PLATE I 
:AVERAGE NO. OF 
- DEATHS PER 
■ ANNUM 
PULMONARY 
TUBERCULOSIS 
PNEUMONIA 
HEART DI8. 
KIDNEY DIS. 
D. AR R HEAL 
DISEASES 
VIOLENCE 
CANCER 
APOPLEXY 
TYPHOID 
BRONCHITIS 
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 1,500,000) from IO 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) 256. OUTLINES 
OF 
INTERNAL MEDICINE 
FOR THE USE OF NURSES AND JUNIOR 
MEDICAL STUDENTS 
BY 
/ 
CLIFFORD BAILEYxFARR, A.M., M.D. 
DIRECTOR OF LABORATORIES, PENNSYLVANIA HOSPITAL, DEPARTMENT FOR 
MENTAL AND NERVOUS DISEASES; FORMERLY ASSOCIATE IN 
MEDICINE, UNIVERSITY OF PENNSYLVANIA 
FOURTH AND REVISED EDITION 
ILLUSTRATED WITH 69 ENGRAVINGS AND 6 PLATES 
LEA & FEBIGER 
PHILADELPHIA AND NEW YORK 
1924 Copyright 
LEA & FEBIGER 
1924 
PRINTED TN U. S. A. TO 
DR. JOSEPH SAILER PREFACE TO THE FOURTH EDITION. 
This text-book is intended to supply the basis for a system- 
atic course in medicine for nurses, and, in addition, to serve 
as a work of reference to which the nurse may turn for infor- 
mation concerning the rarer cases which may come under 
observation. The chief emphasis is laid upon etiology (pro- 
phylaxis), course, and symptoms; pathology, diagnosis, and 
treatment are briefly discussed for "information" but not 
for "guidance." 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 In many instances, 
case histories, especially of patients whom the nurses have 
seen, may be introduced in the lectures with good results. It 
is hoped that the book may also prove useful for those who 
are beginning the study of medicine. 
The book is divided into ten "Parts," eight of which are 
devoted to diseases of the various systems and two to harm- 
ful agencies (physical, chemical, bacterial) invading the body 
1 For example: Neurasthenia and hysteria, epilepsy, chorea, neuralgia 
and neuritis, locomotor ataxia, hemiplegia (all causes), anemia and leukemia, 
exophthalmic goiter, arteriosclerosis and aneurysm, pericarditis, valvular 
heart disease and cardiac insufficiency, bronchitis and bronchopneumonia, 
asthma and emphysema, pleurisy, ulcer and cancer of the stomach, gas- 
troptosis 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 pneu- 
monia, influenza, tuberculosis, infantile paralysis, tonsillitis and rheumatic 
fever, measles, scarlet fever, typhoid fever, sleeping sickness and intestinal 
parasites. VI 
PREFACE TO THE FOURTH EDITION 
from without. Each "Part" is introduced by a discussion of 
the symptoms, signs, etc., most often observed in diseases of 
the particular system under consideration. When infectious 
diseases (Part X) are taken up, therefore, the student has 
already become familiar with the widely diversified clinical 
manifestations 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 
freely consulted original articles and standard text-books. 
He has not, however, thought it necessary, except in occasional 
instances, to insert any references to original sources. In 
the present edition, he has had the assistance of Dr. Borman 
in preparing the manuscript, and the valued advice of 
Dr. Eyman and others of the Pennsylvania Hospital Staff, 
to all of whom he wishes to extend his thanks. 
C. B. F. 
PHILADELPHIA, 1924. CONTENTS. 
PART I. 
NERVOUS AND MENTAL DISEASES. 
CHAPTER I. 
General Considerations 17 
CHAPTER II. 
Mental Diseases and Functional Diseases of the Nervous 
System 29 
CHAPTER HI. 
Organic Diseases of the Nervous System 43 
PART II. 
DISEASES OF THE BLOOD AND GLANDS 61 
PART III. 
DISEASES OF THE CIRCULATORY SYSTEM. 
CHAPTER I. 
Diseases of the Bloodvessels and Pericardium .... 77 
vii viii 
CONTENTS 
CHAPTER II. 
Diseases of the Heart 92 
PART IV. 
DISEASES OF THE UPPER AIR PASSAGES, LUNGS, 
PLEURA 105 
PART V. 
DISEASES OF THE DIGESTIVE TRACT AND 
PERITONEUM. 
CHAPTER I. 
Diseases of the Mouth and Esophagus 129 
CHAPTER II. 
Diseases of the Stomach 142 
CHAPTER III. 
Diseases of the Intestines 158 
CHAPTER IV. 
Diseases of the Pancreas, Liver, Bile Passages, and Peri- 
toneum 172 
PART VI. 
DISEASES OF METABOLISM . . 183 CONTENTS 
ix 
. PART VII. 
DISEASES OF THE URINARY PASSAGES AND 
KIDNEYS 203 
PART VIII. 
DISEASES OF THE MUSCLES, BONES, AND 
JOINTS 219 
PART IX. 
DISEASES DUE TO HEAT AND OTHER PHYSICAL 
CAUSES AND TO POISONS ... 227 
PART X. 
INFECTIOUS AND PARASITIC DISEASES. 
CHAPTER I. 
General Considerations 241 
CHAPTER II. 
Infectious and Parasitic Diseases-Class I 261 
CHAPTER III. 
Infectious and Parasitic Diseases-Class II 279 
CHAPTER IV. 
Infectious and Parasitic Diseases-Class III .... 288 X 
CONTENTS 
CHAPTER V.' 
Infectious and Parasitic Diseases-Class III (Continued) 307 
CHAPTER VI. 
Il'FECTIOUS AND PARASITIC DISEASES-CLASS HI (CONTINUED) 320 
CHAPTER VII. 
Infectious and Parasitic Diseases-Class IV .... 344 
CHAPTER VIII. 
Infectious and Parasitic Diseases-Class IV (Continued) 358 INTERNAL MEDICINE. 
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 symptoms 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 
understanding 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. 18 
NERVOUS AND MENTAL DISEASES 
THE NEURONS. 
The brain and cord consists essentially of gray matter 
(cells) and white matter (fibers), with investing and support- 
ing 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 dia- 
grammatically in Fig. 1, C-D. The cell C has fine, so-called 
protoplasmic processes, which interlace with similar fibrils 
from other cells, and a main or axis-cylinder process which 
ends in a muscle (Zl). A sensory fiber (A-B), on the other 
hand, begins in the skin, e. g., and runs toward the cell B, 
Fig. 1 
Skin. 
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 conveyed 
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 and motor 
neurons or tracts. If a motor cell (O') in the spinal cord is 
destroyed its axis-cylinder process and the muscles which the 
latter supplies will degenerate, as in infantile palsy. 
Muscle. MOTOR AND SENSORY TRACTS 
19 
MOTOR AND SENSORY TRACTS. 
A motor "tract" consists of at least two superimposed neu- 
rons or segments (Fig. 2). The "upper segment" begins in 
a cell (O') in the cortex of 
the brain, passes downward 
through a narrow bundle, 
called the internal capsule, 
and crosses to the opposite 
side of the body, either at the 
lower part of the brain or in 
the spinal cord. After cross- 
ing it ends in twig-like pro- 
cesses D', which surround 
the cell body (0) of a second 
neuron ("lower segment"). 
The latter continues to its 
termination in a muscle, as 
already described. If any 
injury occurs to the upper 
segment 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 de- 
generate or waste, and after 
the first shock has passed re- 
flex action will be found pre- 
served. Usually, indeed, it is 
increased, because the mod- 
erating (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 
Fig. 2 20 
NERVOUS AND MENTAL DISEASES 
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 sen- 
sory 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 abnor- 
mal sleepiness. The latter is a symptom of both acute and 
chronic infections, as in measles and "sleeping sickness." It 
also occurs in exhaustion, myxedema, 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 morphine 
and other sedatives are often tortured by intractable insom- 
nia upon withdrawal of the drugs. Simple insomnia, when 
it is not due to pain, is perhaps most frequently to be attrib- 
uted 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 tendtodraw 
the blood from the brain; by hot applications to the feet; by 
warm drinks, such as hot milk; by diversions or light reading; 
by the formation of regular habits and by omission of tea, 
coffee and chocolate. 
Delirium and Confusion.-Pathological disturbances of con- 
sciousness 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. Ordinary active delirium is charac- 
terized by muscular restlessness, by insomnia, by failure to 
recognize surroundings or friends and by illusions, hallucina- 
tions and delusions. Illusions may be defined as faulty per- SYMPTOMS AND SIGNS OF NERVOUS DISEASE 
21 
ceptions, that is, the patient mistakes common objects and 
noises for "shapes and shrieks and sights unholy." Hallu- 
cinations, 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 someone 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; and 
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 con- 
ditions, 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 convulsions and 
Cheyne-Stokes respiration, and that of diabetes by rapid 
deep breathing ("air hunger"). In hysteria patients at times 
lie in an apparently unconscious condition, but their appear- 
ance is that of simple sleep. In cataleptic states the patient 
may assume fixed or rigid positions, or he may walk about 
without apparently being conscious of what he is doing. 
Aphasia.-Aphasia (speechlessness) is a "partial or com- 
plete loss of the power of expressing ideas by means of speech 
or writing." It is associated with other paralytic phenomena 
in cerebral hemorrhage, softening and tumor, and is of value 
in localizing the situation of the brain lesion, because its 
various forms are dependent on injury to quite different por- 
tions of the cerebral cortex. In sensory aphasia spoken or 
written words are not understood or remembered. In motor 
aphasia words may be comprehended, but on account of cere- 
bral disease the power of speech or writing is lost. Defective 
1 The orderlies at the Philadelphia Hospital, from long experience, attach 
grave prognostic significance to this particular hallucination. 22 
NERVOUS AND MENTAL DISEASES 
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 diagnosed on account of the asso- 
ciated paralysis. Ordinary loss of voice (aphonia) is due to 
mere local changes in the larynx, such as congestion or tumor 
of the vocal cords. Hysterical aphonia, however, is undoubt- 
edly 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 affec- 
tions 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 circulation, either congestion or 
anemia. (5) Headache may 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 digestive and genital organs. (7) Hysterical head- 
ache 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, gastrointestinal), 
toxic causes, as in alcoholism and uremia. Dizziness also 
occurs in neurasthenia and epilepsy. 
1 The B&rdny "turning" tests, designed to detect disturbances of the 
internal ear and of the corresponding centers, assumed great prominence 
during the war on account of the importance of excluding vertigo in pros- 
pective aviators. SYMPTOMS AND SIGNS OF NERVOUS DISEASE 
23 
Hyperesthesia, Anesthesia and Pain.-Disturbances of sen- 
sation 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 sensation 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 appre- 
ciation of heat and cold and of pain may be lost. The sense 
of form and of position may also be tested by appropriate 
methods. 
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 degeneration"). 
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, com- 24 
NERVOUS AND MENTAL DISEASES 
monly known as "dead fingers," in which one or more fingers 
or toes become white and bloodless, later blue and, finally, in 
extreme cases, gangrenous. In angioneurotic edema intense 
but transient edema may appear. An arm may swell sud- 
denly 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 manifesta- 
tion 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 extremities; 
diplegia, affecting all the extremities; and monoplegia, in 
which one extremity only is affected. In some affections 
paralysis may be irregularly distributed. Familiar examples 
of paralysis are ptosis (paralysis of the upper eyelid), facial 
palsy and wrist-drop. (See Fig. 4, p. 44; Fig. 5, p. 46.) 
Incomplete loss of power is often designated as paresis. 
Convulsions.-In convulsions there is abnormal involuntary 
activity of the muscles. In the "clonic" type the contrac- 
tions occur intermittently and irregularly, as in infantile con- 
vulsions, uremia, puerperal eclampsia and epilepsy. This 
type is simulated by hysterical convulsions, which, however, 
are not accompanied by complete unconsciousness. "Jack- 
sonian" convulsions begin in, or are often limited to, one 
part. In the beginning, at least, they are not accompanied 
by unconsciousness. They point to a localized irritation of 
some motor area in the brain, caused, for example, by a 
tumor. "Tonic" convulsions are characterized 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 
at the onset of an epileptic convulsion in tetanus, meningitis 
and in strychnine poisoning. Extreme retraction 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 dilatation of the stomach, etc. The elbows 
are bent, the thumbs turned into the palms of the hands and 
the feet extended (straightened out). Opisthotonus in a Case of Cerebrospinal Meningitis. (Koplik,) 
PLATE II SYMPTOMS AND SIGNS OF NERVOUS DISEASE 
25 
Contractures and Spasticity.-Contractures bear a super- 
ficial resemblance to tonic spasms but are more permanent. 
In this condition there may be an apparent shortening of 
the muscle, due to irritation, or there may be an actual short- 
ening, 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 hemorrhages. Writers' cramp is a 
disease characterized by spasm or cramp of the muscles of 
the hand when attempting 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 impor- 
tant 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 goiter 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. Choreiform movements are involuntary, irregu- 
lar and excessive in degree. The patient makes queer grim- 
aces, 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 accomplish 
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. 26 
NERVOUS AND MENTAL DISEASES 
Reflexes.-The coijdition of the reflexes is of great impor- 
tance 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 determined are the patel- 
Fig. 3.-Method of eliciting the knee-jerk. (Hare.) 
lar reflex or knee-jerk, the biceps-jerk, ankle clonus and cer- 
tain skin reflexes, particularly the abdominal reflexes and the 
Babinski reflex. The knee-jerk is brought out by tapping the 
patellar tendon below the knee. It is necessary for the leg 
to be relaxed, as when the knees are crossed. The plantar Lumbar Puncture. 
Illustrates topography of the parts and method of holding patient. In children the needle is frequently 
inserted in the middle line. (Koplik.) 
PLATE III LUMBAR PUNCTURE 
27 
reflex is elicited by stroking the sole of the foot; this normally 
causes flexion of the toes, but in the newborn and in certain 
nervous diseases may cause a?n extension of the toes (Babinski 
reflex). 
Special Senses.-The special sense organs are also investi- 
gated in nervous and general diseases. The examination of 
the retina often gives early and positive indications of cere- 
bral disease, arterial disease, nephritis, anemia and even 
tuberculosis. In brain tumor, for example, 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 investigated 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, arsphenaminized serum 
and antimeningitic serum are introduced in a similar manner 
after spinal fluid in an amount at feast 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 disin- 
fected at the time of operation by the aid of soap and water, 
alcohol and tincture of iodine (or by the latter alone). The 
patient's back is arched as strongly as possible 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 con- 
scious 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 introduced in the mid- 
dle line, on a level with the third or fourth (second to fifth) 
lumbar spine, and is pushed forward and slightly upward 28 
NERVOUS AND MENTAL DISEASES 
between the vertebrae for 2 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 by drop 
or in spurts, and should be collected in sterile test-tubes.1 
In some cases a coarse wire, or stilet, will be 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. 1 he punc- 
ture wound is covered 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. Common sequela? 
of these procedures are headache and dizziness, which may be 
avoided by rest in bed for forty-eight hours. 
1 In. meningitis the spinal fluid is cloudy and contains the causative 
organism of the disease. CHAPTER II. 
MENTAL AND FUNCTIONAL DISEASES OF THE 
NERVOUS SYSTEM. 
Mental Diseases. 
Postinfectious Psychosis. 
Exhaustion Delirium. 
Senile Psychosis. 
Manic-depressive Psychosis. 
Dementia Precox. 
Mental Deficiency. 
Functional Diseases of the Ner- 
vous System. 
Neurasthenia. 
Hysteria. 
Infantile Convulsions. 
Epilepsy. 
Chorea. 
Paralysis Agitans. 
Neuralgia. 
MENTAL SYMPTOMS. 
Postinfectious Psychosis and Exhaustion Delirium. - 
Many organic diseases, particularly those involving the cen- 
tral nervous system, may be accompanied by mental symp- 
toms (see Paresis and Senile Psychosis). The commonest 
conditions, however, coming under the observation of the 
physician or nurse outside of special institutions, are the con- 
fusional states which follow exhausting illnesses, such as 
typhoid fever, childbirth or prolonged lactation. In many 
cases it is hard to decide whether infection or exhaustion 
plays the greater role. Other types of insanity which may 
develop in predisposed persons under these conditions are 
not included. The most striking symptoms, aside from loss 
of weight, fever, etc., are: confusion, loss of the sense of time 
and place, failure to recognize friends or mistaking strangers 
for old friends, fleeting delusions and hallucinations, physical 
unrest, uncleanly habits. These cases may appear very 
unfavorable, but the prognosis is usually good unless there 
are foci of infection which cannot be removed or the patients 
are old and cachectic. External toxins, such as alcohol, may 
produce similar symptoms, but there are usually character- 30 
MENTAL AND FUNCTIONAL DISEASES 
istic features in addition to the history. The common alco- 
holic psychoses (delirium tremens and the form accompanied 
by neuritis) are described elsewhere. Acute alcoholic hallu- 
cinosis bears a closer resemblance to the affection we have 
described, but hallucinations, as the name implies, occupy a 
more prominent place. 
Treatment.-The treatment of toxi-infectious and exhaus- 
tion psychoses requires prolonged mental and physical rest, 
with forced feeding, continuous warm baths to calm excite- 
ment and promote elimination, the search for and removal 
of foci of infection, fresh air, sunlight (heliotherapy, quartz 
lamp), iron and other tonics. Restraint and sedative drugs 
are seldom necessary. In convalescent patients hydrotherapy 
gymnastic exercises, occupational therapy and diversion 
(travel) are useful. 
Senile Psychosis.-In senile dementia, loss of memory is 
usually the first deviation to be noted. Confusion, disori- 
entation and delusions may be prominent features. 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. In special types due to cerebral arterioscler- 
osis there may be aphasia and hemiplegia. Since the disease 
in any case is due to arteriosclerosis, atrophy or softening, 
the prognosis is practically hopeless. 
Manic-depressive Psychosis.-Mania and melancholia are 
now considered as phases of a single mental symptom-com- 
plex (manic-depressive insanity). This type of insanity has 
little bearing on general medical conditions, although it may 
be accompanied by disturbances of digestion and nutrition. 
Periods of emotional depression, associated with difficulty in 
thinking and acting, may alternate with periods of mania or 
exaltation, characterized by undue physical activity and an 
abnormal flow of loosely connected ideas. In other cases 
either mania or depression may be dominant throughout. 
Mild types of depression and elation (hypomania) are com- 
mon. The prognosis for individual attacks is usually good, 
but recurrence is only too common. Involutional melan- DEMENTIA PRECOX 
31 
cholia is closely related to and by many considered identical 
with the depressive phase of the above disease. It occurs 
most often in women at the menopause, more rarely in men 
a little later in life. It is characterized by depression with 
agitation. The patients often imagine that they have com- 
mitted some unpardonable sin, or that their digestive organs 
have been destroyed. They may pace backward and for- 
ward, "wringing their hands in hopeless despair, or sit absorbed 
in their own woes. The prognosis is fair, but the disease may 
extend over a period of years. Suicide is common, and its 
prevention requires constant vigilance on the part of the nurse. 
Dementia Precox.-Dementia precox, that is, the insanity 
of adolesence, is probably dependent upon congenital factors. 
At any rate, a psychopathic heredity is common. Patients 
have usually been of the "shut-in" type of personality, in 
contrast to the open friendly expansive type of person who 
develops a manic-depressive form of disease. They may be 
equal to the strain of ordinary life until puberty or later. In 
some instances they may have been unusually brilliant, but 
eventually their adaptation fails and mental deterioration 
becomes manifest. The most typical symptoms are indica- 
tive of a certain incongruity between ideas, emotions and 
actions. Intelligence may be good aside from a certain 
tendency toward suspiciousness, but the emotional expres- 
sions are silly, or out of place, and the actions not the natural 
outcome of their ideas or emotions. Striking manifestations 
are negativism, i. e., perverse resistance or opposition to 
everything that is suggested; catatonia, characterized by the 
maintenance of rigid or uncomfortable attitudes or by stereo- 
typed movements; paranoid ideas. The paranoid patient 
imagines that other people are talking about him, that spies 
have been detailed to follow his movements, that electrical 
devices have been introduced to torment him, etc. The prog- 
nosis in dementia precox is usually unfavorable. A certain 
proportion may recover sufficiently to live a protected exist- 
ence. The majority become permanent inmates of institu- 
tions and gradually deteriorate mentally. They may live to 
a considerable age. In state hospitals they are often able to 
perform many useful functions. 32 
MENTAL AND FUNCTIONAL DISEASES 
Another group of mental cases resembles the paranoid type 
of dementia precox, but differs from it in that no other evi- 
dence of deterioration is seen aside from ideas of references 
and delusions of persecution. Cases whose delusions form a 
complete and logical system (paranoiacs) have always 
attracted a great deal of popular attention, but are actually 
rare. Many of the assassins of history are thought to belong 
to this small group. 
