 sites, the frequency of occurrence and percentages (including the cases which had pneumonic processes in both lungs) of the more common sites, is as follows: Left lower lobe, 102 cases, 26.62 per cent. Total right lung, 52.21 per cent. Right “ “ 76 “ 19.84 “ * “ left “ 47.78 “ Entire right lung,51 “ J3.31 “ Total cases involving both lungs, 15.14 “ “ left “ 46 “ 12.01 “ TABLE III. This table requires but little comment. The figures agree with those of other authors in that they show a more frequent involvement of the right lung than of the left ; the difference is somewhat less than the one usu- ally observed, perhaps because the bilateral cases are in- cluded in the calculation. The left lower lobe was the most frequent seat of disease, occurring in 26.62 per cent of the cases. This also agrees with experience gained 6 MOUNT SINAI HOSPITAL REPORTS. elsewhere. Pye Smith gives the following figures in his 434 cases: left base, 151; right base, 140. s o •-t E. crt- Both sexes Total. -3 Ci Ot .£>■ CC tO — 1 1 1 1 1 1 1 1 1 1 G0~3C5ia,£>.o:to — *— OOOOOOOOOt© MS - g 73 O Sex Lobe. GO 05 co © C M — ©©©©©© B Right O © © © © © C © © © i— upper. O a 05 © © © tO — • © i— © * Right lower. Cl to ©©©©©©©©to© • 3 CO CO o o o o o o o o ooo Right middle. CO CO - OOOOOOOOOO • n a to CO 00 — — —iu-.f^oi-ko — o S Entire Cl 0^. *ax to ©©©to©©— ©©I— right lung. X to H-1 O O O O —1 0.0000 « Right CO ■ax ©©©©©—©©©© bilobar. CO 00 Total right lung s to oootooto — ototo * o o oooooooooo « Left upper. >fc o oooooooooo GO O - © ate m os — © © © © « Left lower. to vx to © © © © © © i— — oo f CO a *-*■ 00000-0000 g Entire left & CO CO d Respiration in a Series of 38 Deaths. These tables give a general idea of the type of case we had to deal with in 183 recoveries and 38 deaths, at least so far as a record of pulse, temperature, and respiration can fdo so. The data do not include cases under 14 8 MOUNT SINAI HOSPITAL REPORTS. years of age, because of their less intimate relation in children to the type of disease. In 183 cases of recovery, 40 had temperature of 105° and over—about 22 per cent. In 183 cases of recovery, 02 had pulse of 120 and over —about 50 per cent. In 183 cases of recovery, 100 had respiration of 40 and over—about 54 per cent. By a study of Tables V. (a) and V. (b) we see that out of a total of 122 cases in which pulse ran to 120 or over, there were 92 recoveries to 30 deaths—in other words, a little less than 25 per cent of deaths. This result is more favorable than that of Griesinger (quoted by Juergensen), who, from a study of 72 cases, inferred that per cent of the patients die under these circumstances; but Juer gensen objects to a generalization from so small a num- ber of cases. There was similarly a death rate of about 26 per cent in which the temperature ran to 105° or over (14 out of 54), and a death rate of about 30 per cent in cases in which the respiration ran to 48 or over (20 out of 65). The following details of the tables are of in- terest: 8 recoveries with temperature of 106° and over, 4 recoveries with respiration between 80 and 100. Tabulation op tub moke frequent Complications occurring in the whole Series op 500 Cases. TABLE VI. (a) Complication. «M 5p o w 0 tl Sex. T3 Frequen- cy in per- centage. . ce o o M. F. (m 3 o Diet Pulmonary oedema .. 29 21 8 3 26 5.80 Pleurisy with effusion 25 14 11 20 5 5.00 Empyema 18 12 6 12 6 3 60 General bronchitis 11 8 3 8 3 v.20 Acute conjunctivitis 5 5 0 5 0 1.00 Pericarditis with effusion 7 5 2 5 2 1.40 Acute endocarditis 5 3 2 4 1 1 00 Acute nephritis 5 1 4 3 2 1.00 Acute endocarditis and pericar- ditis with effusion 4 3 1 1 8 0 80 Pleuritis sicca 2 2 0 2 0 0,40 Colitis 5 2 3 2 3 1.00 MEYER: FIVE HUNDRED CASES OF LOBAR PNEUMONIA. 