Mental Deficiency.-Mental deficiency (amentia) is usu- 
ally 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 cretinism 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 inde- 
pendent 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 development 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 period of childhood. Thus a patient may appar- 
ently develop normally until the tenth year, but be quite 
incapable of progressing beyond that point either in the intel- 
lectual or the moral sphere. The mental capacity of these 
patients is usually gauged by their ability to cope with defi- 
nite intellectual tests appropriate to the various age periods 
(Binet tests).1 Many of the less marked cases are chiefly 
1 Subjects, even adults, who are able to pass the test for the age of four- 
teen are considered to be normal, that is, the intelligence quotient ("I. Q.") 
is 100 per cent. Those who have an I. Q. of 70 per cent or lower, that is, 
in an adult, an intelligence equivalent of ten years, are classified as morons; 
those with an I. Q. of 50 per cent, the equivalent of seven years, as imbeciles; 
those with an I. Q. of 20 per cent or less, the equivalent of three years, as 
idiots. FUNCTIONAL DISEASES OF THE NERVOUS SYSTEM 
33 
notable for their lack of moral sense and from them a consid- 
erable portion of the criminal and vicious classes-thieves, 
prostitutes, etc.-are recruited. Institutional care is essen- 
tial 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 trans- 
mit their defects to their offspring, it is of great advantage to 
the community 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, dissipa- 
tion, 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 exces- 
sive or, as is more common, the patient may have a low initial 
resistance. Thus there may be a congenital asthenia (liter- 
ally lack of strength) with structural defects, such as flat 
chest, stooping shoulders, downward displacement ("ptosis") 
of the stomach, intestines and kidneys, and in women malde- 
velopment or malposition of the uterus. On the other hand, 
many so-called neurasthenics are fat and rosy. Some of the 
latter class are hypochondriacs or valetudinarians, 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 dis- 
turbances, particularly abnormal fears (phobias) and com- 
pulsions. For example, a dread of open or high places may 
develop, so that the patient may be absolutely unable to cross 
a street or square; others have an impulse to perform some 
foolish movement, e. g., to step on the cracks in the pavement. 
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 inter- 34 
MENTAL AND FUNCTIONAL DISEASES 
preted as evidences of serious disease and lead to great depres- 
sion 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 manifesta- 
tions 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 common 
symptoms of neurasthenia: 
Psychic and Nervovs.-Irritability, failure of concentra- 
tion, indecision, headache, dizziness, vertigo, insomnia, 
indefinite pains, localized areas of tenderness. 
CirculatoryGeneral flushing, sweating, urticaria, pallor, 
blueness, palpitation, precordial distress. 
Gastroin testin a/.-Nervous indigestion, acid eructations, 
belching, distention, constipation. 
Genitourinary.-Frequent urination, transient polyuria, 
menstrual disturbances, sexual manifestations, etc. 
A large fraction of all gastrointestinal disturbances may 
be traced to neurasthenia, and, conversely, the majority of 
neurasthenics present digestive symptoms. 
Treatment.-The milder, or ambulant, cases are usually 
improved by regulation of the mode of life, by tonics (par- 
ticularly cold affusions, strychnine, 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 suc- 
cessful method of treatment. The patient is usually isolated 
in a hospital, or nursing home, under the care of a competent FUNCTIONAL DISEASES OF THE NERVOUS SYSTEM 
35 
nurse, who must be at the same time firm and kind. If the 
nurse is able, during convalescence, to entertain the patient 
by cheerful conversation 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, overfeeding 
is practised. To spare the digestive and eliminative 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 connec- 
tion with rest and milk-feeding, massage and electricity form 
a prominent part of the treatment, the purpose being to main- 
tain 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 permitted. 
Hysteria. -Hysteria, as the name implies, is perhaps more 
commonly seen in women, especially the emotional and con- 
vulsive forms. Nevertheless, certain cases, particularly of 
the paralytic type, are not at all uncommon in men, and were 
particularly frequent on the Western Front during the late 
war. Characteristic cases of hysteria are quite distinctive, 
but there are many intermediate forms in which it is difficult 
to differentiate 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 
Osler, " emotional states control the body." Another author- 
ity defines it as a "disease caused by suggestion, and cured 
by persuasion." The predisposition persists throughout 
life, but symptoms are more likely to be manifest during 
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 36 
MENTAL AND FUNCTIONAL DISEASES 
is excellent 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 emo- 
tional 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 cap- 
able of explanation. A physician of the writer's acquaintance, 
who is gifted w ith a very sympathetic personality, was called 
upon to treat a case of this sort and effected a startling cure 
much to his own surprise. He w as subsequently besieged by 
cripples and paralytics, most, if not all, of wrhom were suffer- 
ing from incurable organic diseases. Suspicion is usually 
aroused by the abnormal distribution of the loss of power, 
which is often unlike that of organic diseases, by the absence 
of wasting and by the presence of suggestive symptoms, such 
as anesthesia. Hysterical convulsions resemble epilepsy, but 
the movements are sometimes purposeful; unconsciousness 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 in dementia 
precox-is one of the most startling manifestations of hys- 
teria. The limbs may be held rigidly in unusual attitudes for 
a long time. Anesthesia has 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 sympathetic 
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 water 
1 Dr. Mills advises the nurse not to make the diagnosis of hysteria, and 
never to employ the term. FUNCTIONAL DISEASES OF THE NERVOUS SYSTEM 
37 
may relieve the severest pain or most obstinate insomnia. 
Hypnotism has not proved to be of a permanent value, but 
certain forms of hydrotherapy 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 Convulsions. -In infancy and early childhood 
convulsions are frequent, and may result from comparatively 
simple causes, such as rickets, gastrointestinal disturbances, 
the onset of acute infections and reflex irritation (phimosis, 
worms and teething). Intracranial affections, such as men- 
ingitis, hemorrhage, abscess and tumor may give rise to con- 
vulsions 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 twitch- 
ing 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 convul- 
sions may be repeated frequently. Holt has seen as many as 
eighty in one day. 
Treatment.-The convulsions may be controlled by the 
cautious (!) use of chloroform and at the same time a dose 
of chloral or bromide may 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 table- 
spoonful to a quart of warm water), or a mustard bath may 
be given (five to ten minutes), in which the mustard should 
be in the proportion of a tablespoonful to the gallon. The 
temperature of the bath should not exceed 105° F., and 
should be tested by a thermometer if possible. 
When the attack has been controlled the physician will 
proceed according to the cause. If the child has eaten indi- 
gestible food or has suffered from digestive disturbances 
lavage of the stomach and irrigation of the colon are in order. 
Emetics and purgatives may be used. The detection of albu- 
min in the urine will point to uremia, while lumbar puncture 38 
MENTAL AND FUNCTIONAL DISEASES 
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 necessary 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 star- 
ing, but in a moment may resume conversation without realiz- 
ing that he has been unconscious. 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 
immediately this tonic phase passes into violent clonic con- 
vulsive movements. The face is swollen and congested, the 
pupils dilated 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 (epi- 
leptic coma). When the patient awakes he may feel well 
aside from 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. Gastrointestinal symptoms are very 
common, and patients are sometimes improved by treatment 
of their digestive anomalies. 
Treatment.-Medicinal treatment is purely palliative. 
Certain drugs are capable of greatly reducing the frequency 
of the attacks, particularly luminal. A free use of bromides 
will also reduce the frequency of the attacks, but it brings FUNCTIONAL DISEASES OF THE NERVOUS SYSTEM 
39 
undesirable symptoms in its train-mental torpor, skin erup- 
tions and digestive disturbances. To secure intensive action 
bromides are sometimes used to replace common salt in the 
diet. Epileptics may pursue ordinary occupations with suc- 
cess, 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 
provided. 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 occasionally 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 articu- 
lar rheumatism and endocarditis, and it is possible, or even 
probable, that it is an 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 aggravated 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 away 
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. When arsenic is being administered in large or 
ascending doses the nurse should watch carefully for indica- 
tions of poisoning, such as loss of appetite, nausea, diarrhea, 
colic, puffiness about the eyes in the morning, skin eruptions 40 
MENTAL AND FUNCTIONAL DISEASES 
or disturbances of sensation (complaint of numbness or ting- 
ling). If such are noted they should be immediately reported 
to the physician. Quinine has also been used to control the 
choreiform movements. 
Symptomatic chorea occurs in encephalitis lethargica. 
There are other forms of chorea occuring in adults which are, 
however, entirely independent diseases. As they are rare, we 
will not further concern ourselves with them. 
Paralysis Agitans.-Parkinson's disease, 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 body 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. In advanced cases there is 
distinct loss of power. The tremor of old age is some what 
similar, but involves the head particularly. The disease in 
itself is not fatal, but is incurable. Any treatment should be 
directed to improving the nutrition of the patient by means 
of tonics, massage and hydrotherapy. 
Neuralgia.-Neuralgia is a term which is applied to a par- 
oxysmal 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 accompanied 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 neu- 
rasthenic, anemic or "gouty," using the latter term in a FUNCTIONAL DISEASES OF THE NERVOUS SYSTEM 
41 
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 attrib- 
uted to neurasthenia until a roentgen-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: Trigem- 
inal neuralgia, sciatica, brachial neuralgia and intercostal 
neuralgia. Trigeminal neuralgia or tic douloureux affects 
one or more of the three branches of the fifth cranial nerve: 
The first, supplying the forhead and eye; the second, the 
upper jaw; 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 dis- 
tinct neuritis. True sciatica is almost always unilateral, 
whereas bilateral pain is more likely to be due to some intra- 
pelvic pressure. Tumors and bony outgrowths, such as are 
found in arthritis deformans, are the common causes of such 
pressure. Intercostal neuralgia is characterized by pain at 
the exit of the nerve near the spine and anteriorly where it 
comes forward and becomes superficial. In intercostal neu- 
ritis 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: 
(1) With the discovery of the cause and its removal, and (2) 
with symptomatic treatment. Under the first heading would 
come the removal of bad teeth and the treatment of anemia, 
or of rheumatic and gouty conditions. Palliative treatment 
embraces the use of a large number of drugs, most of them 42 
MENTAL AND FUNCTIONAL DISEASES 
too well known, of which phenacetine and morphine may be 
taken as types. The latter is an extremely dangerous drug 
to use in this condition (formation of habit) and only very 
exceptional reasons would warrant its use. Local measures 
are frequently helpful. These include medicated ointments, 
hot applications, blisters, actual cautery and, rarely, elec- 
tricity. In tic douloureux, after other measures have failed, 
injections of alcohol into the nerve sheaths 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. 
Facial Palsy. 
Pressure Paralysis. 
Toxic Neuritis. 
Multiple Neuritis. 
Progressive Muscular Atrophy. 
Herpes Zoster. 
Myelitis. 
Multiple Sclerosis. 
Locomotor Ataxia. 
General Paresis. 
Cerebrospinal Syphilis. 
Meningitis. 
Hemiplegia. 
Hemorrhage, Thrombosis and Em- 
bolism. 
Subdural Hemorrhage. 
Hydrocephalus. 
Tumors of the Brain. 
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. Neu- 
ritis may be Idealized, affecting any one of the cranial or 
spinal nerves, or there may be a more or less general involve- 
ment 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 sud- 
denly without obvious cause other than exposure to cold 
("draught"). There is no pain, but the side of the face 
affected is smooth and expressionless. The eye cannot be 44 
ORGANIC DISEASES OF THE NERVOUS SYSTEM 
completely closed, the mouth is drawn to the opposite or 
healthy side, food collects in the cheek and the saliva Hows 
from the corner of the mouth. In some cases there is loss 
of taste. It is possible to determine what portion of the nerve 
is affected by the presence or absence of this or other symp- 
toms. After a few weeks the paralysis usually clears up. 
This does not apply, however, 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, caus- 
ing 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 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 MULTIPLE NEURITIS 
45 
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 probaly 
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 con- 
tamination 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 neu- 
ritis 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 involve- 
ment of both the sensory and motor nerves. The patients 
complain of numbness, tingling, burning and 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-drop 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 46 
ORGANIC DISEASES OF THE NERVOUS SYSTEM 
be glossy and even edematous. When the patient is able to 
walk 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 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 contractures. In 
many cases it is wise to put the patient upon an air-bed to 
Fig. 5.-Multiple neuritis. Double wrist-drop and double foot-drop. 
(Lloyd.) 
avoid the possibility of bed-sores, which are prone to develop 
because of interference with the normal trophic influences. 
During the acute stage the local measures mentioned under 
Neuralgia are usually employed, particularly heat. In con- 
valescence passive movements, massage and electricity are 
all of great value. In this stage strychnine 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 
conditions, in which suitable restrictions may be necessary. 
Progressive Muscular Atrophy.-In poliomyelitis the dis- 
ease process does not affect the motor nerves primarily but 
the cells in the anterior part of the spinal cord which control HERPES ZOSTER 
47 
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 sup- 
plies become paralyzed and atrophied and the reflexes are 
lost. Acute poliomyelitis is due to infection and will be dis- 
cussed under Infectious Diseases. Chronic poliomyelitis, or 
progressive muscular atrophy, is by many thought to be of 
syphilitic origin. It 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 devel- 
ops. 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 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 com- 
monly seen on the 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. It is probably due to 
a specific virus. 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. 
Treatment.-There is no treatment for chronic poliomyeli- 
tis, aside from general hygienic measures. Herpes zoster is 48 
ORGANIC DISEASES OF THE NERVOUS SYSTEM 
also uninfluenced by treatment, except in a palliative sense. 
Sedatives in the form of dusting powders, ointments or solu- 
tions in collodion may be applied along the affected nerve. 
After the disappearance of the eruption electricity in the 
form of galvanism will sometimes relieve neuralgia. 
Fig. 6.-Herpes zoster. Diagram showing different positions in which 
the eruption may occur. These areas correspond to the distribution of 
certain nerves or to a definite spinal segments; 6, 5 and 1 are the most com- 
mon types. 
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 MULTIPLE SCLEROSIS 
49 
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 experiences 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 which 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 numb- 
ness, 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 clean and should be fre- 
quently turned to avoid any danger of bed-sores. An air-bed 
or water-bed is to be preferred. 
Particular attention must be directed to the prevention of 
irritation from incontinence of urine and feces. Absorbent 
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 move- 
ments are necessary and useful to maintain the nutrition of 
the muscles. In some cases, after prolonged 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. 
Multiple Sclerosis.-Spinal sclerosis is characterized 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. Disseminated or multiple sclerosis 50 
ORGANIC DISEASES OF THE NERVOUS SYSTEM 
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 spas- 
ticity. The reflexes are increased. In typical cases there is 
tremor upon effort, lateral oscillation of the eyeball (nystag- 
mus), 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 localiza- 
tion of the disease 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 occasionally cases of so-called "taboparesis," in 
which these conditions overlap, but usually they are distinct. 
Locomotor ataxia is so-called because of the peculiar dis- 
order of gait which characterizes it. The synonym "tabes" 
refers to the "wasting" or sclerosis of the posterior 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 occur- 
rence 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 ina- 
bility 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 cot- 
ton, 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 LOCOMOTOR ATAXIA 
51 
stands with his eyes shut he sways, or even falls. When 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 
Fig. 7.-Footprints on floor for practice in walking. (White and Jelliffe.) 
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 bedridden 52 
ORGANIC DISEASES OF THE NERVOUS SYSTEM 
and paralyzed, and suffer from incontinence of urine and 
feces. Finally, mental symptoms supervene. Death occurs 
from exhaustion or from some accidental disease. The excru- 
ciating 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 observation. In addition to the 
complications already mentioned, trophic conditions, includ- 
ing perforating ulcer of the foot and degenerative changes in 
the joints (knee, as a rule), are seen. 
Tabes is relatively rare in the colored race; it is more com- 
mon in men than in women. The disease is incurable, but 
frequently stationary for long periods of time and susceptible 
to great improvement by treatment. 
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 ordi- 
nary syphilitic treatment, but in recent years intraspinous 
injections of arsphenaminized serum have been used with 
some success. The physical measures consist largely in reed- 
ucation of the muscles, so that precision of movement may be 
restored. Other sense organs are educated to take the place 
of the impaired sensory nerves. The patient practises walk- 
ing a chalked line, putting his feet into ruled spaces, inserting 
pegs into holes, etc. (Fig. 7.) 
General Paresis.-In general paralysis mental symptoms 
predominate, though nervous symptoms (often misdiagnosed 
as neurasthenic) and slight evidences of paresis may exist 
long before the former are apparent. In the fully developed 
disease the pupils are usually irregular, the face is smoothed 
out, there is an irregular tremor of the tongue and lips, the 
enunciation is indistinct (elision of letters, etc., is observed) 
and there is tremor of the hands with characteristic changes 
in writing. Convulsions are common and may initiate or 
terminate the disease. 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 development of the disease, delusions 
of importance or grandeur may become dominant; he becomes CEREBROSPINAL SYPHILIS 
53 
extremely extravagant and engages in foolish business ven- 
tures in which his fortune, if he has one, is sometimes lost. 
Other cases may be characterized by depression, delusions, 
etc. Finally, the mental powers begin to wane and the case 
progresses to complete dementia. At the same time the 
weakness of the muscles becomes more and more extensive, 
until the patient is helpless, unable to feed himself and with 
no control over his sphincters (incontinence of urine and 
feces). Bed-sores frequently develop, and complicating dis- 
eases are not at all unusual. The usual duration of the 
disease is from two to five years. 
Treatment.-Treatment is largely institutional, principally 
directed to the care, comfort and protection of the patient. 
Antisyphilitic medication is of relatively small value; never- 
theless, encouraging results have been obtained by the early 
use of arsenicals intraspinally. 
Cerebrospinal Syphilis.-Under this heading we include a 
large number of cases due to the syphilitic virus which lack 
the typical symptomatology of tabes and paresis. This 
disease may attack the small bloodvessels, causing obstruc- 
tion to the circulation and consequent injury to the nervous 
tissue; there may be patches of meningitis, causing localized 
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 deteri- 
oration, 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 invaded 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 (lymphocytes). 
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 potassium 54 
ORGANIC DISEASES OF THE NERVOUS SYSTEM 
iodide or intravenous injections of arsphenamine or neo- 
arsphenamine. 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 meningitis. 
Syphilitic meningitis of the cord and of the brain has been 
mentioned. Other forms of local meningitis may depend on 
injury or abscess. Cerebrospinal meningitis 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 invariably fatal. In children 
the disease may begin with irregular fever, irritability, 
increasing stupor and convulsions. In the early stages a 
child may utter sharp cries which are characteristic when 
once heard. In the stage of coma extreme degrees of retrac- 
tion of the head, with curving of the back (opisthotonos) are 
seen. The disease may last for several weeks, and emacia- 
tion become excessive. It is sometimes spoken of as acute 
hydrocephalus, 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 will 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 strepto- 
coccus. 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 manifestations depend 
upon the situation of the lesion. Certain areas of the cor- 
tex, 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 HEMIPLEGIA 
55 
cortex are arranged on either hand like the ribs of a palm-leaf 
fan (Fig. 8). They converge near the base of the brain, pass 
.Cortical centre for op- 
posite leg 
Lesion of cerebral mo- 
noplegia (brachial) 
-Cortical centre for op- 
posite arm 
.Cortical centre for op- 
posite side of face 
Lesion of ordinary 
hemiplegia 
Internal capsule (pos- 
terior limb) 
Pons 
-Motor nerve to face 
Lesion of cross paralysis- 
(face of same side with 
limbs of other side) 
-Decussation of pyra- ' 
mids 
-Crossed pyramidal tract 
Motor nerves to upper 
limb 
A lesion causing paraplegia- 
A lesion causing hemi 
paraplegia 
■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.) 
through the narrow spaces on each side known as the inter- 
nal capsules in the peduncles (or steins) of the brain, and 56 
ORGANIC DISEASES OF THE NERVOUS SYSTEM 
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 lower down. The 
above-mentioned nuclei and cells form a part of the lower 
motor neurons and belong to the cranial and spinal nerves 
respectively. The former supply the eye and its muscles, 
the face, tongue, etc., and the latter, the muscles of the trunk 
and extremities. 
The arrangement of the circulation of the brain is such 
that the arteries which supply the internal capsules are pecu- 
liarly 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 oppo- 
site 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 hem- 
orrhage is found, as a rule, in those past middle age, because 
in them the vessels are prone to be weakened by arterioscler- 
osis. 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 characterized by a more 
gradual onset of paralysis and unconsciousness, but the 
differentiation is probably not as easy as is often supposed. 
Some authorities hold that thrombosis rather than hemor- 
rhage is the usual lesion. Embolism occurs frequently in HEMORRHAGE, THROMBOSIS AND EMBOLISM 
57 
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 (throm- 
bosis) and softening. In many cases hemorrhage or soften- 
ing, 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 premoni- 
tion, but is sometimes preceded by vertigo, numbness or 
convulsions. The patient is unconscious (comatose), the 
extremities are relaxed, the pulse is full and strong and 
the respiration deep and snoring (stertorous). 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 evi- 
dent. 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 paralysis 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 uninjured the ganglion cells 
of the lower neuron which control nutrition. The reflexes on 
the affected side are increased. When the patient walks he 
swings the affected leg from the hip and supports the para- 
lyzed arm with the opposite hand. Elderly patients who 58 
ORGANIC DISEASES OF THE NERVOUS SYSTEM 
have suffered one stroke are liable to subsequent attacks. 