9 Statistics from various cities show some differences with regard to frequency of various complications, though some of the differences may be accidental. In our own cases pulmonary oedema was both the most frequent and the most fatal complication, occurring in 5.8 per cent of the cases, and of these nearly 90 per cent ended fatally. Pleurisy with effusion comes a close second with a frequency of 5 per cent. Effusion statis- tics from other sources vary from 4 to 15 per cent. Aufrecht gives 5.5 per cent in 1,501 cases. He includes, however, the empyemas. If we add our own empyema figures to those of effusion we get a somewhat larger number, 8.6 per cent. Pericarditis occurred 11 times (4 with endocarditis)—2.2 per cent. Of these, 5 died— nearly one-half. In 1 of the 5 cases of conjunctivitis the purulent discharge was examined microscopically and the presence of pneumococci demonstrated. There were 4 cases of colitis. There has been some conflict of opinion regarding the relation of colitis to pneumonia. Some experiences with the Widal reaction in the past two years excite a suspicion that this type of case may belong to the masked typhoids, in the recognition of which in the future the Widal reaction will pla)7- a prominent role. The small number of acute nephritis cases I am in- clined to attribute to imperfections in the records as well as to the rigid exclusion of the simple albuminuria of fever. Table of Jaundice Cases with reference to Site and Mortality. TABLE VI. (6) Site of pneumonic process. Cured. Died. 1 Right upper lobe 0 1 2 “ lung entire 0 1 3 “ upper lobe 0 1 4 “ and left base 1 0 5 “ lung entire 1 0 6 “ lower lobe 0 1 7 “ lung entire 0 1 Total number of jaundice cases in series of 325 cases. 10 MOUNT SINAI HOSPITAL REPORTS. In view of the many discussions regarding the nature and classification of cases complicated by jaundice, I have arranged them in a separate table. There were 7 cases out of 325 (2.15 per cent). In Vienna and Stock- holm there were 53 cases out of 8,354 (0.62 per cent). Pye-Smith gives 4 cases out of 434 (0.9 per cent). Aufrecht found 15 cases out of 1,501 (1 per cent). In Basle it was observed 65 times in 230 cases (28.3 per cent), which unusual frequency does not seem to be en- tirely explained by Juergensen’s theory that the jaun- dice had been looked for more carefully. Of Aufrecht’s 15 cases 2 ended fatally (1 complicated with chronic nephritis), which is no more than his average mortality. In cases complicated by . jaundice not due to obstruction, and which he believes are due to other infection than the diplococcus pneumoniae, he be- lieves the prognosis is much worse. It is an interesting fact that the right lung was involved in every one of our 7 cases and that in 3 of them the entire right lung was affected. Pye-Smith’s 4 cases were also right-sided. Our mortality was high in these cases, 5 out of 7. TABLE VII. Number of Cases and Deaths, with Percentages of Each, occurring in the Different Seasons, in the Entire Series. ■ Season. No. of cases. Perc;- ntage of cases. No. of deaths. Percentage of deaths. Spring—March, April, and May 167 33.40 29 30.85 Summer—June, July, and August 86 16.60 8 8 51 Autumn—September, October, and November.. 92 18 40 20 21.27 Winter—December, January, and February.... 158 31 60 37 29.26 500 100.00 94 In this table the largest morbidity is shown in the winter and spring months, 65 per cent, and only 35 per cent for the summer and autumn. Aufrecht, from a MEYER: FIVE HUNDRED CASES OF LOBAR PNEUMONIA. 11 study of 1,501 cases, gives for the first half of the year 66.9 per cent and for the second half 32.9 per cent of the cases. As was to he expected from the greater morbid- ity, the total mortality is also greater in the winter and spring than in the autumn and summer, our percentages being respectively 70.21 per cent and 29.79 per cent. Juergensen gives as a result of a study of the mortality tables in six large European cities 66.2 per cent for the winter and spring and 33.8 per cent for summer and autumn. Our summer cases appear to have been more benign than those of other seasons, for, though they represent 16.60 per cent of the morbidity, they give only 8.51 per cent of the deaths. TABLE VIII. Showing the Frequency of Occurrence of Previous Attacks of Acute Lobar Pneumonia in a Sekies of 325 Cases. No. of cases, Cured, Died, BO 27 8 Frequency in per cent, Total cases in series, Mortality, 9% 825 10* If Juergensen’s view were true that “one attack probably increases the disposition to a recurrence,” it would seem to me there would be a larger number of cases with previous attacks than our table shows—30 out of 325 (9 per cent). Pye-Smith gives 18 recurrences in 434 cases, which is a still smaller percentage (4.1 per cent). Aufrecht believes in a congenital predisposition, and quotes Ziemssen, who found recurrences 19 times among 201 pneumonic children; 14 had 2 attacks, 3 had 3 at- tacks, and 2 had 4 attacks. The believers in a specific causation of pneumonia may find some satisfaction in the fact that the percentage of deaths (10 per cent) in the recurrences is materially less than the mortality of all the cases (18.8 per cent). The recurrences, in other words, appear to be of a milder type, as is not infre- quently the case with typhoids. 