Sometimes these may be very slight, and it is not rare for 
the patient to die of some complicating 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 practice to bleed the 
patient freely with the purpose of lowering the blood-pressure 
and checking the hemorrhage. At this stage croton oil (cau- 
tion) is frequently administered to produce purgation. The 
treatment in other respects is symptomatic. During con- 
valescence 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 formation 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 parti- 
cles " 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 mem- 
branes 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 convulsions. The pressure is likely to 
involve parts of the motor area, and leads either to hemi- 
plegia or monoplegia, more often the latter. Thus, if the 
arm center is pressed upon there is paralysis of the corres- 
ponding 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, spas- 
modic ("athetoid") movements. 
Treatment.-Treatment consists in an effort to restore func- 
tion in the temporarily affected muscles by massage and ABSCKSS OF THE BRAIN 
59 
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 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 sub- 
stance; in the others the accumulation 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, nar- 
row 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 with labor, and sometimes the spinal cord or 
the ventricles have to be drained to permit delivery. Hydro- 
cephalic children are usually weak and do not often sur- 
vive 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. 
I nlike other tumors they are amenable to treatment. Benign 
and malignant growths also occur, and produce: (1) Symp- 
toms common to all brain tumors, and (2) localizing symp- 
toms, 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 
pressure. Localizing symptoms include disturbances of the 
various senses, paralysis, vertigo, disturbances of gait, etc. 
Abscess of the Brain.-Abscess of the brain produces symp- 
toms which may be similar to those seen in tumor, but are 
more sudden in onset, and are accompanied by fever, leuko- 
cytosis 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. 60 
ORGANIC DISEASES OF THE NERVOUS SYSTEM 
Treatment.-If an accurate localization can be made, and 
the tumor is in a situation where it can be safely 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 
eyesight. 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 Polycythemia. 
Leukemia. 
Hodgkin's Disease. 
Purpura. 
Hemophilia. 
Diseases of the Lymphatics and 
Lymphatic Glands. 
Diseases of the Ductless Glands. 
Simple Goiter. 
Myxedema and Cretinism. 
Exophthalmic Goiter. 
Thymic Asthma, Thymus Death, 
etc. 
Addison's Disease. 
Infantilism and Acromegaly. 
DISEASES OF THE BLOOD. 
General Considerations.-Pallor of the skin is not a trust- 
worthy 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 com- 
paring 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 hemoglobinometer for this purpose. 
One of the simplest is that of Sahli, which consists of two 
tubes, one containing colored 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. 62 
DISEASES OF THE BLOOD AND GLANDS 
Blood counts are made by diluting 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 (counting chamber) and covered with 
a glass slip. From the figures thus 
obtained the number of cells in a 
cubic millimeter is calculated. Us- 
ually the number of red corpuscles 
varies from 4,000,000 to 5,000,000. 
In the "severest" anemias the number 
of "reds" may fall below 1,000,000. 
The white blood cells usually number 
from 8000 to 10,000. In typhoid 
fever and measles1 they are reduced 
below this minimum (leukopenia), 
but in most infections, e. g., pneu- 
monia, they are increased to 15,000, 
20,000, 30,000 or more (leukocytosis), 
The greatest increase is seen in leu- 
Fig. 9.-Sahli's hemoglobi- 
nometer. (Simon.) 
Fig. 10.-Blood-counting chamber 
(ruling). (Simon.) 
kemia ("white blood") in which disease they may be num- 
bered by the hundred thousand. To make a "differential ' 
count a drop of blood is spread upon a slide or cover-slip and 
stained, after which the various kinds of white blood cells 
are noted and recorded in percentages. In normal blood of 
1 Other infections in which leukocytosis is absent are uncomplicated 
tuberculosis, influenza, mumps and malaria. PLATE IV 
BLOOD 
(Ehrlich triple stain.) 
(Prepared by Dr. Lyon.) 
FIG. 1 
TYPES OF LEUKOCYTES. 
a. Polymorphonuclear neutrophile. b. Polymorphonuclear 
eosinophile. c. Myelocyte (neutrophilic). d. Eosinophilic 
myelocyte. e. Large lymphocyte (large mononuclear), f. 
Small lymphocyte (small mononuclear). 
FIG. 2 
VARIETIES OF RED CORPUSCLES. 
ay 
a. Normal red corpuscle (normocyte). b, c. Anemic red 
corpuscles. d-g. Poikilocytes (irregular cells). h. Microcyte 
(small cell). i. Megalocyte (large cell). j-n. Nucleated red 
corpuscles, j, k. Normoblasts. I. Mieroblast. m, n. Megalo- 
blasts. DISEASES OF THE BLOOD 
63 
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 suggestive of anemia, etc. The nor- 
mal red cells are of a uniform size and color, but in anemia 
they may be pale (throughout or in the center), irregularly 
stained or variable in size and shape. Sometimes in severe 
anemias some of the red cells may be nucleated. Large 
nucleated red cells (megaloblasts) are characteristic of per- 
nicious anemia. (See Plate IV.) 
In acute secondary anemia (hemorrhage) and in pernicious 
anemia it may be necessary or wise to attempt to supply the 
deficiency in the volume of the blood by enteroclysis, hypo- 
dermoclysis, intravenous saline infusion or blood transfusion. 
These measures are also of value in "shock," in uremia (when 
combined with venesection), in toxemias and in infections. 
In the operation of hypodermoclysis a pint or more of fluid 
(usually physiological salt solution) is injected into the loose 
connective tissue beneath the breasts, in the axilla or else- 
where. 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 scrupulous cleanliness and asepsis is, however, 
essential as the infiltrated tissues seem to be prone to infec- 
tion. I have seen severe and even fatal infection follow this 
simple operation. In intravenous infusion a large vein, usu- 
ally at the bend of the elbow, is chosen, and a sharp needle 
is thrust directly into it in the direction of the heart. Accur- 
ately made sterile salt solution at body temperature, or 
blood, may thus be injected directly into the patient's circu- 
lation. In blood transfusions it is necessary that the blood 64 
DISEASES OF THE BLOOD AND GLANDS 
of the donor and recipient do not agglutinate, which is 
avoided by selecting suitable donors by means of "typing" 
and "cross-agglutinating" tests, otherwise a fatal outcome 
may result. Enteroclysis is discussed on page 134. 
Anemia.-Anemia is a deficiency in the quality or quan- 
tity 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 disturb- 
ance and has nothing to do with the composition of the blood; 
we have an example in transitory anemia of the brain, causing 
syncope or "fainting." Acute anemia is generally the result 
of a profuse hemorrhage, as in injury, accidents of childbirth, 
gastric ulcer, cirrhosis of the liver, typhoid fever or phthisis. 
The most important anemias are chronic and either primary 
or secondary. The primary anemias are, as far as we know, 
definite diseases involving blood formation and destruction; 
the secondary anemias are symptomatic of other conditions 
and diseases-repeated hemorrhages, intestinal 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 indi- 
vidual cells may be darker than normal. This sort of anemia 
is observed in "essential" 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 writh menstrual disturbances, PERNICIOUS ANEMIA 
65 
constipation, improper diet, overwork and unhygienic con- 
ditions. 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 for- 
merly very prevalent, but has practically 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 tuberculosis, intestinal toxemia, hookworm 
disease, etc., were formerly called chlorosis. 
Treatment. - Treatment consists in proper hygiene and 
diet, laxatives, glandular therapy, and iron, the latter usually 
in the form of "Bland'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 termina- 
tion. 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), particularly if very large (megalo- 
blasts) or small (microblasts) are suggestive of this form 
of anemia. In hemorrhagic anemia normoblasts alone are 
seen. Another type which is fulminating in character known 
as "aplastic pernicious anemia" is characterized by a rapid 
onset, the prompt development of the above symptoms and 
a quickly fatal termination. The blood shows a rapid dis- 
appearance of red blood cells without the occurrence of 
nucleated forms. 
Sometimes irritation or inflammation of the gums and 
tongue may be found, or the stomach and intestines may 
show evidences of complete atrophy. There may also be 
associated symptoms due to involvement of the spinal cord, 
e. g., spastic paralysis and sensory impairment or loss. The 
heart is very frequently enlarged with associated symptoms 66 
DISEASES OF THE BLOOD AND GLANDS 
-breathlessness, soft pulse, etc. Edema, if slight, may be 
due to anemia alone; Many cases which have been consid- 
ered 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 spontaneously 
or after the use of iron, bone-marrow and arsenic. The last 
named is the most valuable remedy and is given by 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 benefit. 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), enlargement 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 destruc- 
tive action on the blood (avoid headache "cures"!). 
Leukemia.-In leukemia there is, sooner or later, a pro- 
nounced anemia in addition to an enormous increase in the 
number of white blood cells. The latter, which normally 
amount to less than 10,000 per c.mm. may increase in this 
disease to 300,000 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. PURPURA 
67 
Patients with leukemia come to the physician for bleeding 
from the gums, epistaxis, or other forms of hemorrhage, for a 
tumor in the abdomen (large spleen), for enlarged glands, or 
merely for general weakness. In myeloid or splenomyelogen- 
ous leukemia the commoner variety of the disease, there is 
tremendous enlargement of the spleen; in lymphatic leu- 
kemia the superficial lymphatic glands are enlarged. The 
diagnosis is made by examination of the blood and if this is 
neglected the 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. 
Treatment.-Treatment consists of rest, good food, atten- 
tion to the general hygiene and the administration of arsenic. 
The roentgen-rays are often useful. Temporary improve- 
ment, as in pernicious anemia, is not at all unusual. 
Hodgkin's Disease.-Hodgkin's disease (pseudoleukemia), 
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 leu- 
kemia 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 intrathoracic glands are first and predominantly 
affected, causing pressure on the bronchi, etc., with resulting 
cough, dyspnea and cyanosis. Ultimately most of the lym- 
phatic groups become involved. The disease is chronic 
and the outcome doubtful. An infectious origin has been 
suggested. Treatment is along lines similar to those found 
useful in leukemia. The roentgen-ray treatment is tempo- 
rarily 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 68 
DISEASES OF THE BLOOD AND GLANDS 
may be large and diffuse (ecchymoses) or minute and discrete 
(petechite). 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 
Fig. 11.-Hodgkin's disease. Notice the enormous enlargement of the 
lymphatic glands of the neck and axillae. (Hare.) 
with hemorrhagic or purpuric eruptions; in typhus fever and 
epidemic meningitis petechise are a characteristic feature. In 
the latter disease cases occur in which the eruption is the 
dominant symptom. Certain drugs and poisons, such as HEMOPHILIA 
69 
quinine 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 extremities; 
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, stom- 
ach, intestines and bladder show that the affection is not 
confined to the visible mucous membranes. Although there 
is, as a rule, no fever or other constitutional symptom, never- 
theless 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 constituents which are neces- 
sary 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 abso- 
lute rest, sometimes secured by a hypodermic of morphine 
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 circum- 
stances seem to indicate. At the present time, while we still 
use these measures, we depend more on the following: Pack- 
ing, syringing with hot water, the application of adrenalin, 
the internal use of calcium chloride or lactate and the sub- 
cutaneous administration of blood serum. After the admin- 
istration of normal horse serum, as after diphtheria antitoxin, 
urticaria may develop or, very rarely, severe or even fatal 70 
DISEASES OF THE BLOOD AND GLANDS 
collapse. If the physician cannot be reached immediately 
a hypodermic of morphine and atropine should be promptly 
administered. 
DISEASES OF THE LYMPHATICS AND LYMPHATIC 
GLANDS. 
General and local enlargement of the lymphatic glands 
may result from tuberculosis, syphilis and other infections 
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. Tuberculous 
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. Occasion- 
ally the condition may exist alone and give rise to intractable 
cough. Tuberculosis of the mesenteric glands occurs in 
children and causes excessive wasting (tabes mesenterica). 
In syphilis there is a slight general enlargement of the super- 
ficial lymphatic glands, particularly significant when it 
involves the glands at the inner side of the elbow (epitroch- 
lear) 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. Frequently 
the irritation caused by head lice leads to enlargement 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 may be considered as a filter for the blood stream, 
exerting perhaps a formative as well as a destructive influence 
upon the red blood cells. It may also be concerned with the 
production of immunity to infection. It is not, however, an 
organ which is essential to life. The remaining ductless 
glands, as well as the pancreas, testicles and ovaries (which 
have an internal secretion in addition to their more obvious DISEASES OF THE DUCTLESS GLANDS 
71 
function) have a regulative influence on growth, 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 symptoms may develop. 
The suprarenal capsules have to do with the maintenance of 
blood-pressure. If their influence 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 over- 
growth of bones and tissues, leading to gigantism on the one 
hand, or the retention of the characters of infancy with 
obesity (infantilism) on the other. The pancreas, whose 
principal secretion is concerned with intestinal digestion, also 
has an internal secretion known as "insulin," which enables 
the body to utilize sugar. 
Simple Goiter.-An undue persistent enlargement of the 
thyroid gland, unaccompanied by general symptoms, is 
known as simple goiter. It occurs in two forms, the cystic 
or colloid and the adenomatous. The first-mentioned form 
may assume grotesque proportions (such cases were common 
in Switzerland before the days of goiter surgery); the latter 
may become "toxic," and simulate Graves' disease in many 
respects. Both types may give rise to pressure symptoms if 
the esophagus or trachea are encroached upon. These types 
of goiter, as well as myxedema and cretinism, are common in 
so-called goiterous countries. The most extreme cases are 
seen in high mountainous regions, such as Switzerland; the 
milder forms are very common in our own country, princi- 
pally in the so-called "goiter belt," which borders the Great 
Lakes on the south and thence extends northwest to Wash- 
ington and Oregon. Most of the areas in which goiter is 
prevalent are of glacial formation, while the coastal plains 
are relatively free from the malady, which is now thought 
to be due to lack of iodine-a substance which is abundant 
in the sea and in ocean deposits. This theory has led to the 
extensive use of iodine in minute doses (| to 1 gr. of sodium 
iodide-or its equivalent-daily for one month, the course 
to be repeated twice yearly) as a preventative measure, with 
brilliant results. 72 
DISEASES OF THE BLOOD AND GLANDS 
Myxedema and Cretinism.-Myxedema, whether resulting 
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 
Fig. 12.-Sporadic cretinism, aged twenty-one years. Before treatment. 
(Dock.) 
edema. These deposits are most often seen above the clavi- 
cles. 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, manifests its symptoms in childhood, although 
the patients may survive until adult life. ,They retain the 
fat chubby appearance of infants, partly as a result of exten- 
sive deposits of mucoid tissue. The tongue is large and lolls MYXEDEMA AND CRETINISM 
73 
out of the mouth, and a high degree of mental deficiency is 
present. If they learn to walk they only do so imperfectly. 
Treatment.-Simple goiter is often benefited by iodine treat- 
ment. If the growth reaches a considerable size, or produces 
pressure symptoms, partial but not total excision is advisable. 
Complete removal will cause the development of symptoms 
Fig. 13.-Case of Dr. Hermon Sanderson. After four months' treatment 
with thyroid extract. (Dock.) 
of myxedema on account of the loss of the thyroid secretion. 
If the goiter is of the adenomatous type, and loss of weight, 
rapid pulse and other toxic symptoms develop, the treatment 
is similar to that of exophthalmic goiter. The treatment of 
myxedema and cretinism by thyroid extract or thyroxin has 
been one of the triumphs of modern therapeutics. If the ex- 
tract is administered to cretins mental improvement occurs in 
a short time, often with complete restoration of normal devel- 74 
DISEASES OF THE BLOOD AND GLANDS 
opment and growth. Excellent, although less striking, results 
are obtained in myxedema by the aid of the same remedy. 
Iodine and the iodides are usually beneficial, as in myxedema. 
It is an interesting fact that normal thyroid itself contains 
an unusual proportion of iodine. 
Exophthalmic Goiter.-Exophthalmic goiter, or Graves' 
disease is not peculiar to any locality. It is apparently due to 
or associated with, oversecretion of the thyroid. The pulse 
is rapid, the mind alert and overactive and all the vital pro- 
cesses 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 moderately 
enlarged, and is frequently symmetrical. The chief diagnos- 
tic signs of exophthalmic goiter are: (1) Prominence of the 
eyeballs and widening of the aperture between the eyelids, 
so that when the patient looks downward the white of the 
eye is seen above the iris; (2) a "fine," rapid tremor of the 
hands; (3) moderate enlargement of the thyroid gland; (4) 
rapidity of the pulse; (5) increased basal metabolism. 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. Certain cases of adeno- 
matous goiter may after many years, usually in early middle 
life, develop hyperthyroid symptoms. The prominent eyes 
and other characteristic signs of Graves' disease are usually 
lacking. 
Treatment.-Medical treatment is unsatisfactory in the 
above-described conditions, because we have no specific drug 
and the only method of limiting the oversecretion is by remov- 
ing 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 sometimes 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 irri- 
tability has disappeared. He should also be shielded from 
anything which might cause worry or excite attacks of tachy- 
cardia (rapid pulse). Surgeons are so mindful of this fact EXOPHTHALMIC GOITER 
75 
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 con- 
sidered opportune to push anesthesia to a degree sufficient 
for operation. Drugs which retard the pulse, such as digi- 
talis, are not of much use. An ice-bag over the precordium is 
Fig. 14.-Exophthalmic goiter. (Dock.) 
usually more effective. Iodides and iodine preparations are 
often valuable in adenomatous cases, even if toxic, but most 
physicians avoid them in typical Graves' disease. 
Thymic Asthma and Thymus Death. -Diseases of the thy- 
mus are rare, and can receive only a passing notice. This 
gland, situated beneath the upper part of the sternum is 76 
DISEASES OF THE BLOOD AND GLANDS 
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 obstruc- 
tion, due to pressure of the enlarged gland on the air passages 
-thymic asthma. At 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. 
If the disease is recognized roentgen-ray treatment may be 
used, at times with excellent results. 
Addison's Disease.-Addison's disease is due to deficient 
secretion of the adrenal glands and may result from tubercu- 
lous infiltration, tumors, etc. The symptoms are pronounced 
pigmentation of the skin and mucous membranes, excessive 
weakness and soft pulse. The patients almost invariably die 
of cardiac failure. This disease is extremely rare. I per- 
formed an autopsy in one case (tuberculous), 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 develop- 
ment of the sexual characters, as in "infantilism." Disease 
of the pituitary are at present attracting 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, par- 
ticularly of the face, hands and feet. The features became 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 and 
optic neuritis. 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. 
Hydropericardium. 
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 informa- 
tion, especially when interpreted by modern instrumental 
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 characteristics, 
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; (6) the condition of the vessel wall. 
The normal adult pulse-rate ranges between 65 and 80, 
varying with the individual and the position, whether reelin- 78 
THE BLOODVESSELS AND PERICARDIUM 
ing, sitting or standing. It is markedly affected by exercise, 
and in nervous persons and children by excitement.1 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 ordinarily 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 tachycardia. 
Paroxysmal tachycardia is a nervous affection of the heart, 
characterized by periods of extremely rapid pulse. Tachy- 
cardia may or may not be accompanied by the sense of 
palpitation. A persistently slow pulse is spoken of as brady- 
cardia. 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-beat. 
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 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 
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 
79 
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 from the radial artery (or heart) 
and from one of the large veins of the neck. The fol- 
lowing 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 inspi- 
ration; 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 ("extrasystole"), 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 signifi- 
cance, 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 insuffi- 
ciency), 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 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 80 
THE BLOODVESSELS AND PERICARDIUM 
abdominal vessels are dilated, while during exercise more 
blood flows to the muscles. In any one individual these fac- 
tors compensate for each other, so 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 alternating contraction and relaxation of the heart; 
with the pulse, or systole, the pressure increases; with the 
interval, or diastole, it diminishes. 
Fig. 15.-Determination of blood-pressure by auscultation or by palpation 
of the radial pulse. (Musser.) 
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 sphyg- 
momanometer, or blood-pressure instrument. It 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. SYNCOPE 
81 
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 pulsation 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 patholog- 
ical 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 (poly- 
graphs) not only record the pulse at the wrist but also the 
heart-beat and the pulsation of the veins in the neck. In 
this way the sequence of events in the cardiac cycle may be 
studied, and the nature of irregularities determined. More 
accurate data are obtained by the electrocardiograph, an 
elaborate instrument which records the minute electric cur- 
rents which are associated with the wave of muscular con- 
traction which begins in the auricles and spreads to the 
ventricles with each contraction of the heart. Tracings (or 
electrocardiograms) 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 pul- 
sating at a different and more rapid rate than the lower (ven- 
tricle)-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 con- 
vulsions occur. 
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 82 
THE BLOODVESSELS AND PERICARDIUM 
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. Dis- 
tressing nocturnal dyspnea with precordial pain, particularly 
in aortic disease, sometimes compels the patient to sit up 
in bed (orthopnea). Cheyne-Stokes respiration was origin- 
ally 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, geni- 
tals, body, etc. The pleural, pericardial and abdominal 
cavities are often filled with fluid (hydrothorax, hydroperi- 
cardium and ascites). The dropsy of liver disease begins 
with ascites and that of nephritis with edema of the eyelids 
and subcutaneous tissues without 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 seen in pneumonia, emphysema, etc., 
as well as in obstructive 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 circulatory 
phenomenon, not always to be distinguished by inexpert DISEASES OF THE BLOODVESSELS 
83 
observers from the pulsation of the arteries (carotids) which 
is so prominent in nervous persons and in those with aortic 
insufficiency. Cardiac pulsation is normally seen at the apex 
and abnormally over a wider area. In aneurysm the pulsa- 
tion is outside the limits of the normal heart area. 
Capillary Pulse.-The capillary pulse is seen in aortic insuffi- 
ciency, less often in normal persons. If the forehead 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 designated as a fric- 
tion or rub. 
Heart Area.-The size and position of the heart are deter- 
mined by percussion (dulness), palpation (pulsation) or by 
the roentgen-ray. 
DISEASES OF THE BLOODVESSELS. 
Arteriosclerosis.-Thickening or "hardening" of the arter- 
ies is known as arteriosclerosis. As the minute capillaries 
are also involved, the condition is sometimes called arterio- 
capillary fibrosis. Thickening of the veins (phlebosclerosis) 
is not so common, or, to casual examination, so evident. In 
arteriosclerosis the vessel wall may be thickened and leathery, 
or little bony plates like beads may be felt in the artery. 
The affected vessels are elongated and tortuous ("snake- 
like"), so that they appear too long for their beds; this tortu- 
osity 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 frequently 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 84 
THE BLOODVESSELS AND PERICARDIUM 
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. Tox- 
emia 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, enlargement of the heart and signs of involvement 
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 circum- 
stances shortness of breath, dropsy and effusion of fluid into 
the large cavities occur, a condition which is difficult to dis- 
tinguish 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 with apoplexy, aneurysm or exces- 
sive involvement of the peripheral arteries, causing inter- 
mittent lameness (claudication) 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. In 
recent years great stress has been laid on the use of butter- 
milk and other beverages containing lactic acid and lactic- 
acid bacilli. These are supposed, by their advocates, to 
diminish fermentation and putrefaction in the intestines and 
1 Some authorities deny the injurious effect of alcohol in this condition. ANEURISM 
85 
to prevent the formation and absorption of injurious poisons. 
The diet should contain only a moderate amount of meat, 
and should be free from cabbage and other coarse vegetables 
which often cause excessive flatulence in arteriosclerotic 
patients. Milk and eggs, cereals and green vegetables may 
be used freely. 
Potassium iodide, in small doses, apparently has a favor- 
able influence on the course of the disease. Other specific 
medicaments have been suggested, but are seldom employed. 
Fig. 16.-Saccular aneurysm. 
(Ashhurst.) 
Fig. 17.-Fusiform aneurysm. 
(Ashhurst.) 
Aneurysm.-An aneurysm is a localized dilatation of an 
artery. This may be symmetrical, involving the whole cir- 
cumference, 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 a common cause of cerebral hemor- 
rhage. 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 86 
THE BLOODVESSELS AND PERICARDIUM 
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 years of age, 
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 inter- 
spaces may be seen to heave, and an abnormal area of dulness 
may be found on percussion. If the hand is laid on the aneu- 
rysmal tumor a vibratory sensation or thrill is appreciated. 
Dilatation of the artery in itself occasions more or less pain, 
but the severe pain of aneurysm is principally due to pressure 
upon, and erosion of, surrounding structures. If the aneu- 
rysm is progressive the wall will finally become so attenuated 
that oozing of blood occurs, or sudden rupture with dangerous 
or fatal hemorrhage. 
Most of the symptoms and signs of aneurysm are attrib- 
utable 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 perforated. 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. Pressure 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 
dilation 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 ANEURYSM 
87 
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 con- 
solidation in the sacculated variety and to relieve symptoms. 
If the disease is progressing and the pain severe absolute 
rest with the use of the bedpan, etc., is required. If an 
attempt is to be made to cure the aneurysm, a dry diet, con- 
taining not over 8 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 aneu- 
rysmal sac. Before the needle is withdrawn an electric cur- 
rent is sent through the wire to hasten the process of clotting. 
Opinions are divided as to the desirability of this operation. 
Potassium iodide is a favorite remedy in aneurysm as in 
arteriosclerosis. Morphine is often required to relieve pain 
or to calm excitement in threatened hemorrhage. Occasion- 
ally slow bleeding occurs, but in the majority of cases the 
hemorrhage is sudden and rapidly fatal, and therefore not 
susceptible to treatment. 
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 ulti- 
mate distribution is cone-shaped, and may be compared to 
the trunk and branches of an elm tree. Usually there is more 
or less communication between neighboring areas, but this 
is not invariable (brain). If a small fragment of fibrin (" vege- 
tation"), or a minute clot plugs one of these small arteries, 
clotting or thrombosis 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 88 
THE BLOODVESSELS AND PERICARDIUM 
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 
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.) 
occasion pain, and in the former, bloody urine. Embolism 
of the mesenteric vessels supplying 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 PERICARDITIS 
89 
the coagulability of the blood. Thrombosis in a vein inter- 
feres 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 col- 
lateral branches (anastomoses). The thrombus may be 
absorbed or converted into a fibrous mass. The femoral 
(left) and subclavian veins are commonly 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 envel- 
oping membrane of the heart. The pericardium is a serous 
membrane similar to those 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: 
ous pericarditis, in which the adjoining surfaces of the mem- 
brane are covered by a 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 cc) 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 com- 
pletely, and in severe cases adhesions may also form 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 endo- 
carditis. Children develop these complications in the mildest 
joint cases, too often dismissed as growing pains. Other 90 
THE BLOODVESSELS AND PERICARDIUM 
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 compli- 
cation in many chronic disorders, such as Bright's disease and 
diabetes. It is due to the particular infection which termi- 
nates life and is seldom recognized. Chronic pericarditis 
with effusion or adhesions is frequently tuberculous. Some- 
times the pericardium, pleura and peritoneum are involved 
at the same time. 
Fig. 19.-Fibrinous pericarditis (hairy heart). (Adami.) 
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 effu- 
sion, particularly if purulent, there is pain, oppression, insom- 
nia, restlessness, delirium, etc. The heart dulness is increased 
and in children the chest may bulge. When the pericardium PERICARDITIS 
91 
becomes adherent symptoms 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 hypertro- 
phied 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 th e diaphragm, etc. 
Treatment.-The treatment of acute pericarditis demands 
absolute rest, the use of the bedpan and the administration 
of food by the nurse. The diet should be 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 appli- 
cations, 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, otherwise medicinal treat- 
ment 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 treat- 
ment of cardiac insufficiency; operation is sometimes under- 
taken 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 paracentesis is 
required. CHAPTER II. 
DISEASES OF THE HEART. 
Angina Pectoris and Precordial 
Pain. 
Soldiers' Heart. 
Hypertrophy and Dilatation. 
Cardiac Insufficiency. 
Myocarditis. 
Valvular Heart Disease. 
Acute Endocarditis. 
Chronic Endocarditis. 
Individual Valve Lesions. 
Treatment of Acute Endocarditis 
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 impending death. 
In the painful area there is usually hyperalgesia (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 eructation 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 drinking. True 
angina is generally believed to be due to atheroma of the 
coronary arteries (the vessels which supply the heart muscle 
itself), or of the first portion of the aorta. Some authorities 
believe that angina may also be caused by disease, functional 
or organic, involving extreme exhaustion of the heart muscle. 
Certain it is that we often find our cases of aortic aneurysm 
and aortic valvular disease suffering from nocturnal attacks 
of intense precordial pain. 
Treatment.-The prophylactic treatment consists in the 
restricting of 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 HYPERTROPHY AND DILATATION 
93 
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, hypodermically as nitroglycerin, 
by the mouth as spiritus glycerilis nitratis, and as an inha- 
lation in the form of amyl nitrite pearls. Hot drinks, for 
example, brandy and water, may be given for immediate 
relief. Morphine and chloroform are of great use, the former 
particularly in the precordial pain of aortic disease. Treat- 
ment 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 exhaustion of 
the nervous and circulatory systems (" neurocirculatory 
asthenia"). The commonest symptoms are dizziness, faint- 
ness, exhaustion on moderate exertion, shortness 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 occupations 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 and pul- 
monary circulations. The force required for this purpose 
varies greatly, depending upon position, exercise and resist- 
ance to bloodflow. 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 accom- 
panied 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 dispropor- 94 
DISEASES OF THE HEART 
tionately large. Hypertrophy in itself is a useful condition, 
indicating 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 power- 
ful heaving impulse. The pulse is full and strong and often 
of high tension. The degree of hypertrophy is limited, how- 
ever, and demand beyond this point results in decompensa- 
tion. In dilatation the heart is also enlarged. The apex 
impulse is indistinctly felt as a feeble tap. The heart sounds 
are faint (clicking) and the pulse is of a corresponding poor 
quality. 
Cardiac Insufficiency. -Symptoms.-The symptoms of car- 
diac 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 men- 
tioned later. The symptoms are as follows: Breathlessness, 
sometimes amounting to orthopnea, cyanosis, precordial dis- 
tress, 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. The enlargement of the liver is due 
to "passive" congestion. 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 
accommodate 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 con- 
gestion 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-rheu- MYOCARDITIS 
95 
matism, syphilis, arteriosclerosis and nephritis-are respons- 
ible for more than 90 per cent of the cases. Other infections 
and intoxications (goiter) and congenital disease account for 
a small number of cases. Congenital diseases include mal- 
formations due to faulty development and intrauterine infec- 
tions. 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 particularly 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 hypertrophy of the left ventricle of the 
heart. If the heart fails 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 stiffen- 
ing 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 mus- 
cle accompanies all the more serious infections, e. g., typhoid 
fever and diphtheria. If the patient survives the convales- 
cent period few permanent evidences of the affection may 
persist. Occasionally sclerotic or scar-like areas betray the 
preexisting disease. Arteriosclerosis is accompanied by scler- 
otic changes of the heart muscle which diminish the contrac- 
tile power of the organ. In the obese the heart is frequently 
burdened 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 vari- 96 
DISEASES OF THE HEART 
able 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 symp- 
toms. 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 rheu- 
matism of which it forms an integral part rather than a 
complication. At this period it is often overlooked, 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 examinations of the heart for altered 
sounds or murmurs. Subsequently, enlargement of the heart 
will confirm the diagnosis. If rest at this period is prolonged 
perfect compensation may be secured and no further symp- 
toms will be observed. Very often, however, the patient 
gets up too soon, hypertrophy is insufficient and symptoms 
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 compensation are also com- 
mon, with or without fresh endocarditis. The symptoms of 
loss of compensation are those of cardiac insufficiency. 
At the opposite extreme is the so-called malignant endo- 
carditis. 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 96° F. to 106° F. The pulse 
and respiration are extremely rapid. There may be distinct 
murmurs, but sometimes the action of the heart is so tumul- 
tuous, or the respiration so that nothing can be dis- 
covered by physical examination. Examination of the blood 
reveals a leukocytosis, and cultures from the same fluid will 
often discover the causative organism (gonococcus, strepto- 
coccus, etc.). These cases, after a stormy course of a few 
weeks, terminate fatally. Intermediate varieties are much VALVULAR HEART DISEASE 
97 
more common than the latter extreme. If an autopsy is per- 
formed on a case of simple endocarditis little wart-like vege- 
tations are found on the affected valves, while in the malig- 
nant variety the vegetations are larger and are accompanied 
by ulceration, hence the contrasting terms, warty (verrucose) 
and ulcerative endocarditis. 
Fig. 20.-Diagram modified from Page to show the relation of the various 
valves. The tricuspid valves lie between the right auricle and right ven- 
tricle; the pulmonic, between the right ventricle and the pulmonary artery; 
the mitral, between the left auricle and the left ventricle; the aortic, between 
the left ventricle and aorta. If the valves do not close accurately, leakage 
occurs (vulvular insufficiency); if the orifices are narrowed (stenosed) the 
bloodflow 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.) 
Chronic Endocarditis. -The mode of onset of chronic rheu- 
matic endocarditis has already been sketched. The varieties, 
due to syphilis, arteriosclerosis, etc., are chronic from the 
beginning and are first revealed when the shrinking and dis- 
tortion of the valves have interfered with the action of the 98 
DISEASES OF THE HEART 
heart, and have brought on symptoms of cardiac distress 
(pain and dyspnea) Or cardiac insufficiency. Patients suffer- 
ing from chronic endocarditis improve 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 thp 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. 
Fig. 21.-Malignant endocarditis. (Episcopal Hospital.) 
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 preventing their closure, 
thus permitting the blood to leak backward or regurgitate 
("insufficiency"). (Fig. 20.) 
Lesions of the pulmonary valve are almost always of con- 
genital origin. I have, however, seen cases in pneumonia and 
syphilis. Congenital heart disease is characterized byjlysp- CHRONIC ENDOCARDITIS 
99 
nea, chronic cyanosis and clubbing of the fingers. The tri- 
cuspid 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 ventricle. It is therefore spoken of as relative 
insufficiency. In myocarditis with loss of compensation there 
is also 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 button-hole 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 
characteristic 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 compara- 
tive comfort. Sudden death is exceptional. In mitral ste- 
nosis 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 corresponding presystolic 
murmur is characteristic of the disease. With beginning 
cardiac embarrassment the patients suffer from nosebleed, 
orthopnea, precordial pain and palpitation. Later on, the 
ordinary symptoms of cardiac insufficiency develop. Embo- 
lism, although it occurs in all forms of heart disease, is unusu- 
ally frequent in mitral stenosis. The emboli lodge most often 
in the kidney, spleen or brain. In the latter instance hemi- 
plegia develops. 
True aortic stenosis is much less common than aortic 
insufficiency. Roughening, which is often mistaken for nar- 
rowing 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 men- 
tal impairment occur. Aortic insufficiency, on the other hand, 
is accompanied by very characteristic signs and symptoms. 100 
DISEASES OF THE HEAR! 
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 in the heart and arteries, e. g.), which can 
only be appreciated 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, witfi mitral 
insufficiency or stenosis, in all possible combinations are not 
at all unusual. 1 once performed an autopsy on a patient 
who had been under the care of two physicians, a father and 
Fig. 22.-Warty endocarditis of aortic valve. (Adami and McCrae.) 
son, for over sixty years. She had almost complete obstruc- 
tion 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 Endocarditis and Myocarditis.-Pro- 
phylactic 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. Rheu- 
matism should be treated from the beginning with efficient TREATMENT OF CARDIAC INSUFFICIENCY 
101 
doses of salicylates to prevent the extension of the 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 usu- 
ally require no medicinal treatment beyond strychnine and 
tonics. In acute endocarditis, if the heart is rapid and irri- 
table, the ice-bag may be employed, as in pericarditis. Mor- 
phine and bromides may also be used for the purpose of 
quieting the heart action. Rest in bed, if not already pre- 
scribed 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 bedpan, 
and urinal, 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 strychnine, caffeine or 
strophanthin, etc. If the case develops the symptoms of car- 
diac insufficiency, the treatment described below will apply. 
The Treatment of Cardiac Insufficiency.-The treatment 
of cardiac insufficiency, whether due to loss of compensation 
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 chest (see 
page 124) by aspiration, from the abdomen by the trocar and 
cannula (see page 180), 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 sub- 102 
DISEASES OF THE HEART 
cutaneous tissues of the lower extremities, and attached to 
small rubber drainage tubes. Scrupulous cleanliness both 
before and after this treatment is necessary to avoid infec- 
tion. Sweating by the hot-air bath or vapor bath, as a 
method of removing dropsy is contraindicated in severe car- 
diac failure. If pulmonary 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. 
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 apo- 
Fig. 23.-Venesection. (Heath.) 
plexy and in the early stages of pneumonia (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. At present, venesection is 
usually performed by thrusting a large hollow needle directly 
into a vein in a peripheral direction. Eight to 10 ounces of 
blood are commonly withdrawn. Formerly, an incision was 
made obliquely through the vein with a sharp scalpel or 
lancet. 
Medicinal Treatment.-The remedy par excellence in cardiac 
insufficiency with dropsy is digitalis. Of this there are num- 
berless preparations, none of which is more efficacious, though 
some may be less nauseating, than the leaves themselves. TREATMENT OF CARDIAC INSUFFICIENCY 
103 
The dose of the leaves is 1 gr. (0.07 gm.), administered in pill 
or capsule. It is a common practice to precede the adminis- 
tration by a dose of mercury, 3 to 10 gr. (0.2 to 0.6 gm.), 
or to combine it with a smaller one, the purpose being to 
relieve if possible the congestion of the gastrointestinal 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 prepara- 
tions of digitalis universally used are the infusion, the tincture 
and the essential principles (digitalin, etc.), but the last- 
mentioned are not very reliable. Strophanthin, 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 injected intravenously. Squills and 
caffeine are often used with digitalis to supplement its action. 
Theobromine and theophyllin are employed to promote diu- 
resis and relieve dropsy. To overcome the extreme irregu- 
larity (fibrillation) characteristic of some failing hearts, quini- 
dine, a derivative of cinchona, is now extensively employed. 
It must be used under close supervision. With treatment, 
such as that described, the majority of patients, at least in 
their earlier attacks, recover a greater or less degree of com- 
pensation, and many are able to return to their usual occupa- 
tions. 
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 circum- 
stances it is the object of the physician to strengthen gradu- 
ally 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 sys- 
tematized, but have perhaps been overdone. In this country 104 
DISEASES OF THE HEART 
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 increasing concentration and duration and of dimin- 
ishing temperature. 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 resistance 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 gymnas- 
tic exercises, especially adapted to the patient's needs. 
Finally, the best and simplest 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 compensation, 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. 
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, cab- 
bage and coarse root vegetables, should be excluded from 
the dietary. The quantity of fluid may often be restricted 
with advantage. Creosote in small doses, cardamom, spirit 
of chloroform, 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 Dis- 
ease. 
Diseases of the Upper Air Pas- 
sages. 
Rhinitis. 
Hayfever. 
Pharyngitis, Tonsillitis and Ade- 
noids. 
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. 
Respiratory Movements. -The Respiration may be costal, 
abdominal or costo-abdominal. These terms show the direc- 
tion in which expansion chiefly takes place and indicate 
whether the intercostal muscles or the diaphragm are prin- 
cipally 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 disease; in ordinary 
pleurisy the chest may be almost motionless, 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 trapezii. In adults under normal condi- 
GENERAL CONSIDERATIONS. 106 
DISEASES OF THE UPPER AIR PASSAGES 
tions there are sixteen to twenty-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. Expiration is slightly longer 
than inspiration, but the inspiratory murmur (heard on aus- 
cultation) is three or four 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 asso- 
ciated 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 painfully 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 
imperceptible, 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-tuberculosis, 
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. Eree secretion and a loose cough may exist 
without expectoration, particularly in children (sputum swal- 
lowed) . A dry cough usually has a ringing or barking quality. 
A hacking cough is often due to nothing more serious than 
irritation of the pharynx. In pertussis a series of paroxysmal EPISTAXIS 
107 
coughs ends with a sharp inspiratory whoop. The inspira- 
tory crow of laryngismus 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 mucopurulent, 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 cavita- 
tion the sputum acquires a horrible fetid stench or a sweet, 
sickening odor hardly less disagreeable. Microscopical exam- 
ination 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. Pneumococci, streptococci, influ- 
enza 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, rupture 
of a small septal vessel just within the external nares. It is 
usually not serious and ceases either of itself or after the 
use of simple measures, such as astringents, local caustics 
(e. g., chromic acid for a ruptured vessel), the application of 
cold, adrenalin, 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 can- 
nula) is convenient, but the following method will suffice in 
an emergency. A long, stout silk ligature is threaded through 108 
DISEASES OF THE UPPER AIR PASSAGES 
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 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 naso- 
pharynx 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. 
Fig. 24.-Packing the posterior nares. (Ferguson.) 
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 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"). Rales may 
also be produced by changes in the caliber of the bronchial 
tubes. When the fluid is abundant in the trachea or bronchi, ACUTE AND CHRONIC RHINITIS 
109 
as in advanced edema of the lungs, the bubbling sounds 
("death rattle") are easily heard at a distance. Consolida- 
tion 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 symp- 
toms may also be brought about by constitutional 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 (bromine, 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 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 congestion 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 tenderness and sometimes with redness, swell- 
ing and edema. Other sinuses connected with the nose may 110 
DISEASES OF THE UPPER AIR PASSAGES 
also be involved. If the inflammation of a sinus becomes 
purulent it is sometimes necessary to open, 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 infec- 
tion so far as possible by preventing close contact with those 
who are infected. 
Treatment.-The curative treatment of acute rhinitis is 
not satisfactory, although most persons have some favorite 
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 (atropine) is employed to 
check excessive secretion and to promote drainage from the 
sinuses. Quinine, strychnine, ammonium chloride and cam- 
phor probably act as general 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 impor- 
tance. The most important prophylactic factors are cool, 
well-ventilated living rooms (winter), cool or cold morning 
baths, daily exercise in the fresh air, regulation 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 con- 
gestion and thickening of the mucous membranes, increased 
secretion and more or less obstruction. Rhinitis of this type 
is aggravated by repeated acute attacks, by cold humid cli- 
mates and by constitutional conditions. It is often sus- 
ceptible of great improvement and cure by local treatment, 
change of climate or correction of general medical conditions. HAYFEVER 
111 
Atrophic rhinitis, on the other hand, is characterized by 
pallor and smoothness (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 dis- 
tressing odor, which is, however, not apparent to them, by 
appropriate douches (potassium permanganate, etc.). Ter- 
tiary syphilis with ulceration and bone destruction may 
produce a similar foul discharge. 