12 MOUNT SINAI HOSPITAL REPORTS. Showing Number of Cases and Deaths each Year in the Entire Series of 500 Cases. TABLE IX. Year. No. of cases. No. of deaths. Mortality 1888 17 5 29.41$ 1889 40 8 20.00$ 1H90 30 7 23.33$ 1891 68 7 10.29$ 1892 40 6 15 00$ 1893 79 19 24.05$ 1894 62 8 12 86$ 1895 69 19 27.53$ 1896 48 11 22.9 $ 1897 47 4 8 51$ Total.. .... 500 94 18.80$ This table is interesting as showing a mortality vary- ing between wide limits in different years—8.51 per cent in 1897 and 29.41 per cent in 1888. Aufrecht’s extremes (already referred to in Table I.) are 6.6 per cent and 25.3 per cent. These changes in mortality rate, so striking at Mount Sinai Hospital as elsewhere, are continually urged as a confirmation of their view by those who be- lieve in a “ status epidemicus” or in the varying viru- lence of the pneumococcus. Treatment. — With reference to the treatment it may be said that there has been no single method in vogue at Mount Sinai. Stimulants, both alcoholic and medicinal (digitalis, sparteine, strychnine), have entered more largely as a factor than any other; for out of 284 cases stimulants were used in 250, either alone or combined with other measures (in 85 cases cold compresses on chest, tepid sponging, and, rarely, plunges). In 89 cases antipyretics were used, either alone or combined with stimulants and hydrotherapy. It is extremely difficult to draw conclusions as to the influence of treatment on the result—first, because the treatment was rarely limited to a single active procedure; second, because of the varying severity of the disease. MEYER: FIVE HUNDRED CASES OF LOBAR PNEUMONIA. 13 Neither Petresco’s method of using very large doses of digitalis, nor Aufrecht’s of employing hypodermatic in- jections of muriate of quinine, has been used sufficiently to permit of any deductions. The question of venesection in the treatment of pneu- monia is still a mooted one. Some condemn it utterly, and Aufrecht thinks it has been positively proven that pericarditis is more frequent in cases thus treated. Others, again, like Pye-Smith, urge that it should not be forgotten or neglected, and believe venesection suitable at the commencement of the disease, or during its course ‘‘to relieve the overpressure in the right side of the heart and the systemic veins.” In our own cases we have records of only four patients in whom venesection was practised; three of these died and one recovered. In none of them is there any mention of pericarditis. They were all severe cases; the area involved was extensive, and the three fatal ones were complicated by an acute nephritis. In other words, the prognosis was unfavor- able irrespective of the treatment. NOTES ON SOME INTERESTING RESULTS WITH THE WIDAL TEST. By ALFRED MEYER, M.D., ATTENDING PHYSICIAN. In view of the complaint in various quarters that the Widal reaction appears so late, in doubtful cases, as to be of little practical value in the very type in which it is most needed, the following cases, though few in num- ber, may not be without interest. They are all cases that have been observed within a year on my own ser- vice, with the exception of the case of Benjamin K., for which I am indebted to Dr. M. Manges, on whose service it occurred. Only brief extracts from the histories will be given. 1. Abortive Typhoid.—Dina K., admitted December 22, 1897, aet. 26 years. Sick one week, last four days in bed; headache, lassitude, anorexia, nausea, no epistaxis, bowels regular, well nourished, tongue slightly dry. Physical examination: Heart, lungs, and spleen negative; a few erythematous spots on abdomen. Temperature on admission 99.6°, pulse 96, respiration 24. She had with her a report from the Board of Health that the Widal reaction was positive. Temperature, afternoon, 103.2°. December 24, temperature range 100.6° to 101.8°; tongue moist and clean; all evidence as bearing on a probable typhoid negative. December 26, tempera- ture touched normal, did not go above 100°; Widal posi- tive. December 28: Convalescence may be said to have commenced