Hayfever.-Hayfever is a disease of the nasal and con- 
junctival mucous membranes, due to hypersensitiveness to 
certain pollens which are, for the most part, wind-borne. 
This predisposition, or hypersusceptibility, is more often 
found in persons of neurotic make-up, and it may exist for 
not only one but for many of the pollen proteins as well 
as for the ordinary food proteins. Its onset is coincident with 
the season when the specific pollens are being carried about 
by the winds. Hypersensitization to insect-borne and other 
pollens, and even to bacteria, does exist, but it is of relatively 
minor importance. "Rose cold'' (a misnomer) develops in 
the spring, and is caused by the pollens of the grasses (tim- 
othy, red top, orchard grass, etc.). Attacks of hayfever 
usually begin on a definite date, the middle of August in the 
common variety due to ragweed, and are 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. Desensitization, by means of 
subcutaneous injections of increasing doses of pollen extract, 
given at intervals of two or three days, are often useful in 
the prophylactic treatment of hayfever. The course of treat- 
ment usually extends over a period of six weeks in advance 
of the date of the usual onset of the disease. Before begin- 112 
DISEASES OF THE UPPER AIR PASSAGES 
ning such a treatment the patient's susceptibility to the 
suspected pollens is determined by skin tests. As a rule, the 
ragweed is the offending substance. This treatment must be 
repeated yearly, because of the transient nature of the 
immunity produced. 
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 pharyngitis are com- 
monly 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 affect- 
ing 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 lymphoid 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 breathing. 
Enlargement of the tonsils causes a lesser degree of obstruc- 
tion and sometimes induces irritating cough or stridor. These 
enlarged masses of lymphoid tissue are also liable to harbor 
infection and thus give rise to recurring 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, 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, PHARYNGITIS, TONSILLITIS AND ADENOIDS 
113 
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, and irregularities of the teeth and, in the 
rachitic, deformities of the chest. Adenoid vegetations 
usually disappear spontaneously before adult life. 
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.) 
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 opera- 
tion with impunity, usually after the second year. Enlarged 
tonsils should be removed if they are of unusual size or badly 
infected. A focus of infection in these glands may be the 
cause of repeated attacks of rheumatism or endocarditis. 
In adults treatment by cautery, etc., is sometimes sufficient. 114 
DISEASES OF THE UPPER AIR PASSAGES 
Acute infections of the tonsils are described in the chapter on 
Infectious Diseases. 
Fig. 26.-Examination of adenoids. (Koplik.) 
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 SPASMODIC CROUP 
115 
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. 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. 
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 charac- 
terized 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 respons- 
ible 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 nocturnal 
attacks of "holding the breath" with blueness and threatened 
asphyxia, which terminate in a peculiar "crowing" inspira- 
tion. In these cases there is no catarrh of the larynx. Mem- 
branous croup is an old-fashioned name for diphtheria of 
the larynx. 
Treatment.-Acute laryngitis is treated by inhalations of 
steam, plain or medicated, by ipecac, tartar-emetic, rest of 
the voice, etc. The general measures advised in acute rhi- 
nitis 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 treat- 
ment 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, can- 
cer, 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 laryngo- 
scopic examination. The prognosis in tuberculosis or cancer 
is extremely bad. In benign tumors the voice may be restored 116 
DISEASES OF THE UPPER AIR PASSAGES 
by removal of the tumor either by operation or the roent- 
gen-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 epi- 
glottis 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 the term which is commonly 
applied to inflammation of the trachea (tracheitis) and of 
the large and medium-sized bronchial tubes. The same pro- 
cess, if it extends to the finest bronchioles, is called capillary 
bronchitis. This is seldom distinguishable from broncho- 
pneumonia 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 accompanied 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 
mucopurulent. The fever rarely lasts more than a few days, 
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 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 obstruction and induce attacks of suffocation, 
with cyanosis and collapse, which require the prompt use of 
emetics, mustard baths and other counterirritants. 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 TREATMENT 
117 
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 compli- 
cated 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 inter- 
vals of freedom. Frequent attacks of acute bronchitis pre- 
dispose 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.-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 dry, warm 
atmosphere, or even to a dry, cold one. Acute cases are bene- 
fited 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 occupations, and may be relieved 
by the use of ventilators or respirators. In a similar way 
the treatment of underlying gastric, cardiac, renal or other 
disease may cure an otherwise intractable cough. For anal- 
ogous reasons stimulants, tonics and alteratives (strychnine, 
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, 
spirit of nitrous ether, etc. At the same period "sedative 
expectorants," such as wine of antimony, syrup of ipecac 
and apomorphine hydrochloride are used to relax the cough. 
As the case progresses the "stimulant expectorants" 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 118 
DISEASES OF THE UPPER AIR PASSAGES 
is also useful in chronic bronchitis. If the cough is excessive 
demulcents, such as licorice and flaxseed, or sedatives, such 
as bromides, spirit of chloroform, hydrocyanic acid, codeine, 
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 
Fig. 27.-The croup kettle. (Hare.) 
substances may be given in this way, although the beneficial 
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 varie- DISEASES OF THE LUNGS 
119 
ties, such as accompany or follow measles or influenza, abso- 
lute rest in bed is imperative on account of the danger of 
bronchopneumonia. In the later stages fresh air in abund- 
ance or actual open-air treatment has its place. 
DISEASES OF THE LUNGS. 
Bonchopneumonia (Catarrhal Pneumonia). - Broncho- 
pneumonia or lobular pneumonia involves, as these appella- 
tions 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 Infectious Diseases) in 
that the latter involves a whole lobe almost from the begin- 
ning 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 respira- 
tion is usually rapid and cyanosis marked. Bronchopneu- 
monia 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 broncho- 
pneumonia were rife. Healthy young adults, including 
many pregnant women, were particularly attacked. The 
causative organisms varied, but seem to have most commonly 
been types of pneumococci or streptococci, sometimes asso- 
ciated with influenza bacilli. The treatment is partly that 
of bronchitis and partly of pneumonia (7. 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 con- 
dition that succeeds congestion of the dependent parts of the 
lungs in cardiac cases and in weak and bedridden patients. 
It is frequently the "last straw" which finally turns the bal- 
ance, but is to be regarded as a contributing rather than a 120 
DISEASES OF THE UPPER AIR PASSAGES 
principal cause of death. Aspiration pneumonia is a some- 
what 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 pre- 
vent this in the normal individual, but these may be over- 
come by destructive disease 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 
interstitial 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 various 
trades. Such a condition is sometimes called pneumokoniosis 
and, as a rule, is complicated by tuberculosis (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 endo- 
carditis), gangrene or abscess of the lung may develop. 
Gangrene and abscess may also occur after pneumonia or 
from the aspiration of infective material (e. g., after tonsil- 
lectomy). Under these conditions the patient runs an irregu- 
lar hectic fever, often with sweats and chills, and expectorates 
either pus in the one case, or fetid gangrenous material in 
the other. EMPHYSEMA 
121 
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 are promi- 
nent and contracted. When the attack has passed relaxation 
occurs and sleep is again possible. Asthma is sometimes a 
sequel of hayfever, and like that disease is supposed to be 
more common in neurotic people. Its underlying cause is 
in the nature of a hypersusceptibility to various proteins 
derived from foods, dust, animal hair or fur, feathers, etc. 
The prognosis for the attack is good; for permanent 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 atropine or atropine and morphine 
administered hypodermically, or by the inhalation of the 
fumes of burning saltpeter, usually mixed with belladonna, 
or stramonium leaves in varied combination. These are the 
principal constituents of the ordinary "asthma pastilles'' and 
"asthma cures." Often, as in hayfever, it is possible to 
determine the substance to which a patient is hypersensitive. 
Prophylaxis may thus be successfully carried out: Avoiding 
certain animals, discontinuance of the use of a feather pillow 
or moving into another home. 
Emphysema.-Emphysema is a disease characterized by 
an increased volume of the lungs, due to permanent disten- 
tion 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, 122 
DISEASES OF THE UPPER AIR PASSAGES 
and is sometimes somewhat cyanotic. In protracted cases 
hypertrophy and dilatation 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. Aside from the ordinary form of emphysema, 
there is a temporary distention or hypertrophic emphysema 
of the healthy lung in pneumonia, pleural effusion, etc., 
which compensates for its crippled fellow. This 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 (diaphragmatic pleura). 
Inflammation of the pleura is known as pleurisy; sometimes 
it is localized in one portion of the membrane, e. g., dia- 
phragmatic pleurisy. Pleurisy is a common accompaniment 
of diseases of the lungs, particularly of tuberculosis and 
pneumonia. In these conditions there is usually a dry pleu- 
risy 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 microorgan- 
isms, most commonly to the tubercle bacillus and the pneu- 
mococcus. 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 EMPYEMA 
123 
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 forma- 
tion of slight adhesions. These probably cause the "stitch 
in the side," of which patients complain from time to time 
for years. Frequently 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, short- 
ness 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. 
Uncomplicated 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 usu- 
ally follow a simple pleurisy, but is common after pneumonia. 
It is to be suspected after the subsidence 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. Physical examination is usually 
decisive, but sometimes the signs of the preceding disease 
complicate the examination. In other cases the pus is 
between the lobes of the lungs, and cannot be detected 124 
DISEASES OF THE UPPER AIR PASSAGES 
except by the needle'. The diagnosis is confirmed by explora- 
tory puncture and by the withdrawal of pus. 
Pneumothorax.-Pneumothorax almost invariably results 
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 examina- 
tion, the affected half of the chest is found to be increased 
in size, with a hyperresonant or drum-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 hydropneumothorax, while if it is purulent, as is 
usually the case, it is known as pyopneumothorax. 
Hydrothorax.-In heart disease, Bright's disease, anemia, 
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. Sometimes 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, 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 hypodermic injection 
of morphine. 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 purpose Potain's aspirator, or a similar 
apparatus, is usually employed (Fig. 28). It is very neces- 
sary that the apparatus should be tested before the opera- 
tion 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 due to blood clots or thick pus, but usually DISEASES OF THE PLEURA 
125 
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. 
Fig. 28.-Removing fluid from the chest by aspiration. (After Hoppe- 
Seyler.) 
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. Other- 
wise the patient may develop an alarming acute edema of 
the lungs, characterized by the expectoration of large quan- 126 
DISEASES OF THE UPPER AIR PASSAGES 
tities of serous fluid.' If this accident should occur a timely 
hypodermic of atropine and morphine 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 
Fig. 29.-Removing fluid from the chest by syphonage. (After Hoppe- 
Seyler.) 
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 DISEASES OF THE PLEURA 
127 
in the "camps" following measles and influenza, repeated 
tappings were successful in saving life, and occasionally in 
avoiding 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. Continuous or inter- 
mittent irrigation with Dakin's solution (by means of tubes) 
has been found to improve the results of operation. In pyo- 
pneumothorax tapping or drainage is of little or no benefit, 
Fig. 30.-Apparatus for expanding the lung after empyema. (Hare.) 
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) which greatly aids in pre- 
venting the development of a chronic condition. PART V. 
DISEASES OF THE DIGESTIVE TRACT AND 
PERITONEUM. 
CHAPTER I. 
DISEASES OF THE MOUTH AND ESOPHAGUS. 
General Considerations. 
Anorexia. 
Dysphagia. 
Heartburn. 
Belching. 
Fulness and Distress. 
Pain and Colic. 
Vomiting. 
Constipation and Diarrhea. 
Lavage. 
Test-meals. 
Enteroclysis. 
Rectal Feeding. 
Miscellaneous. 
Diseases of the Mouth, Tongue 
and Salivary Glands. 
Stomatitis. 
Pyorrhea Alveolaris. 
Teething. 
Parotitis. 
Diseases of the Esophagus. 
Stricture and Tumor. 
Hemorrhage. 
Anorexia.-Anorexia is a term used to designate 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 gastrointestinal 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 (excessive appetite); children and occasionally 
adults may have perverted appetites, eating clay and other 
indigestible substances. 130 
DISEASES OF THE MOUTH AND ESOPHAGUS 
Dysphagia.-Dysphagia (difficulty in swallowing) occurs 
in inflammation of the throat and gullet, in intrathoracic 
(mediastinal) tumors, in 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 synonymous 
terms, pyrosis and heartburn, emphasize the distressing 
burning sensation at the pit of the stomach and beneath 
the sternum which accompanies this phenomenon or occurs 
independently (irritation at cardiac orifice). 
Belching.-In belching swallowed air or, less often, mal- 
odorous gas produced by fermentation is eructated, some- 
times 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 more frequently due to disturbances 
of motility. Normally the gas is absorbed or expelled 
unconsciously. 
Fulness and Distress.-Fulness and distress are sensations 
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 the bladder. In intestinal colic LAVAGE 
131 
and lead poisoning the pain is referred to the center of the 
abdomen. In ulcer, less often in cancer, there may be local- 
ized 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 indis- 
tinguishable. 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 indi- 
cation 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 consistency 
of the movements. What would be diarrhea in an adult 
might be normal in an infant, and similar but less marked 
differences exist between normal adults. Complete con- 
stipation 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 midline. The patient 
is then asked to close his lips and swallow, the physician 
meanwhile continuing to push the tube onward. 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 132 
DISEASES OF THE MOUTH AND ESOPHAGUS 
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 
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 contents of the stomach are 
syphoned out. (Hare.) 133 
TEST-MEALS 
syphoned off. The funnel is again raised, and a measured 
quantity of plain or medicated water poured into the stomach. 
This is now withdrawn by syphoning and the operation 
repeated 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 sub- 
stituted. 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; 
occasionally 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 normal limits ("40-60") is deter- 
mined by quantitative estimation. The quantity of stomach 
contents normally obtained varies from 50 to 150 cc (1| 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 like 
manner the total acidity may be increased (70 plus), dimin- 
ished (30 minus), 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 breakfast, samples 
of the stomach contents (2 to 3 cc) are removed every fifteen 134 
DISEASES OF THE MOUTH AND ESOPHAGUS 
minutes until the stomach is empty. This "fractional" 
method has been popularized by Rehfuss, 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 with lateral perforations weighted by an 
olive-shaped tip. This may be introduced through the nose 
if necessary. 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. 
Fig. 32.-Rehfuss gastroduodenal tube. 
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 roentgen-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 drip 135 
RECTAL FEEDING 
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. 33). 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. 
Rectal Feeding.-Rectal feeding is 
at the best a precarious method of 
nourishing a patient, but is neverthe- 
less of great temporary service in 
ulcer of the stomach, pernicious 
vomiting, etc. As a rule, not over 
three feedings of 6 to 8 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 temper- 
ature 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 is then turned on 
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Fig. 33.-Apparatus for proctoclysis (enteroclysis). In this case the solution 
is heated as it flows through the tube. (Hare.) 136 
DISEASES OF THE MOUTH AND ESOPHAGUS 
his back and ultimately on his right side to enable the fluid 
to reach the higher portion of the colon where there is greater 
absorption.1 He should also remain quiet for a long time 
after the enema has been given to favor retention. The fol- 
lowing substances are commonly employed for rectal feeding 
-eggs, peptonized milk, glucose, 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 exam- 
inations is too difficult, 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 exam- 
ining the rectum and sigmoid. By the aid of rectal specula, 
strictures, tumors, ulcers and hemorrhoids 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 physi- 
cian. Sticky black stools (tarry) suggest hemorrhage high 
up, fresh blood indicates hemorrhage low down and white or 
clay-colored stools, with jaundice, indicate obstruction 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 diagnosis of ulcer or cancer. Examination of the 
stools for the intestinal parasites and their eggs is also very 
important. 
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, erupting teeth, 
local and general infections and drugs. Simple stomatitis is 
1 Recent clinical tests indicate that long tubes and special positions are 
unnecessary. STOMATITIS 
137 
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 Niemeyer's pill (digitalis, 
squills and blue mass) for cardiac or renal dropsy, and syphil- 
itics 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 treat- 
ment and is not accompanied by much inflammation, or in 
debilitated individuals and in those suffering from severe 
illness, there may be extensive intractable ulceration 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 perfora- 
tion and destruction of the cheek. It is almost always fatal. 
A severe stomatitis, frequently accompanied by ulceration, 
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 a fungus, and is char- 
acterized 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. 
It may be a precancerous condition. 
"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 138 
DISEASES OF THE MOUTH AND ESOPHAGUS 
on the tongue, palate and throat, and in the latter situation 
lead to considerable destruction of tissue. Cancerous ulcera- 
tion and infiltration of the tongue are also common. Tuber- 
culous 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 chewing, soft 
or liquid food, dryness from mouth-breathing or fever, all 
tend to impair the normal attrition and desquamation 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 charac- 
teristic. 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 disease of the gums 
from a medical point of view is pyorrhea alveolaris, which 
in the early stage is characterized by retraction of the gums, 
and later by the formation of pockets of pus about the neck 
and roots of the teeth. Recently minute organisms, known 
as amebae, have been found in pyorrhea pockets. 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 question but that they are responsible for some at 
least of these supposedly toxic states. 
Transverse ridges on the teeth are usually signs of some TREA TMENTS 
139 
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 else- 
where. 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 exag- 
gerated 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 moderate fever may be 
due to erupting teeth. 
Parotitis.-Among the salivary glands the parotids 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, various abdominal dis- 
orders, such as typhoid, pneumonia, colitis, and following 
operations where the mouth is not kept clean by mild anti- 
septic solutions. Chronic enlargements of the parotid occur 
but are more rare. The other 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 primarily 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 antiseptic solution, such as liquor 
antisepticus (diluted), carbolic solution (1 to 200 or weaker), 
or boric acid solution should be applied with the aid of 
absorbent cotton and an orange stick. If there is dryness 
glycerine is useful in the form of boroglyceride, glycerine 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 iodine or injected 
with emetine. 140 
DISEASES OF THE MOUTH AND ESOPHAGUS 
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. Mouth- 
washes containing ipecac are also useful. Ulcers should be 
touched with the solid stick of nitrate of silver; this often 
has a magical effect. In Vincent's angina ipecac, hydrogen 
peroxide, iodine and arsphenamine solution, powdered cop- 
per 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 symptoms 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 men- 
tioned below. Dysphagia is the most common symptom 
referable to the esophagus. This may be due to the pressure 
of a growth outside the gullet, for example, aneurysm. Occa- 
sionally an aneurysm ruptures into the esophagus with result- 
ing 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 or 
become inflamed. 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 per- 
sons 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 DISEASES OF THE ESOPHAGUS 
141 
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 swal- 
lowing 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 dila- 
tation, by sounds or special forms of apparatus or occasion- 
ally by operation. (3) Stricture due to syphilitic ulceration 
is also a common variety. (Much more rare are simple, 
tuberculous and typhoid ulcers.) The diagnosis is made by 
the history and associated symptoms or by the Wassermann 
reaction. Mercury and potassium 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 obstruction 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 sur- 
prisingly 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 obstruc- 
tion consists in the administration of a concentrated, 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 concentrated 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 Gastroenteri- 
tis. 
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 alterations, 
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 disturbances 
of various kinds a great variety of symptoms develops with- 
out any corresponding organic basis. As the result of pro- 
longed functional disturbances secondary organic changes 
may finally occur. In many cases dyspeptic 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 Gastroenteritis.-Acute gastritis and 
gastroenteritis 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 symp- 
toms of gastritis are loss of appetite, nausea, vomiting of 
food and mucus, pain and tenderness in the pit of stomach, 
and if the intestines are also involved general abdominal 
tenderness, colic and diarrhea. In ordinary cases if food is ORGANIC DISEASES OF THE STOMACH 
143 
withheld for a day, and afterward a light diet is given, recov- 
ery is rapid. In the severer cases there may be excessive 
vomiting and purging, with fever and prostration. Ordi- 
nary acute gastritis in adults is almost always mild, but 
repeated attacks may lead to chronic gastritis. Ih 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 overloaded, 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 Gastritis (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 equiva- 
lent 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 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 undi- 
luted on an empty stomach, is the leading cause. Hot breads, 
pastry, fried foods, sweets, etc., doubly bad if unskilfully pre- 
pared, are doubtless important in the causation of gastritis. 144 
DISEASES OF THE STOMACH 
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. Ulceration and cancer of the stomach itself, as well 
as many of the functional states, may ultimately be com- 
plicated 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 symp- 
toms are loss of appetite, flabby tongue, belching, slight 
pain and general epigastric tenderness after meals and con- 
stipation. 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 con- 
tinuous, though aggravated 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 dis- 
pensary use, illustrates the general character of the diet for 
a mild case. 
Soups: Consomme, bouillon, beef, chicken, mutton, 
oyster and clam broths, tomato, asparatus, pea and celery 
puree. 
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 prep- 
arations. ORGANIC DISEASES OF THE STOMACH 
145 
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 breakfast. The medicinal treatment 
consists of nux vomica and other bitters to promote appetite 
and secretions, dilute hydrochloric acid to supplement secre- 
tion, 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. For- 
merly ulcer of the stomach 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. 
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. 146 
DISEASES OF THE STOMACH 
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 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 
Fig. 34.-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.) 
only be recognized on the development of some threatening 
complication. 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 duodenum 
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 causation. 
Complications.-In typical cases of ulcer there is usually 
free hemorrhage or hematemesis, sometimes a pint or more. ORGANIC DISEASES OF THE STOMACH 
147 
The vomited fluid is dark red, usually clotted and sometimes 
mixed with gastric contents. The author 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 unsuspected ulcer and, subsequently, 
to an operation (gastroenterostomy) and the permanent cure 
of the patient. Hemorrhage, due to cirrhosis of liver, is in 
itself indistinguishable from that due to ulcer. In pulmonary 
hemorrhage 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 dis- 
turbance of which the patient is conscious. 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 con- 
striction may be produced, forming 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 dilatation. 
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., 6 ounces of 
peptonized milk and an egg every 8 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 subjec- 
tive pain no longer occurs a very light diet is gradually begun, 
at first consisting merely of milk, gruels and beef preparation; 
later eggs and other semisolid articles are added. After a 148 
DISEASES OF THE STOMACH 
few weeks the patient may take a diet sueh 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 physician 
puts the patient on teaspoonful doses of iced milk or beaten 
white of egg, administered at fifteen-minute intervals 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. 
Another favorite method is to combine a similar diet with 
large doses of alkali (sodium bicarbonate, magnesia, etc.) 
to neutralize the gastric acidity. Convalescent ulcer cases 
usually require iron and other tonics. Milder cases are 
treated by the ambulant method with a light diet (principally 
milk, gruel and eggs), bismuth subcarbonate in large doses 
or nitrate of silver. Severe hemorrhage is treated by abso- 
lute rest, by the application of an ice-bag to the epigastrium, 
by the administering of morphine hypodermically as well as 
by adrenalin and astringents internally. If bleeding recurs 
constantly operation is indicated. Gastroenterostomy (or 
pylorectomy) 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 experience I have 
seen only a few cases of each. Commonly the cancer is of 
the hard or scirrhus variety, but soft cauliflower-like growths 
are not rare. Sooner or later ulceration 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 resem- 
bling coffee grounds. In the stools blood is present in 
minute amounts, and it may only be detectable by chemical 
tests-"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 obstruc- ORGANIC DISEASES OF THE STOMACH 
149 
tion and starvation. A tumor at or near the pylorus ulti- 
mately causes obstruction at that orifice, retention and 
lactic-acid fermentation of the food, hypertrophy and dila- 
tation of the stomach (visible gastric peristalsis) and vomit- 
ing. The visible peristaltic contractions 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 roentgen-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 progressive wasting, loss of strength and anemia 
("cachexia"), with pain, tenderness, hemorrhage and vomit- 
ing. To these may be added symptoms of metastasis (that 
is, the transfer of the disease through the lymphatics or 
bloodvessels) 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 hydro- 
chloric 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, obstruction 
finally gives the patient the 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 con- 150 
DISEASES OF THE STOMACH 
nected to a funnel through which food is introduced. This 
must be finely divided: Sometimes 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 gastroenterostomy, 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 care- 
fully 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 semi- 
fluid, or nutritive enemata will be required, e. g., 6 to 8 ounces 
of peptonized milk every 8 hours. Salt solution by the 
bowel (Murphy method) is of great value in cases of obstruc- 
tion and vomiting, to supply fluid to the tissues. In bed- 
ridden cases care of the mouth and teeth and general atten- 
tion to the skin will be of importance. Hemorrhage rarely 
requires special treatment. Perforation, 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 differences 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. It is also an accompani- ORGANIC DISEASES OF THE STOMACH 
151 
ment of gastroptosis and of many forms of dyspepsia, par- 
ticularly of the nervous variety. 
If there is moderate obstruction at the pylorus there will 
be increase in muscular power to compensate for it and over- 
come it, and as a consequence the peristaltic movements 
will become distinctly visible. With increasing obstruction 
or stenosis the stomach will dilate to accommodate the 
retained food. Relief from excessive dilatation is obtained 
by periodic vomiting. The author recently had a man under 
his care who had vomited almost daily for years. In this 
patient the stomach reached the symphysis pubis, and enor- 
mous peristaltic waves could be seen passing slowly from left 
to right, like a heavy "ground swell.'' In this case at opera- 
tion an obstruction due to the scar of an old ulcer was found. 
Acute dilatation occurs occasionally postoperatively or after 
acute infections. 
The principal causes of stenosis may be enumerated as 
follows: Cancer of the pylorus, ulcer in the neighborhood 
of the pylorus with spasm or cicatricial contraction, adhesions 
due to gall-bladder disease, kinking due to displacement of 
the stomach (gastroptosis) and congenital hypertrophic ste- 
nosis. The latter is a rare affection seen in infants and due to 
thickening of the circular muscle at the pylorus. I he prin- 
cipal symptoms are vomiting and rapid and usually fatal 
inanition. The causes of hypertrophy or dilatation of the 
stomach include the causes enumerated for stenosis, and in 
addition, simple atony and enlargement due to overfilling. 
Treatment.-The treatment of stenosis is usually operative. 
In the congenital form prompt operation is imperative. 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 pri- 
mary disorder, operative or otherwise. In dilatation, insofar 
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 152 
DISEASES OF THE STOMACH 
divided and easily digested foods. Water may be adminis- 
tered 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 acute dila- 
tation immediate lavage is effective. 
In simple atony an effort may be 
made to stimulate the musculature 
of the stomach by large doses of 
nux vomica or strychnine, by the 
use of electricity and by douches 
against the spine and the epigas- 
trium, or even into the stomach 
itself. In hyperacidity, alkalies, 
such as chalk, magnesia and soda, 
may relieve a spasmodic contrac- 
tion of the pylorus. 
Gastroptosis. - Splanchnoptosis 
fe a term applied to downward dis- 
placement of the abdominal organs. 
Gastroptosis refers particularly to 
the stomach, but in most cases it 
is associated with "falling" of the 
kidneys, of the colon and even of 
the liver. With these displacements 
there is usually associated a peculiar 
formation of the thorax, drooping 
shoulders, 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, neurasthenia and 
digestive disturbances. Downward displacement of the 
Fig. 35.-Habitus enterop- 
toticus (Aaron.) ORGANIC DISEASES OF THE STOMACH 
153 
stomach or of other organs may occur in persons of normal 
build, and particularly in women who have worked hard and 
borne many children in rapid succession. 
Fig. 36.-Position of stomach in ptosis as shown by the roentgen-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.) 
In a case of gastroptosis the abdomen is prominent below 
the umbilicus (Fig. 35) 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. 37.-Rose's belt. (Lockwood.) 
times even to the symphysis pubis. To diagnose the position 
of the stomach water is sometimes given and the lower bor- 
der of the stomach marked out by means of the splash. More 154 
DISEASES OF THE STOMACH 
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 administration of successive 
Fig. 38.-Rose's belt as applied. (Lockwood.) 
(loses of tartaric acid and sodium bicarbonate). Under these 
conditions its position is evident to inspection or easily 
mapped out by percussion. The roentgen-rays are the most FUNCTIONAL DISORDERS OF THE STOMACH 
155 
satisfactory means of diagnosis; they are also valuable for 
locating the colon which is usually displaced in common with 
the stomach. Patients with gastroptosis may suffer no ill- 
effects, but with loss of weight and lowered tone they fre- 
quently develop symptoms of atonic dyspepsia and complain 
of vague sensation 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 suspend the 
stomach. The most satisfactory support for temporary 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, approximately 1 yard long 
and 7 inches wide, is cut as shown in Fig. 36. The apex of 
the large piece (7) 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 patient lies in 
the supine position, the abdomen being firmly supported in 
the desired position by the physician's hand placed over the 
plaster. The remaining strips (ZZ and III) are reversed 
before being applied and serve to keep the soft parts from 
bulging at the sides (Fig. 38). The associated symptoms 
are treated as described elsewhere. 
FUNCTIONAL DISORDERS OF THE STOMACH. 
Functional disorders are usually traceable to psychic or 
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, burning and 
distress (hyperesthesia), or intense paroxysmal pain may 
develop (gastralgia). Gastralgia may be a purely sensory 
phenomenon (rare) or it may be a manifestation of local 
irritation, as in ulcer, or of reflex dyspepsia, as in disease of 156 
DISEASES OF THE STOMACH 
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 
gastric musculature (atony) and undue muscular irritability. 
The former causes delayed expulsion of the ingesta (reten- 
tion) . The latter is exemplified by nervous vomiting, nervous 
belching and hypermotility. In nervous belching constant 
eructations occur quite independently 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 heartburn 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 abdominal 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 neuras- 
thenia. The symptoms are manifold and are described 
in great detail by the patients. The commonest gastric 
symptoms are belching, flatulence, nausea, heart-burn, ful- 
ness and distress (not severe pain or localized tenderness) 
and constipation. 
Reflex or symptomatic dyspepsia is most frequently due 
to gall stones, appendicitis, constipation, pulmonary tuber- 
culosis, heart disease, Bright's disease and pregnancy. I nless FUNCTIONAL DISORDERS OF THE STOMACH 
157 
the physician is continually on his guard, 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. Indiges- 
tion 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. Atropine 
is used to check secretion and alkalies (sodium bicarbonate, 
powdered chalk, magnesia and bismuth subcarbonate) to 
neutralize acidity. Subacidity 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 OP THE INTESTINES. 
Diarrhea and Enteritis. 
Infantile Diarrhea. 
Diarrhea in Adults. 
Chronic Constipation. 
Intestinal Obstruction. 
Hernia, Volvulus and Intussuscep- 
tion. 
Intestinal Tumors. 
Stricture of the Rectum. 
Hemorrhoids, Fistulas and Fis- 
sures. 
Appendicitis. 
Diverticulitis. 
Diarrhea and Enteritis.-Diarrhea is one of the commonest 
symptoms of intestinal derangement; it may be functional 
or dependent on organic changes in the intestines. 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 
susceptible 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 purgatives and 
enemas affords relief. An analogous form of diarrhea, some- 
times 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 dysen- 
tery, typhoid and tuberculosis are considered elsewhere. 
Ulceration is a manifestation of severe enteritis and colitis in 
infancy and childhood; ulceration of the colon is also a com- 
mon terminal condition in the aged or in the subjects of INFANTILE DIARRHEA 
159 
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 predisposing 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 reference to the small 
intestine. Duodenitis (inflammation of the duodenum) is 
supposed to be one of the causes of catarrhal jaundice (7. ®.). 
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 rec- 
tum respectively. Involvement of this portion of the intes- 
tinal 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 gastrointestinal 
tract (gastroenteritis). 
Infantile Diarrhea.-Diarrheal disturbances are much more 
frequent and serious in infants and children than in adults. 
In artificially-fed infants the mortality from intestinal dis- 
turbances 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 diarrhea, (2) fermenta- 
tive diarrhea and (3) catarrhal or infectious 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 removal of the 
offending material. Fermentative diarrhea is brought about 
by bacterial decomposition of sugars, either on account of 
the ingestion of excessive amounts or because of impaired 
digestive capacity (congenital or acquired). The resulting 
acids act as laxatives (irritation 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 160 
DISEASES OF THE INTESTINES 
frequent and the fever high. Ultimately, if the condition is 
unrelieved the child becomes prostrated (subnormal tem- 
perature), 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 dysen- 
tery bacillus. They are most apt to occur in the hot weather 
of early and mid-summer. The stools are often offensive 
(decomposition of protein) and in the aggravated cases con- 
tain mucus, blood and even pus. The severe and neglected 
forms may become subacute or chronic and are accompanied 
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 condi- 
tions, 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 com- 
mon 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 subnormal temperature cor- 
responds 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 tuberculosis, 
to toxemias, such as uremia, to chronic inflammation 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 underlying causes. The latter 
must be sought out by painstaking clinical and laboratory 
studies. In most varieties the stools are of a thin puree-like 
consistency and are passed without pain. In chronic dysen- 
tery there is tenesmus (painful straining) and the passage of 
mucus and blood. In mucous colitis there is an alternation TREATMENT OF DIARRHEA 
161 
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 Gastroenteritis) and in initial purgation. These meas- 
ures are followed by antiseptics, astringents, local and gen- 
eral 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 but- 
tocks 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 intro- 
duced and then the flow of water started, after which it may 
be pushed in for 8 to 10 inches. The funnel should not be 
more than 1 or 2 feet above the level of the body, and a 
pint or more of fluid may be introduced at a time. As por- 
tions 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 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 bicarbo- 
nate solution may be given subcutaneously or intravenously 
(the latter usually intravenously). In addition to these 
measures fresh cool air and clean 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 162 
DISEASES OF THE INTESTINES 
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 tem- 
porarily, and albumen water, sugar water or gruel substi- 
tuted. 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 uni- 
form composition. Such milk is relatively free from bacteria 
(riot over 10,000 per cc) 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 1,000,000 per cc). The number of bacteria is most impor- 
tant as an index of the care with which the milk has been 
handled. Certified milk is unfortunately too expensive for 
general consumption, although the poor may afford it tem- 
porarily in case of illness. An effort is being made to improve 
the general milk supply, so that it may approximate this 
high standard. Meanwhile commercial pasteurization is 
being demanded for all milk that does not meet the highest 
requirements. 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 temperature of the air high, 
domestic pasteurization can be practised with advantage. 
Complete sterilization necessitates heating the milk to the 
boiling-point for a half hour on three successive days. Nearly 
sterile milk may be obtained by a single heating. 
1 See Malnutrition, p. 203. CHRONIC CONSTIPATION 
163 
Chronic Constipation.-The average healthy person has a 
regular formed evacuation of the bowels daily. Perfectly 
normal persons may, however, have two or perhaps 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 consti- 
pation and diarrhea. Stools in constipation may assume 
peculiar forms, ofttimes appearing as small balls like sheep 
dung. Band or ribbon-like movements may occur in spas- 
modic 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 characteristic 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 spasmodic. 
In one case the constipation is due to undue relaxation of the 
colon and lack of irritability of the rectum; in the other there 
is excessive irritability and spasm, delaying the progress of 
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 
treatment, 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, many of 
our foodstuffs are offered in such a digestible form and so 
free from waste material that there is little residue remain- 
ing to give bulk to the feces and to stimulate the peristaltic 
movements. It is believed that this lack of pabulum checks 
the growth of useful microorganisms, which normally con- 
stitute a very considerable bulk of the feces and secrete sub- 
stances which stimulate peristalsis. For this reason Graham 
bread, rye bread, oatmeal, shredded wheat, green vegetables, 164 
DISEASES OF THE INTESTINES 
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 admin- 
istered 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 "bal- 
last," 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 irregularity. 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 favor the most efficient use of the 
abdominal muscles. In defecation the normal crouching posi- 
tion 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 likelihood 
of a return to primitive habits. This topic bears directly 
on the next cause of constipation, that is, impairment of 
muscular power, from maldevelopment (as in gastroptosis), 
from lack of exercise, from undue relaxation of the abdominal 
muscles following multiple pregnancies, and from injury to 
the rectal and perineal muscles in childbirth. Most of these 
causes are especially operative in women in whom constipa- 
tion 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. A very common fault is an insufficient 
water-intake. An average of about six glasses of water 
should be taken during the course of twenty-four hours. If 
the individual will drink a glass of water just before or after 
each meal, he will find it a very easy matter to drink at least 
six glasses of wTater a day. Not to multiply causes we may INTESTINAL OBSTRUCTION 
165 
finally allude to the abuse of laxatives. The homeopathic 
physicians perhaps go too far in their distrust of purgatives, 
hut there is no doubt that there would be less constipation 
if people paid more attention to diet and regularity, 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 constipa- 
tion 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. Sim- 
ple enemas (soap and water) and suppositories (glycerine, 
gluten or the home-made "soap stick'') are harmless methods 
of inducing an evacuation of the bowel if not too long con- 
tinued. They should be used with the ideas 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 mean- 
while 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 enumerate 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 166 
DISEASES OF THE INTESTINES 
mistaken for obstinate constipation. The distinction is very 
important, since purgatives which are indicated in constipa- 
tion, may be extremely dangerous in obstruction. In obstruc- 
tion the lumen of the bowel is shut off, from one cause or 
another, so that the contents cannot pass; in acute obstruc- 
tion there is usually in addition strangulation, i. e., cutting 
off of the blood supply. Chronic obstruction develops insidi- 
ously, and is usually due to tumors, benign strictures (follow- 
ing 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 peritoneum 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 obstruction 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 
complicated knot, causing obstruction, gangrene and death. 
Volvulus occurs chiefly in the aged. In infants and young 
children the most important cause of obstruction in intussus- 
ception. In this condition, which is probably the result of 
spasmodic contraction, one part of the bowel above becomes 
telescoped into the part below (Fig. 39, A, B, C), 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 vomiting, constipation, 
paroxysmal pain, rigidity, distention and visible peristalsis. 
These symptoms are indistinguishable from those produced 
by acute perforation or thrombosis of the mesenteric vessels. 
If the obstruction is high up the vomiting is frequently fecal. 
The constipation is usually complete (obstipation), but there INTESTINAL OBSTRUCTION 
167 
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 completeness 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 atropine, admin- 
istered hypodermically. In obstruction due to external hernia 
or to a low-lying intussusception, if the patient is seen early 
Fig. 39.-Intussusception. (Park.) 
in the disease, the bowel may sometimes be reduced by 
manipulation. In the majority of cases obstruction " spells" 
immediate operation. If the strangulation has existed for a 
short time only in 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 treat- 
ment, preliminary 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 comparatively 
rare condition which presents similar symptoms-embolism 
or thrombosis of one of the larger abdominal arteries or veins. 168 
DISEASES OF THE INTESTINES 
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 circula- 
tion 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 commonest, 
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 vary- 
ing degree depending on the part affected. Any portion of 
the intestines may be attacked by carcinoma, but the usual 
sites are the ascending colon, the 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 sometimes 
ribbon-shaped or pencil-shaped, but this appearance may be 
produced by simple spasmodic constipation. Other symp- 
toms 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 microscopical examination. 
Treatment.-The treatment of cancer, when an early diag- 
nosis has been made, is operative-excision of the growth. 
In advanced cases palliative measures are alone indicated. 
These may include operations, e. g., the formation 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 order- 
ing 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 alto- 
gether unlike those of carcinoma. The general cachexia is, 
however, lacking, and the history and symptoms of syphilis 
distinguish the affection. The Wassermann reaction affords HEMORRHOIDS FISSURES AND FISTULAS 
169 
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, chronic 
heart disease and childbirth. In internal hemorrhoids the 
most prominent symptom is hemorrhage, which may be per- 
sistent and lead to intense anemia. Occasionally the piles 
may be caught in the sphincter and strangulated, with the 
production of great pain. External 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 oint- 
ments or suppositories, by attention to the bowels to prevent 
constipation or diarrhea and by local applications of cold. 
Cleanliness is of great importance. When hemorrhoids do 
not yield to palliative measures operation is demanded. For 
external hemorrhoids it may suffice 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 spincter muscle to prevent spasm, by 
touching with lunar caustic or by surgical excision. 
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, excision of the diseased tissue and closure. They are 
common in tuberculous subjects. 170 
DISEASES OF THE INTESTINES 
Appendicitis. -Inflammation of the appendix presents very 
distinctive symptoms which call for separate consideration. 
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 contains 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 variable and sometimes inadequate. The lumen 
of the organ is often narrowed or obliterated by adhesions, 
by kinking, by repeated attacks of inflammation or by the 
lodgment 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 inflam- 
matory products. These and other conditions favor the 
frequent development of bacterial infections. The colon 
bacillus and the streptococcus are the common infecting 
organisms, the latter being the more dangerous. 
Inflammation of the appendix may be acute or chronic. 
The acute forms are the catarrhal, suppurative, gangrenous 
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 peritonitis. In the gangrenous form the 
appendix often perforates 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, nausea and vomiting, 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. 
Occasionally 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 DIVERTICULITIS 
171 
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, and if the patient is " unoper- 
ated" death will follow from peritonitis. In chronic appen- 
dicitis 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 appen- 
dicitis 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 uncomplicated cases consists 
in the removal of the appendix (appendectomy). If an 
abscess has formed it must be drained, while if general peri- 
tonitis has developed free drainage of the peritoneal cavity 
is necessary. In chronic appendicitis the necessity of opera- 
tion will be largely determined by the severity of the dyspep- 
tic symptoms. The medical treatment of acute appendicitis 
is usually confined to rest in bed in the semi-Fowler position, 
nothing by mouth, cold, local applications, low enemas and 
enteroclysis. Purgatives are contraindicated. 
Diverticulitis.-Diverticulitis is a name applied to a some- 
what 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 resemblance to the 
appendix, but is considerably larger. This is due to the 
abnormal persistence of the vitelline duct, 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 appen- 
dicitis, but the pain, etc., is often on the left side. The author 
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-blad- 
der. 
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 pro- 
duced 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. Obstruction of this duct by 
tumor or gall stones may cause chronic pancreatitis, a con- 
dition often recognized by surgeons at the operating table. 
The presence of chronic pancreatitis is suggested by an 
excess of fat and undigested 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, 
particularly 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 of the bowel 
or perforation of a gastric or duodenal ulcer is usually sus- 
pected. At operation or autopsy extensive hemorrhage into JAUNDICE 
173 
the pancreas is found, with fat necrosis (destruction) through- 
out 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 operation. Cancers, cysts and other tumors, 
as well as stone, may occur in the pancreas. 