from this day; tongue moist and clean; no clinical evidence of illness; no roseola nor headache; feels perfectly well; Widal positive. Widal tests made daily to January 2, inclusive, were positive. January 4. soft diet. Discharged January 16, cured. MEYER : THE WIDAL TEST. 15 Here is a woman in whom convalescence was practi- cally established in ten days or less after taking to bed; whose temperatuie touched normal on the fourth day after admission to the hospital; in whose <-ase there was scarcely a symptom outside of the fever, headache, and anorexia; and in whom in former years the indefinite diagnosis of febricula would have been made, or possi- bly a suspicion of typhoid entertained, or the case might have been relegated to the class of intestinal toxaemias. 2. Irregular Typhoid.—Henry T., aet. 44, clerk, admit- ted September 27, 1898. Illness began about a month ago. Nothing ails him but sleeplessness, and can ascribe no reason for this trouble. Has no headache; talks pecu- liarly; says he was the “beautyof the family”; has had no mental worries, except the care of an aged mother; appetite fair, bowels regular; has lost flesh and strength. House physician noted slight ptosis of left eyelid, and tongue deviates to right side; occasional tremor of right side of face and of tongue, and tremor of voice while speaking; speech hesitating, and tendency to repeat; some indistinctness of enunciation; marked tache cere- brate; patellar tendon reflexes markedly exaggerated. Temperature 101.8°, pulse 126, respiration 30. Physical examination: Chest and abdomen negative In the eve- ning, temperature normal; for the next three days, temperature ranged between 99° and 100.6°. October 1, temperature 100° to 101°; 2, 100° to 103°; 3, 100° to 102.4°; 4, 99° to 102°; 5, 99° to 103°; 6, 99° to 102.4°; 7, 99.2° to 101.2°. Partial Widal reaction. Has been having- one movement of bowels daily, either by enema or spon- taneously. October 8, 99.6° to 103.6°; positive Widal; no symptoms, subjective or objective, of any kind out- side of fever; no headache, no muscular pains; tongue moist and clean; no roseola, no spleen, no diarrhoea, no tympanites. October 9, 101° to 102.4°; Widal positive, but less marked. From this date to October 25 these slight variations of temperature continued; otherwise patient was perfectly well. Daily inquiries elicited the reply that he was “first rate,” that he had nothing to complain of except that he received nothing to eat. From October 26 to the date of discharge on November 9 his temperature remained normal. 16 MOUNT SINAI HOSPITAL REPORTS. Here the prominence of the nervous symptoms (sleep- lessness for a month before admission, motor disturb- ances of face and tongue, exaggerated reflexes, etc.), with the almost complete absence of fever at the time of admission, did not even excite the suspicion of typhoid fever. As it was, the Widal test, taken in a routine way, disclosed the true state of affairs, and the patient convalesced after the fever had continued exactly four weeks. 3. Typhoid Obscured by Pneumonia.—Benjamin K., set. 44, presser, admitted February 26, 1898. Owing to patient’s poor mental condition and refusal to answer questions, history imperfect. Illness of eight days’ stand- ing. Began with a chill, followed by fever, cough, diffi- cult expectoration, and pain in chest. General condition fair; fairly well nourished. Tongue dry and brown. Lungs: anteriorly, negative. Posteriorly at left base a dull note, crepitant and subcrepitant rales. All other organs negative. Slight general tenderness of abdo- men. On admission, pulse 102, respiration 36, tempera- ture 100.2°. February 27, temperature, afternoon, 105°; urine 22 ounces, 1020, albumin; trace of bile, few pus cells. Ehrlich positive. Next day albumin increased to 0.4, many casts present; urine involuntary in part. March 1, chill of ten minutes’ duration this morning; temperature above 104° all day; physical signs unchanged. Widal positive. Treatment with plunges begun. With the exception of delirium, his condition continues about the same until March 4, when the pulse begins to in- termit. In spite of rectal and hypodermatic stimulation, he died early on March 5. Until the Widal reaction was obtained on the third day after admission, it would scarcely have been justifi- able to make a diagnosis of typhoid; the pulmonary signs were prominent, and the fever, mental and renal condi- tions could very reasonably be explained as secondary to the pulmonary trouble, perhaps more reasonably than by a typhoid only in its tenth day. And yet the result of the Widal was decisively the other way. MEYER : THE WIDAL TEST. 17 4. Typhoid Obscured by Pneumonia.