Jaundice.-Jaundice is a symptom common to many dis- 
turbances and diseases of the liver, such as congestion, cir- 
rhosis, 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 mistake brownish-yellow 
deposits of fat in the sclera for jaundice. The brown "liver 
spots" (chloasma), so commonly 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 pro- 
nounced 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 mani- 
festation of septic infection. Septic or infectious jaundice 
of adults (Weil's disease) has recently been found to be due 
to a spirochete. It is characterized by fever, vomiting, jaun- 
dice 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. Jaundice is not an uncommon 
complication of pneumonia, and in some epidemics a large 
DISEASES OF THE LIVER AND BILE PASSAGES. 174 
DISEASES OF THE LIVER AND BILE PASSAGES 
proportion of the patients are thus affected. Catarrhal 
Jaundice is a common affection in young people, and usually 
follows dietary indiscretion. It is commonly associated with 
acute duodenal catarrh, or occasionally with a general gas- 
troenteritis (vomiting, diarrhea, etc.). The congestion and 
swelling of the mucous membrane of the duodenum probably 
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 evidences 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 symp- 
toms. Accompanying it there are hemorrhages into the skin 
and from all the mucous membranes. 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 fol- 
low 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 covered 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). In the latter case they are often nicely 
faceted, so that they fit closely together and frequently com- 
pletely 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, however, 
may be severe, particularly when there are large rough stones 
which cannot escape. These excite inflammation, local adhe- 
sions or reflex spasm of the pylorus. Several hours after CIRRHOSIS OF THE LIVER 
175 
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 the 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 (7. r.), with the addi- 
tion 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 hypo- 
dermic administration of morphine and atropine, by local 
hot applications, etc. If the stone becomes impacted early 
operation is advisable to prevent complications. In cases 
with recurrent gall-stone colic operation is also indicated. 
Opening of the gall-bladder, with drainage, is known as 
cholecystostomy; its removal, as cholecystectomy. In chole- 
dochotomy 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 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 applicable if gin is under- 
stood to mean whisky. There are many forms of cirrhosis, 176 
DISEASES OF THE LIVER AND BILE PASSAGES 
but only two or three are of common occurrence, to wit: 
the alcoholic (portal) type and 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 immoderate beer drinkers (Munich liver) and occa- 
sionally in chronic tuberculous patients. Much more common 
is the so-called atrophic type which is seen in those who 
Fig. 40.-Liver, advanced cirrhosis; typical hob-nailed organ. A, gall- 
bladder. (Hare.) 
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. 40). 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 CIRRHOSIS OF THE LIVER 
177 
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 cirrhosis is a comparatively 
rare disease. It is accompanied by severe jaundice and can- 
not 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 gradu- 
ally 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-vomiting of mucus in 
the morning, anorexia, diffuse epigastric distress and bowel 
disturbances. Frequently there will be a history of inter- 
current attacks of acute gastroenteritis with vomiting, diar- 
rhea and sometimes jaundice. 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 (ruptured esophageal piles) settles the nature of the 
case. There may be slight jaundice revealed by the muddy 
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 improvement 
is possible, but usually the course is steadily downward. 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 invari- 
able. 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 outcome always suggests that the disease 
may be largely a chronic peritonitis, but in some cases 
improvement is due to vascular adhesions, with the develop- 178 
DISEASES OF THE LIVER AND BILE PASSAGES 
ment 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 (glucose or levulose); another depends upon the abil- 
ity of the liver to remove phenoltetrachlorphthalein from 
the blood and to excrete it by way of the bile. 
Treatment.-Syphilitic cases should be treated in accord- 
ance with the principles laid down elsewhere. In ordinary 
alcoholic cirrhosis alcohol should be forbidden, and a bland 
diet suitable for chronic gastritis should be ordered. Purga- 
tives 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 tapping with a trocar (see Ascites). 
Operative treatment (Talma's operation, etc.) consists in 
opening the abdomen, removing the fluid and afterward 
attempting to establish a collateral circulation between the 
omentum or liver 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 infection, in suppura- 
tive appendicitis and in other abdominal 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. 
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. CONGESTION OF THE LIVER 
179 
The chief symptoms are persistent and increasing jaundice, 
an irregular tender liver, ascites and cachexia (anemia, ema- 
ciation 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 fre- 
quent in those who have suffered from neglected gall-stone 
disease. 
Fig. 41.-Case of enormous ascites due to atrophic hepatic cirrhosis. (Hare.) 
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 perfectly smooth, 
and returns to approximately normal size with the relief of 180 
DISEASES OF THE PERITONEUM 
the causal condition. Acute congestion with slight swelling 
and tenderness may occur in so-called bilious attacks, catar- 
rhal 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 intes- 
tines 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 physi- 
cian is attempting to elicit the latter symptom he will 
usually ask the nurse to rest the ulnar side of her hand 
on the midline of the abdomen. This is to prevent the 
transmission of a deceptive wave 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, tubercular 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 puru- 
lent; in cancer it is bloody. Rupture of one of the solid 
organs (liver, spleen, kidney or adrenal) or of an extra- 
uterine pregnancy 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 PERITONITIS 
181 
been previously "prepared" in the usual manner, is made 
anesthetic by infiltration with cocaine solution or by freez- 
ing. A. short preliminary incision is made with a scalpel and 
the trocar inserted by a sudden twisting thrust. As soon as 
the stilet is withdrawn 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 accumu- 
lation 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 trocar (Billroth's) 
provided with a side opening for the attachment of the rubber 
tube and a stopcock 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, general, puru- 
lent 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 gastric 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 con- 
dition 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 ter- 
minates 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 (9. ■».), to 
miscellaneous infections or to unknown causes. There may 182 
DISEASES OF THE PERITONEUM 
be general or local thickening of the peritoneum, adhesions, 
etc. Occasionally we see cases with involvement of the 
peritoneum, pleura and pericardium, which seem to con- 
stitute a special disease (multiple serositis). In tubercular 
peritonitis brilliant results are frequently obtained by inci- 
sion 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. The author has seen 
cases in which it was very difficult during life to distinguish 
cancer from cirrhosis with ascites. Sarcomatous 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, aged twenty- 
seven years, 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. 
Principles of Metabolism. 
Food Values. 
Diseases of Metabolism. 
Obesity. 
Inanition and Malnutrition. 
Diabetes Mellitus. 
Diabetes Insipidus. 
Gout. 
Rickets. 
Scurvy. 
Osteomalacia. 
Beriberi. 
Pellagra. 
General Considerations. -Principles of Metabolism.- 
Metabolism 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 secre- 
tions and excretions after they have escaped from the glands 
of the skin, kidney and gastrointestinal 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 fats and oils, the 
sugars and starches, water, salts and oxygen. In addition, 
"accessory food substances," known as vitamins, which seem 
to be essential to health or even to life, are found in minute 
amounts in the normal diet. Three vitamins (A, B and C) 
are now well recognized. In accordance with their chemical 
and physical characteristics they are usually designated as 
"fat-soluble A," "water-soluble B" and "thermolabile C."* 
* A fourth has recently been demonstrated. 184 
DISEASES OF METABOLISM 
The absence of these substances gives rise to xerophthalmia, 
beriberi and rickets respectively. Scurvy and pellagra are 
probably due to the Itlck of such accessory food substances, 
to ill-balanced dietaries or to a combination of these factors. 
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 constituent of all the organs and tissues. 
An excess of protein 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 70 kilos, or 150 pounds, at ordinary 
work, will require from 60 to 150 gm. (2 to 5 ounces) per day. 
Ordinarily 100 gm. (3j 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 50 to 150 gm. 
of fat, 90 gm. (3 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 carbohydrate (car- 
bonaceous food) is required by those who undertake severe 
physical labor. This is quite in opposition to the popular 
idea that meat in large quantities is essential to those doing 
laborious work. Our hypothetical man will require from 
300 to 600 gm. of carbohydrate daily; 400 gm. (13| ounces) is 
an average amount. Water constitutes nearly 90 per cent of 
the human body, so that a liberal supply is obviously essen- 
tial. 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 food- 
stuffs. The salts include, for example, such substances as 
common salt, which in dilute solution (physiological) bathes 
all the tissues, calcium phosphate, to which the firmness and 
rigidity of the bony structures are due, and iron, which is a 
constituent of the red blood cells. Oxygen, which is absorbed FOOD VALUES 
185 
through the lungs, is an essential agent in the chemical 
changes which take place in living matter. 
The waste products of nitrogenous or protein metabolism 
are excreted in the urine in the form of urea, uric acid, etc. 
Part of the protein, and practically all of the fat and carbo- 
hydrate 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 1 liter of 
water 1° C. (from 15° to 1G°). The caloric value of the various 
food products is determined by burning them in a special 
apparatus. For ordinary purposes, however, we calculate 
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 economy. These fac- 
tors in round numbers are as follows: Protein, 4; fat, 9; 
carbohydrate, 4. 
The method of calculation is shown by the following 
example: One liter (1 quart) of milk contains 40 gm. of fat, 
35 gm. of protein and 45 gm. of milk sugar, hence: 
40 X 9 = 360 calories. 
35 X 4 = 140 
45 X 4 = 180 
680 
Since heat and energy can be obtained within wide limits 
equally well from either fat or carbohydrate, the proportionate 
amounts of these foods may be widely varied. Except in 
excessively 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. Description of articles. 
Descriptions of portions.1 
Rough measure. 
Exact measure. 
Protein, 
grams. 
Fat. 
grams. 
Carbo- 
hydrate, 
grams. 
Calories. 
Grams. 
Oz., av. 
Milk, whole (4 per cent fat) 
A glassful or 7 fluidounces 
217 
7.6 
7.1 
8.7 
10.8 
150 
Milk, skimmed (0.3 per cent fat) 
A glassful or 6j fluidounces 
205 
7.2 
7.0 
0.6 
10.4 
75 
Buttermilk (0.5 per cent fat) 
A glassful or 6| fluidounces 
210 
7.4 
6.3 
1.1 
10.0 
75 
Whey (0.3 per cent fat) 
A glassful ("scant") or 6 fluidounces 
187 
6.6 
1.9 
0.6 
'9.4 
50 
Cream (18.5 per cent fat) 
li tablespoonfuls or 6/« fluidounce 
26 
0.9 
0.6 
4.8 
1.1 
50 
Butter (85 per cent fat) 
1 teaspoonful (rounded) 
7 
0.2 
0.1 
5.5 
0.0 
50 
Sugar (granulated cane-powdered milk, malt, 
etc.) 
2 teaspoonfuls (rounded) of granulated, 1 
tablespoonful (heaping) of powdered 
A glassful or 7 fluidounces 
13 
0.4 
0.0 
0.0 
12.5 
50 
Oatorbarleygruel (loz. of theflourtoqt. of water) 
218 
7.6 
1.0 
0.0 
5.2 
25 
Legume gruel (1 oz. of the flour to qt. of water) 
A glassful or 7 fluidounces 
217 
7.6 
1.7 
0.0 
4.6 
25 
Soda crackers (for use with milk) .... 
One cracker 
6 
0.2 
0.6 
0.5 
4.4 
25 
Toast dried in oven (for use with milk) . 
1 thick (3" x 3" x J*) or 2 thin slices (wt. as 
bread: 39 grams) 
23 
0.8 
3.6 
0.5 
20.4 
100 
Egg 
White of egg (in glass of water, lemonade, or 
One average (weight includes shell) 
57 
2.0 
6.8 
5.3 
0.0 
75 
beef extract) 
Two average "whites" 
49 
1.7 
6.0 
0.1 
0.0 
25 
Beef (round) scraped 
Two small cakes 
64 
2.3 
13.6 
5.0 
0.0 
100 
Beef juice (pressed-Holt) 
Beef broth (Holt, mutton and chicken similar) 
Two tablespoonfuls 
40 
1.4 
2.0 
0.2 
0.0 
10 
Large cup or 8 fluidounces 
250 
8.8 
2.5 
tr. 
0.0 
10 
Olive oil (or cottonseed oil) 
One tablespoonful (even), 2/s fluidounce 
11 
0.4 
0.0 
11.1 
0.0 
100 
Gelatin (1 pkg. gelatin, j lb. sugar, 2 qts. w'ater) 
7 tablespoonfuls, 3j fluidounces 
100 
3.5 
1.8 
0.0 
11.0 
50 
Junket (1 qt. milk 2 oz. sugar) .... 
8 tablespoonfuls, 4 fluidounces 
110 
3.9 
3.6 
4.4 
11.7 
100 
Hot custard (same with 4 eggs) .... 
5 tablespoonfuls, 2| fluidounces 
83 
2.9 
5.0 
5.1 
8.8 
100 
Cornstarch(lqt.milk,2oz.sugar.loz.corn starch) 
7 tablespoonfuls, 3j fluidounces 
100 
3.5 
3.3 
4.0 
13.0 
100 
Rice pudding (1 qt. milk, 2 oz. sugar, 3 oz. of rice) 
6 tablespoonfuls, 3 fluidounces 
83 
2.9 
3.3 
3.3 
14.4 
100 
1 Additional articles calculated in portions 
Ixiii, 1316, or in "A Laboratory Hand-book of 
of 100 calories may be found in an article by Fisher, Journal of American Medical Association, 1907 
Dietetics," M. S. Rose, The Macmillan Company, New York, 1913. 
LIQUID AND SOFT. FOOD VALUES 
187 
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 70 kilos (150 pounds), receiving 
100 gm. of protein, 90 gm. of fat, and 400 gm. of carbohy- 
drate, we find, as shown by the calculation below, that he is 
getting in round numbers 2800 calories per day, or 40 calories 
for each kilo of weight. This is approximately 20 calories for 
each pound. 
100 X 4 = 400 calories. 
90 X 9 = 810 
400 X 4 = 1600 
2810 
A man at rest in bed will require 30 calories per kilo or 15 
per pound, while a man at very hard labor may "burn up" 
as much as 60 calories per kilo or 30 per pound. Infants 
during their first year require more than twice as much in 
proportion as adults at ordinary work, e. g., 80 to 100 calories 
per kilo, equivalent to 40 or 50 per pound. This is partly 
because of their rapid growth and partly because of their 
proportionately large surface. The greater the relative sur- 
face of the body, the greater is the heat loss to 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. 
Elaborate chamber calorimeters have been constructed by 
means of which the intake of oxygen and food materials and 
the output of heat, energy, carbon dioxide, and waste mate- 
rials may be accurately balanced. More recently it has been 
found that measurement of the oxygen consumed will give 
a fairly accurate idea of the total metabolism, that is, of the 
calories being consumed under given conditions. The clin- 
ical test is carried out by means of a gasometer similar in 
principle to the tanks used for storing illuminating gas. 
Special mouth and nose pieces are used and the patient for 188 
DISEASES OF METABOLISM 
a definite length of time breathes in and out of the tank which 
has previously been filled with oxygen. From the amount 
of oxygen consumed the number of calories per hour is cal- 
culated. As the test is usually performed after resting over 
night without food the heat interchange is at a minimum and 
the metabolism is spoken of as basal. In exophthalmic 
goiter the basal metabolism is greatly increased, while in 
myxedema and some other disturbances of the glands of 
internal secretion metabolism is diminished. 
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 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 secretions is not known, 
but it is hardly reasonable to suppose that their influence is 
in opposition to the ordinary principles of metabolism that 
have been mentioned. Accumulation 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 relative amount of body 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 decreasing the intake 
by food limitation or in increasing the outgo by exercise, etc. 
A man of 70 kilos (150 pounds) at moderately heavy work 
requires, as we have seen, 40 calories per kilo, or a total of 
2800 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 INANITION AND MALNUTRITION 
189 
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 desirable because it interferes with proper 
elimination and is moreover of doubtful efficacy. Sweating, 
by means of hot-air or vapor baths, also acts by withdrawing 
fluid, but while it is not open to the same objections as the 
restriction 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 diminish 
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 common in 
Europe as the result of war conditions. In some cases hard 
working, underfed persons developed a "famine edema" sug- 
gestive of heart disease. In infants, particularly 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 digestive (intestinal) dis- 
turbances has already been emphasized. In the cases now 
under consideration the difficulty is one of faulty metabolism. 
One or more of the constituents of the food is badly assimi- 
lated or may even be toxic to the infant; fats and sugars 
are more often at fault than proteins. In a particular case 
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 populations, recalling the 
famous plagues of Egypt and the lamentable pictures described by our 
ancestors." (Guillermin and Guyot: Abstract, Jour. Am. Med. Assn.) 190 
INANITION AND MALNUTRITION 
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 protein 
milk, when the sugar is the chief offender.1 The symptoms 
of inanition comprise digestive derangements such as loss 
of appetite, vomiting and diarrhea, and nutritional distur- 
bances such as pallor, weakness, loss of weight, loose, wrinkled 
skin (senile expression), flabby muscles, etc. In severe cases 
nervous or toxic symptoms, restlessness, 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 intro- 
duced, but it is not properly assimilated. In severe infec- 
tions, such as tuberculosis and in malignant 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 (75 to 150 gm.) should be admin- 
istered to supply 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 2800 
calories, we must supply several hundred extra. One author- 
ity states that if 1 quart (liter of milk, corresponding to 
680 calories, is given in addition to a diet which is otherwise 
sufficient for a patient's normal needs, a gain of 1| pounds 
per week may be expected. The effect may be increased by 
fortifying the milk by additions of cream, and milk or malt 
sugar. 
1 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. DIABETES MELLITUS 
191 
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 absolutely essential to 
obtain a wet-nurse. In cases which have followed prolonged 
experimental feeding with proprietary foods, rational milk 
modifications will often bring about recovery. Mothers, on 
the advice of friends and neighbors, frequently try a great 
variety of proprietary 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 6 or 7 ounces at one time) into heat and energy, or 
"warehouse" it, as fat or glycogen (in the liver and muscles). 
The ability to metabolize sugars seems to be due to an internal 
secretion of the pancreas, known as insulin. Other individ- 
uals, usually gouty, obese, or alcoholic, may show sugar in 
the urine on an ordinary diet. These cases are readily con- 
controlled by moderate restriction, 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 
as such in the form of glucose. In severe cases as much 
as 500 gm. (1 pound) a day are lost in the urine, corres- 
ponding to 2000 calories. To meet the needs of the body, 
the protein, even that of the tissues themselves, 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 192 
DISEASES OF METABOLISM 
disturbance in the fat metabolism with the formation of 
injurious fatty acids, leading in certain cases to "acid intoxi- 
cation." In the latter condition diacetic acid and acetone 
are found in the urine. 
Cause.-Diabetes is more common in men than in women 
and in the well-to-do than in the poor. It is very common 
in Jews; it is rare in negroes. In young adults it is accom- 
panied 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 com- 
plications, particularly itching, boils, and shingles. While 
glycosuria may occasionally depend upon disease of, or injury 
to the brain or upon kidney insufficiency (renal diabetes), the 
ordinary case is traceable to lesions (atrophy, etc.,) of certain 
areas in the pancreas, known as the islands of Langerhans, 
which secrete "insulin" into the blood. Lack of the latter 
substance, as previously stated, diminishes or destroys the 
power of the body cells to make use of sugar. 
Symptoms.-The most characteristic symptom of diabetes 
is the frequent passage of large quantities of pale urine (poly- 
uria) 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 10 quarts, 
with perhaps 5 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, emaciation 
(in most cases), and weakness (in women, cessation of the 
menses). The tongue is often dry and red. Important 
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, restlessness, delirium, som- 
nolence, and coma. The respiration is rapid and deep 
("air-hunger") and the breath is said to have a "fruity" odor. DIABETES MELLITUS 
193 
Acid intoxication is favored by too prolonged adherence to 
a strict diet. 
Treatment.-The treatment of diabetes is primarily die- 
tetic. It is usual to prescribe at first a diet practically free 
from sugar and starch (fifty gm. or less). If the sugar dis- 
appears (mild cases), measured quantities of bread or other 
starchy food are added, taking care not to give enough to 
cause the reappearance of sugar. Protein 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 (2 or 3 gr, 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 intoxication 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 vegetables, or an exclusive diet of 
oatmeal is prescribed. 
Another method of treatment, for which Dr. Allen is 
largely responsible, is based on the assumption that diabetes 
is the expression of a weakened function, and that its mani- 
festations 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 cautiously given, and then gradually 
other starch-containing foods, until the amount of carbo- 
hydrate which the patient can tolerate, without the appear- 194 
DISEASES OF METABOLISM 
ance of sugar in the urine, has been determined. Subse- 
quently 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 examina- 
tions of the urine for sugar are necessary to control this 
treatment. These are made by the nurse or patient. 
"For the detection of glucose in the urine about 5 cc of the 
Benedict (or Folin-McElroy) reagent are placed in a test- 
tube, and 8 to 10 drops (not more) of the urine to be examined 
are added. It is 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. 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 
percipitate forms only on cooling. If no sugar be present, 
the solution either remains perfectly clear, or shows a faint 
turbidity that is blue in color, and consists of precipitated 
urates." (Joslin.) 
Since the introduction of insulin ("Iletin") by Banting, two 
years ago, the dietetic management of diabetes has been con- 
siderably modified. The principles of the Allen treatment are 
still observed, but by making use of insulin the severe restric- 
tions previously in vogue may be relaxed, and the patient's 
nutrition may be correspondingly improved. One of the most 
convenient plans for the dietetic management of diabetes is 
that outlined by Joslin. His diet lists are printed on cards 
and are easily obtained.1 Every nurse should be familiar 
with the principles of this or some other method of diet 
regulation so as to be able to carry out the directions of the 
physician intelligently. The following tables taken from one 
of Joslin's cards, show the carbohydrate content of ordinary 
foods and the corresponding caloric values. 