—Esther L., set. 29, housewife, admitted October 15, 1898. Has been in bed two weeks with a cold. Prominent symptoms were fever, cough, pain on both sides of chest, and severe dysp- noea. No chills. Cough, fever, and dyspnoea persist. Great prostration and weakness. Eight days ago a crop of boils appeared on the body and right hip. Bowels regular On admission temperature 102.2°, pulse 118, respiration 48 ; lips pale bluish ; skin moist, showing a diffuse maculo - papular eruption with acne and furuncles. Spleen enlarged (?). Lung : anteriorly, res- onance on right side ceases at fourth rib, dull note in right axillary line; also a few crepitant rales in both axillae. Posteriorly : dull note below right midscapula and at left base; fine crepitant rales and diminished voice and breathing over right side; crepitant and sub- crepitant rales over left base. Treated as a typhoid suspect. First day had three stools. October 16, temperature 101° to 102.8°, respiration 40 to 48, pulse 108 to 118, Widal negative. The next four days general condition about the same, stools slightly more frequent (from 5 to 8 daily). Widal still negative. October 21, tempera- ture 99.8° to 103.8°; October 22, temperature 99.2° to 103.6°. Partial Widal for the first time. This partial Widal continued daily with normal morning tempera- tures and slight evening rises until the 27th, when the Widal reaction was positive and continued so for several days. October 30, herpes labialis. Discharged cured November 11, 1898. In this case it is true the Widal reaction did not appear until late (the twenty-second day); still it was not too late to be of material service in making the diagnosis of typhoid a certainty. In the ante-Widal days, the sud- den commencement, the prominence of chest symptoms, the early dropping of the temperature to normal, and even the appearance of herpes labialis, would all have rendered the diagnosis of a primary pulmonary com- plaint justifiable. The long duration of the disease and the diarrhoea might have helped to confirm our suspicion of a typhoid even without the Widal, though the uncer- 18 MOUNT SINAI HOSPITAL REPORTS. tainty would not have been entirely removed without the bacteriological test, in view of the occasional occur- rence of severe diarrhoea with pneumonia. 5. Ambulant Typhoid.—Adolph K., set. 19 years, shoemaker, admitted October 16, 1898. Was a volun- teer soldier at Camp Black during August; had slight diarrhoea there. Afterward went to Camp Meade. Ill- ness began there about six weeks ago. Was in hospital at Camp Meade one week during September, with malaise and fever, though he did not take to bed. Was treated for malaria, with quinine. Has lost twelve pounds during last three months. No definite complaint at time of admission. Looks pale and poorly nourished. Temperature 99.6°. Spleen enlarged and easily felt. Widal positive, Ehrlich negative. October 20, spleen still palpable. Widal positive on October 21 and 23, though gradually less marked. October 27, Widal nega- tive. Discharged November 10. Here is a patient who was proven by the Widal test to have been an ambulant case of typhoid through the en- tire disease. He was already in the apyretic stage when he reached the hospital, and was then merely suffering from malnutrition. The military diagnosis of malaria would very likely have been concurred in, had it not been for the bacteriological evidence. That the infection was recent was shown by the gradual disappearance of the reaction while the patient was under observation. Regarding the technique employed in the Widal reac- tion in these cases, I would refer to the report of the pathologist and assistant pathologist of the institution. A CASE OF PERNICIOUS ANAEMIA WITH FATTY HEART OCCURRING DURING PREGNANCY. ALFRED MEYER, M.D., ATTENDING PHYSICIAN. Mrs. Sarah W., set. 37 years, admitted January 28, 1898. Family History.—Negative. Previous History.—Has always enjoyed good health, no illness of any kind, in particular no inflammatory rheumatism or chorea. Has had four children, the last one eight years ago; is now pregnant over four months. Present History.—Illness of about two and one-half months’ standing, beginning with weakness and increas- ing pallor, and dyspnoea on the slightest exertion. There then followed swelling of the feet, slight headache and cough, increased on lying down. Appetite poor, bowels constipated. Also began to have sweats. During the past two weeks pallor, cough, sweats, oedema, dyspnoea, and weakness have become much worse, confining patient to bed. Passes her urine frequently. Chief com- plaints: great weakness and dyspnoea on slightest exer- tion. General Condition.—Good panniculus adiposus, but intense anaemia; conjunctivae perfectly white; mucous membranes very pale and resembling those of a patient dying of hemorrhage; no cyanosis; general anasarca. Lungs— Slightly diminished resonance at both bases, in part due to oedema of soft parts. Coarse and fine rales diffused over chest. Heart—On the right, dulness extends about one finger’s breadth beyond right border of sternum; large mammae and oedema make this somewhat uncertain. Systolic murmurs heard over all the orifices and over the entire precordial region. The apical murmur audible to a point midway between apex and axillary line. Basic sounds not accentuated. 20 MOUNT SINAI HOSPITAL REPORTS. Auscultation difficult on account of the great dyspnoea. Liver—Left lobe apparently enlarged and extending a good four fingers’ breadth beyond free border of ribs. Palpatidn hindered somewhat by the abdominal disten- sion. Spleen—Enlarged to percussion and distinctly palpable beyond the free border of the ribs. Abdomen— Enlarged and contains free fluid. Uterus—Enlarged and extends more than half way to umbilicus. Marked oedema of feet, legs, and hands. On admission, pulse 100, respiration 48, temperature 100°. Urine, first spe- cimen—Cloudy, acid, 10J9, no albumin, no sugar, abun- dant urates, a few blood cells, uric acid crystals, no casts. January 28 (first day): Temperature range, 100° to 108°; pulse range, 100 to 120; respiration range, 48 to 56. January 29: Temperature range, 102° to 103.4°; pulse range, 120 to 182; respiration range, 48 to 56; urine, 54+ ounces; two stools. Blood: haemoglobin 20 per cent; no leucocytosis. January 30: Temperature range, 102.4° to 103.6°; pulse range, 120 to 132; respiration range, 54 to 60. Urine, 37+ ounces; morning specimen: 1009, negative, urea four grains to the ounce; twenty four hours’ specimen: 1019 negative, urea eight grains- to the ounce. Blood count shows: red blood cells, 1,090,000 to cubic millimetre. Reaction of perspiration on chest, forehead, and hands is decidedly acid; saliva ditto A drop of blood, however, does not redden litmus paper. Ophthalmic examination by Dr. Gruening on this date shows the presence of neuroretinitis and of extensive hemorrhagic patches in both eyes. January 31: Temperature, pulse, and respiration, as well as general condition, practically unchanged. Urine: total, 51+ ounces, 1016, negative, a few blood cells and epithe- lia, uric acid crystals. February 1 and 2: Urine on latter date, 59+ ounces, acid, 1016, clear, no albumin, in- dican present, urea nine and a half grains to the ounce. Microscopic examination negative. Marked Ehrlich. February 3: Condition unchanged. Urine, 62 ounces. Urea in twenty-four hours’ specimen, nine grains to the ounce. Widal test negative. Canula introduced into outer aspect of each ankle to relieve the excessive oede- ma. February!: No change in urine. Blood exami- nation: No increase in number of leucocytes; a few neutrophiles and neutrophile granules; poikilocytes fairly numerous; nucleated red blood cells; micro- and macrocytes. Died at 7:45 p.m. MEYER: ANiEMIA WITH FATTY HEART IN PREGNANCY. 21 I append a report of blood examination made for me by Dr. Ewing, of the College of Physicians and Sur- geons: “The blood of Mrs. Sarah W. appears to fall in the class of primary pernicious anaemia on the following grounds: (1) The marked reduction in the number of red cells; (2) the extreme poikilocytosis; (3) the presence of some megalocytes with increase of haemoglobin, al- though the chief character of the blood is the reduction of haemoglobin; (4) the marked reduction in leucocytes; (5) presence of one megalohlast among many normo- blasts; (6) the indications of the clinical history that the case was not one of purpura haemorrhagica, which might prove fatal with blood of very similar morphol- ogy.” (Signed) James Ewing. During patient’s period of observation of one week sleeplessness was a prominent feature, partly produced by the uninterrupted dyspnoea and partly by coughing. The last few nights were spent entirely in a chair. There was at all times a great deal of sweating, particu- larly marked upon the face, where the perspiration gathered in beads. At no time was there any diarrhoea; bowels were kept open by enemata. Stools contained nothing that might explain the intense ana3inia; in par- ticular, no entozoa were discovered. Rectal and vaginal examinations were negative, excepting, of course, the evidence of pregnancy. The patient was seen on the 30th of January by Dr. Munde. The existence of preg- nancy was confirmed and the propriety of bringing on labor was negatived by him, on account of the danger of profuse and possibly uncontrollable hemorrhage dur- ing the third stage, as well as the doubtful utility of such interference in producing a favorable change in the disease. Before she was seen by me she had received infusion digitalis and bitartrate of potash. Afterward the treatment consisted of Fowler’s solution, carnogen, stimulants, enemata of defibrinated beef blood (received only one), washing out of bowels with one per cent sa- line solution by means of a long rectal tube, on the theory of pernicious anaemia being an intestinal tox- aemia, or, as Bramwell has suggested, a gastro-intestinal hepatic anaemia.' ' See Bramwell: “Atlas of Clinical Medicine,” vol. iii., p. 128. 22 MOUNT SINAI HOSPITAL REPORTS. The case herewith reported corresponds very closely in its main clinical features to live cases published by Gusserow in 1871,1 and which have frequently been re- ferred to in the literature of pernicious anaemia and of fatty heart. And still, in spite of the great lapse of time and the many studies in tissue metamorphosis, and great improvements in methods of blood count and examination, this affection still remains as mysterious as ever. Only two years ago Andry, of Lyons, referring to pernicious anaemia in general, wrote in Robin’s “ Traite de Therapeutique Appliquee”: “Nous devons reconnaitre que nous sommes encore mal eclaires sur la nature et l’etiologie de l’affection.” In an article on the relation of pernicious anaemia to spinal cord disease Dr. Paul Jacob2 says: “ Weder ist es gelungen das Wesen, die Aetiologie der perniciosen Anamie uberhaupt zu er- gruenden ...” An effort has recently been made to associate acute pernicious anaemia, in some cases at least, with trau- matism.3 Heretofore this has not been regarded as a possible etiological factor. Strange to say, in both of the quoted cases the injury was left-sided. In my own case there was no history either of injury or of shock. Unfortunately it was not possible to obtain a post- mortem examination in this case, although every pos- sible effort was made to secure the consent of the relatives. The only other possible diagnosis would be a combination of cardiac disease with a chronic Bright’s, but an analysis of the history, symptoms, and course forbids it. The amemia was probably more in- tense than is ever seen in any form of chronic renal disease; it was also more sudden in appearance; the specific gravity of the urine was high for the cirrhotic type that might temporarily have sliowm no albumin; 1 Arch. f. Gyn., Bd. ii. 2 Berl. Klin. Woch., August, 1897. 3 Bret: La Prov. Med., Lyons, Dec., 1897; and James Herrick, of Chicago, Jour. Amer. Med. Assoc., June, 1896. MEYER: ANiEMIA WITH FATTY HEART IN PREGNANCY. 23 albumin and casts were persistently absent in every specimen of urine examined; the daily amounts of urea were large, even for a person on full diet, and, in accord- ance with this fact, there were neither gastric nor nervous symptoms present to indicate a uraemic condition—not even a vomit, and only slight headache at time of admis- sion; the dyspnoea could easily be explained on the score of the anaemia, the pulmonary congestion, and the fever. The ophthalmic picture might have been present in either primary pernicious anaemia or in the secondary anaemia of Bright’s. The microscopic examination of the blood, however, seems to make the diagnosis of pernicious anaemia a certainty.