1 Cards (Forms J 13, J 9 B, J 3, J 5, and J 8) for sale by Thomas 
Groom & Co., 105 State St., Boston, or Joslin, Diabetic Manual (popular), 
Lea & Febiger, Philadelphia. Water, Clear Broths, Coffee, Tea, Cocoa Shells and Cracked 
Cocoa Can be Taken Without Allowance for Food Contents. 
Foods Arranged Approximately According to Content 
of Carbohydrates. 
1 gram protein, 4 calories. 
1 gram carbohydrate, 4 " 
1 gram fat, 9 " 
6.25 grams protein contain 1 
gram nitrogen. 
1 kilogram = 2.2 pounds. 
30 grams (gm), or cubic centimeters 
(cc) = 1 ounce. 
A patient "at rest" requires 25 calo- 
ries per kilogram. 
VEGETABLES* 
Carbo- 
(Fresh or 
canned) 5% 
30 grams (1 oz.) 
hydrate, 
Protein 
Fat, 
l%-3% 
3%-5% 
10%' 
15% 
20% 
contain approximately: 
grams. 
grams. 
grams. Calories. 
Lettuce 
Tomatoes 
String beans 
Green peas 
Potatoes 
Oatmeal, dry weight . 
20.0 
5.0 
2 
118 
Cucumbers 
Brussels 
Pumpkin 
Artichokes 
Shell beans 
Shredded w'heat .... 
23.0 
3.0 
0 
104 
Spinach 
sprouts 
Turnip 
Parsnips 
Baked beans 
Uneeda biscuits, two . 
10.0 
1.0 
1 
53 
Asparagus 
Water cress 
Kohl-rabi 
Canned lima 
Green corn 
Cream, 40 per cent 
1.0 
1.0 
12 
116 
Rhubarb 
Sea kale 
Squash 
beans 
Boiled rice 
Cream, 20 per cent 
1.0 
1.0 
6 
62 
Endive 
Okra 
Beets 
Boiled 
Milk 
1.5 
1.0 
1 
19 
Marrow 
Cauliflower 
Carrots 
macaroni 
Brazil nuts 
2.0 
5.0 
20 
208 
Sorrel 
Egg plant 
Onions 
Oysters, six 
4.0 
6.0 
1 
49 
Sauerkraut 
Cabbage 
Green peas 
Meat (cooked, lean) . 
0 
8.0 
5 
77 
Beet greens 
Radishes 
canned 
Chicken (cooked, lean) 
0 
8.0 
3 
59 
Dandelion 
Leeks 
Bacon 
0 
5.0 
15 
155 
greens 
String beans 
Cheese 
0 
8.0 
11 
131 
Swiss chard 
canned 
Watermelon 
Raspberries 
Plums 
Egg (one) 
0 
6.0 
6 
78 
Celery 
Broccoli 
Strawberries 
Currants 
Bananas 
Vegetables 5% group 
1.0 
0.5 
0 
6 
M ushrooms 
Artichokes 
Lemons 
Apricots 
Prunes 
Vegetables 10% group 
2.0 
0.5 
0 
10 
canned 
Cranberries 
Pears 
Potato 
6.0 
1.0 
0 
28 
Peaches 
Apples 
Bread 
18.0 
3.0 
0 
84 
Pineapple 
Huckleberries 
Butter 
0 
0 
25 
225 
FRUITS 
Blackberries 
Blueberries 
Oil 
0 
0 
30 
270 
Ripe olives (20 per cent) 
Gooseberries 
Cherries 
Fish, cod, haddock (cooked) 
0 
6.0 
0 
24 
Grapefruit 
Oranges 
Broth 
0 
0.7 
0 
3 
* Reckon average carbohydrates in 5 per cent vegetables 
as 3 per cent- 
of 10 per cent vegetables as 6 per cent. 196 
DISEASES OF METABOLISM 
Insulin is supplied in 5-cc ampoules containing ten or 
twenty units to the cc.. Five units or more are withdrawn 
by puncturing the rubber stopper with a hypodermic needle 
and withdrawing the necessary amount. This dose is given 
one to three times a day fifteen minutes before meals. The 
number of units to be administered depends upon the amount 
of sugar excreted in the urine. The object in view is to keep 
the patient sugar-free, and at the same time allow him to 
take a fairly adequate amount of carbohydrate. Insulin is 
also of great value in combating acid intoxication (diabetic 
coma), in preparing diabetic patients for operation, and for 
increasing sugar tolerance during intercurrent infectious 
diseases. 
The strictly medicinal treatment of diabetes has little 
rational basis. Arsenic and opium were formerly much used, 
and the latter seemed to have some effect in controlling glyco- 
suria. Whisky is frequently employed to supply additional 
calories, particularly in aged persons. Local pruritis (itch- 
ing) is common especially in women; it may be relieved by 
scrupulous cleanliness, and lotions or ointments of boric 
acid, phenol (carbolic acid), menthol, etc. If gangrene 
occurs amputation is necessary, though often ineffectual. 
Diabetes Insipidus.-Diabetes insipidus is characterized 
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 danger- 
ous to life. In this disease the kidneys are unable to retain 
the water which is brought to them, or in other terms, the 
kidneys are incapable of secreting urine of normal concen- 
tration. 
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 to obscure origin-joint and muscle pains, GOUT 
197 
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 asso- 
ciated. Uric acid is derived from the nuclei of 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, kid- 
ney, 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 consump- 
tion 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 Eng- 
land, but typical cases, either acute or chronic, are rare in this 
country. It is unusual to see more than one or two typical 
cases a year in a 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 
applications and other treatment, the intensity of the swelling 
soon subsides but nocturnal exacerbations may prolong the 
attack for several days. Recurring attacks are common, 
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 some- 
times falsely styled "rheumatic gout." 
Treatment.-The dietetic treatment is based on the prin- 
ciples stated above. Considering the comparative rarity of 
the disease it would hardly be profitable to discuss the treat- 
ment in detail. It may be mentioned that colchicum is 
supposed to have an almost specific effect in acute gout. 198 
DISEASES OF METABOLISM 
Rickets.-The striking feature in the metabolism of rickets 
is the inability to retain or make use of calcium salts (phos- 
phates), the principal mineral constituents of bones, in spite 
of the fact that there may be no lack of them in the food. 
The disease is due to a combination of dietary deficiency, 
and bad hygienic surroundings. Vitamin C, the lack of which 
may lead to rickets, is very susceptible to heating and is 
likely to be deficient in artificial foods; it is also diminished 
in amount in winter milk. Rickets does not develop in 
children who either receive a sufficiency of vitamin C or on 
the other hand have the benefit of abundant summer sun- 
shine. The disease 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, rest- 
lessness 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 prominent and the spleen large. I )ys- 
peptic 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. 
In the second or third year when the diet becomes more 
varied, the acute symptoms usually clear up and the deformi- 
ties, 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, an abundance of sunlight (seashore 
or mountains), abundant food including fats (cream and PLATE V 
Rachitis. 
Showing the euboidal shape of the head, the thoracic deformity, 
the beaded ribs, the protuberant abdomen, and the enlarged lower 
end of the radius. (Koplik.) SCURVY 
199 
butter), and the administration of phosphorous and cod- 
liver oil. Cod-liver oil is particularly rich in vitamin C, while 
the quartz-light may, in case of necessity, compensate for 
lack of sunlight. 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. If there is anemia, iron 
may be of benefit. 
Scurvy. -Scurvy is a metabolic disorder due to an unbal- 
anced 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 preva- 
lent in ships on long voyages, in prisons, asylums, and alms- 
houses. 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. linfantile scurvy is by no 
means rare and almost always follows the exclusive use of 
sterilized 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 hemor- 
rhages. The latter are situated, as a rule, along the 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 superificial swellings are seen, particu- 
larly 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 organge juice and green 
vegetables rapidly restores health. In infants a diet of fresh 200 
DISEASES OF METABOLISM 
milk and orange-juice, and in older children the same, with 
the addition of potatoes, accomplishes the same marvelous 
results without any medicine whatever. 
Fig. 42.-Scurvy showing petechiae and extensive hemorrhagic infiltration 
about the ankle. The patient had spongy bleeding gums. 
Osteomalacia.-Osteomalacia is a rare nutritional disease, 
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 (9. v.) 
which is due in whole or in part to nutritional disturbances. 
The part that infection may play in its etiology 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 organ- 
ism. These "vitamins" are abundant 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 inhabitants is limited to salt meat, fish, 
and articles made from flour (bolted). Bolted flour is prob- 
ably as unsuitable as polished rice, as an exclusive article of 
diet. PELLAGRA 
201 
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 generalized 
dropsy. The dropsical variety is known as wet beriberi, 
the simple paralytic as dry. 
Fig. 43.-Pellagra. (Siler, Garrison and MacNeal-Thompson-McFadden 
Pellagra Commission.) 
Pellagra. -This disease, which has long been a well-known 
scourge in northern Italy, Roumania, and elsewhere, 
assumed great importance in this country a few years ago. 
In the southern states, particularly, it vied with hookworm 
disease in absorbing the attention of medical men. At 
present it seems to be on the wane. That a disease of such 
chronicity and apparently 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 had 
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 202 
DISEASES OF METABOLISM 
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 most authorities believe it to be due to a poorly 
balanced, monotonous diet, lacking in certain essential ele- 
ments, while others attribute it to infection. 
The chief symptoms are cutaneous, gastrointestinal, 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 red- 
dened and presents an appearance not altogether unlike 
eczema. The eruption is almost always symmetrical. The 
general symptoms are those of recurrent digestive distur- 
bances and diarrhea with weakness and emaciation. As the 
disease progresses, it may be complicated by confusion, hallu- 
cinations, 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 Passages 
and Kidneys. 
Incontinence of Urine and Enuresis. 
Ascending and Descending Infec- 
tions. 
Cystitis. 
Pyelitis. 
Stone. 
Tumors. 
Abscess. 
Movable Kidney. 
Nephritis and Uremia. 
General Considerations.-The Urine.-The daily excretion 
of urine ordinarily amounts to 1| to 3 pints (750 to 1500 cc), 
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 respectively. 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 collecting 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. 
Toluol (one or two teaspoonfuls) is the best preservative. 
The bottle should be frequently shaken after each addition 204 
DISEASES OF URINARY PASSAGES 
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 the specific gravity tends to 
become low and fixed; this may be tested by collecting speci- 
mens every two hours and observing the quantity and specific 
gravity. In 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 alka- 
line (red litmus paper is changed to blue) after heavy meals, 
or after certain drugs such as sodium bicarbonate, etc. In 
cystitis with ammoniacal decomposition the reaction is per- 
sistently alkaline. The color varies between pale yellow 
and a deep reddish yellow or amber. Perfectly normal urine 
is transparent with a delicate floating cloud. If the urine 
is alkaline a heavy white precipitate of phosphates soon sepa- 
rates out. This may be redissolved by adding a little 
acid. If the urine is concentrated (reddish color) and acid, 
or the weather cold, a salmon colored 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 dis- 
ease. As a matter of fact they may indicate nothing of 
importance (low water intake, cold weather, etc.). Perma- 
nent 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 microscope. 
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 originate 
from a focus of inflammation or irritation anywhere in the 
urinary passages, or may be an accidental contamination THE URINE 
205 
(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 concentrated 
nitric acid. About 2 cc (| 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 pres- 
ence of albumin. 
The presence of sugar (glucose) is most certainly indicated 
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 solution of copper sulphate by 
glucose. The details of the Benedict test (a simplified "cop- 
per" test for sugar) are found in the section on Diabetes. 
Other substances sought for in an ordinary routine examina- 
tion are acetone and indican. The former indicates the possi- 
bility 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. 
The microscopical 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 206 
DISEASES OF URINARY PASSAGES 
important objects are casts; these are pale, elongated, 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. 44.-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 (1 cc) 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 within ten minutes and the greater part (80 per 
cent approximately) is eliminated within two hours. In prac- 
tice the urine is collected at the end of one hour and ten min- 
utes 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. CA THETERIZA TION 
207 
Miscellaneous Signs and Symptoms.-The blood-pressure is 
elevated in chronic diffuse nephritis and in uremia. Systolic 
pressures of 200 and 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 79). 
Cheyne-Stokes respiration, also described previously, 
(page 106) is peculiarly characteristic of uremia. Sometimes 
the respiratory distress in uremia closely simulates asthma. 
The edema of kidney disease differs from that of cardiac dis- 
ease 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 epilep- 
tiform type, like those described in the section on Nervous 
Diseases; the coma in many instances is also indistinguishable 
from that of cerebral disease. The convulsions 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 liability of the diseased bladder to infec- 
tion, the most scrupulous care should be used in the steriliza- 
tion 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 lubri- 
cant. The urethra and the labia should be thoroughly 
cleansed, with or without the use of boric acid or weak bichlo- 
ride solution, and, while the labia are separated with one 208 
DISEASES OF URINARY PASSAGES 
hand, the catheter should be introduced directly into the 
urethral opening without touching surrounding structures. 
Eor this a good light is essential. The details of this opera- 
tion are given in books on nursing. Eor 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 roentgen-rays at his command for this 
purpose. 
The use of the cystoscope for observing the mucous mem- 
brane 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 examination 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 diseases, 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 condition 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 consists 
in systematic training, "moral" suasion, restriction of fluid 
after four o'clock in the afternoon, and the use of drugs, ASCENDING AND DESCENDING INFECTIONS 
209 
belladonna (atropine), or strychnine. Atropine 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 pas- 
sages 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 common may be 
considered together. Chemical and mechanical 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 obstruction. 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 
quantities of urine (intermittent hydronephrosis). Stones 
in the kidney or bladder may cause mechanical irritation and 
inflammation, and in the ureter or urethra, pain or obstruction. 
The commonest causes of chronic obstruction are gonorrheal 
stricture and hypertrophy of the prostate. If infection is 
added to obstruction the disease travels upward, successively 
involving the urethra, bladder, 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 infec- 
tion, on the other hand, begins in the kidney or pelvis and 
travels downward it is called a descending infection. Infec- 
tions by the typhoid bacillus and tubercle bacillus are com- 
monly of the latter type, beginning above and traveling 
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 210 
DISEASES OF URINARY PASSAGES 
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 obvi- 
ous evidence of infection, and to the general causes which 
have been mentioned. A fruitful cause of infection is care- 
lessness 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 infec- 
tious form, unless carefully treated, is liable to become 
chronic. 
Symptoms.-The symptoms suggestive of cystitis are fre- 
quent and painful urination, and the passage of urine con- 
taining 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 catheterization of the ureters. 
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 mentioned 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 
relied upon for by the nurse or physician. 
The medical treatment of cystitis in the acute cases con- 
sists 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 urotropine and sodium benzoate. 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, STONE 
211 
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. (/., twenty 
minutes). For this purpose as well as for irrigation a two- 
way catheter is convenient. Local applications through the 
cystoscope or operations fall within the domain of the sur- 
geon or gynecologist. 
Pyelitis. -Pyelitis or inflammation of the pelvis of the 
kidney, may be due to an "ascending" infection, to infection 
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 albu- 
min is more abundant than in cystitis and there may be a 
few casts. In the tuberculous variety admixture of blood 
is frequent and tubercle bacilli are found (catheterized speci- 
mens). In mixed infections hectic fever with sweats is a 
characteristic feature. There may also be tenderness over 
the affected kidney (this is very usual in nephritis). This 
condition may be very puzzling simulating appendicitis, 
pelvic disease, and even typhoid fever. Examination of the 
urine will usually settle the diagnosis. Pyelitis may be uni- 
lateral or bilateral. By catheterization of the uterers 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-carmine or phenol- 
sulphonephthalein) are employed as described at the begin- 
ning of the chapter, but the urine is collected from each 
kidney separately by catheterizing the ureters. 
Treatment.-The medicinal treatment is on the same prin- 
ciples 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 212 
DISEASES OF URINARY PASSAGES 
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 calculi, 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 felt by a 
metal sound or demonstrated by the roentgen-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 atrophy 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 ride, be confirmed by the 
roentgen-rays. Very small or soft stones may not cast a 
shadow. MOVABLE KIDNEY 
213 
Treatment.-The treatment of stone in the bladder is sur- 
gical. The calculus may be either crushed or removed by 
perineal or suprapubic lithotomy. Mild antiseptics, seda- 
tives, and diuretics may be used to relieve symptoms or to 
improve the condition of the urine. In renal calculus 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 morphine and 
atropine hypodermically, hot stupes, hot baths, etc. 
Tumors.-Tumors of the kidney also cause pain and 
bloody urine ("tumors, tuberculosis, stone"). The common- 
est variety is peculiar to the kidney and is known as hyper- 
nephroma. It gives rise to metastasis, frequently to sec- 
ondary 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. The author has removed 
a pair at autopsy either of which would equal an adult's head 
in size (average weight slightly over 4 pounds). They pro- 
duce remarkably little disturbance considering their size 
and the "apparently" 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 nephrop- 
tosis. 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. Normally, the right kidney extends 
1 to 1| inches lower than the left. Movable kidney is asso- 
ciated in many instances with ptosis of the stomach and 214 
DISEASES OF URINARY PASSAGES 
colon (7. v.). It may occur independently, however, in per- 
sons 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.-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 invari- 
able 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 corresponding 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 NEPHRITIS AND UREMIA 
215 
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 cer- 
tain 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 
Fig. 45.-Large white (a) and small granular (6), contracted kidneys (one- 
half natural size), showing relative size. (Adami and McCrae.) 
system. This state is known as uremia, and is often the 
cause of death in chronic Bright's disease. Chemical exam- 
ination of the blood shows a great increase in the amount of 
urea, uric acid, and similar waste products, but since urea is 
not poisonous, when injected subcutaneously, 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 216 
DISEASES OF URINARY PASSAGES 
hebetude, dyspnea, etc. 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 examina- 
tion 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. 
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," prevailed extensively during the World War. The 
onset was sudden, the dropsy well marked, but the outcome 
was usually favorable. 
Acute nephritis is insidious in its onset; edema and pallor 
may be the first symptoms to attract the attention 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 examination 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 popular 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, TREATMENT 
217 
especially about the eyes, and the subcutaneous tissues are 
edematous wherever their loose structure favors the accumu- 
lation 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 kid- 
ney) the symptoms are quite different, 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 without apparent 
cause. The course is very chronic; often the first symptoms 
to attract attention may be headache, failing vision, puffy 
eyelids, dyspepsia, "asthma," polyuria, 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 albuminuric 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 dilatation 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 important 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 generally 
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 218 
DISEASES OF URINARY PASSAGES 
(protein) is most likely to be met in chronic interstitial neph- 
ritis and in threatening.uremia. In parenchymatous nephri- 
tis with dropsy there is more difficulty with salt and water. 
Some physicians hold a contrary view and administer sodium 
chloride (salt) and sodium carbonate by continuous entero- 
clysis. 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., 4 
liters (quarts) of milk, yielding 2720 calories, contain 140 
gm. 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 favored 
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 encouraged 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, caffeine, theobromine, and theophylline. Basham'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 a useful purpose. Bleeding and intravenous injec- 
tions 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. 
Myositis and Myalgia. 
Diseases of the Bones and Joints. 
Acute Arthritis. 
Chronic Arthritis. 
Arthritis Deformans. 
Heberden's Nodes. 
Spondylitis Deformans. 
Monarticular Arthritis. 
Rheumatoid Arthritis. 
Infectious Arthritis. 
Nervous Arthropathies. 
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 encapsu- 
lated. Muscular rheumatism is the commonest 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 muscular and tendinous structures. To 
these cases the term myositis would apply. Myalgias affect- 
ing 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 has 
no connection with acute articular rheumatism to which the 
name should properly be confined. It is well to remember 220 
DISEASES OF MUSCLES, BONES AND JOINTS 
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. Hidden foci of infection may play an 
important role in the etiology as they undoubtedly do in 
some forms of arthritis. Some believe that there is an under- 
lying "rheumatic" or "gouty habit." Fibrositis is another 
name sometimes applied to "rheumatic" affections, particu- 
larly 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, simu- 
lating 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., brachi- 
algia), 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. Between attacks-a search should be made for 
areas of subinfection in teeth, tonsils, sinuses, etc. 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. 
All the ordinary local applications have been used in this 
disease with more or less success, e. g., acetic acid, blisters, CHRONIC ARTHRITIS 
221 
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 medic- 
inal substances (belladonna). In the lumbar region this 
object is best attained by applying broad overlapping strips 
like clapboards. 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 
beneficial 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 mix 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 arthri- 
tis (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 mem- 
branes, joint cartilages, or bones. In this respect it differs 
from true rheumatism (acute and subacute) which does not 
injure the joints permanently. Mild types of chronic arthri- 
tis (joint inflammation) are commonly described as chronic 
articular rheumatism, but the designation is not so popular 
as formerly because it is admittedly misleading. Most people 222 
DISEASES OF MUSCLES, BONES AND JOINTS 
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 character- 
ized by pains, stiffness, and soft grating. The latter is 
easily felt when the joints are manipulated. This "crepita- 
tion" is due to fringe-like folds of synovial membrane pro- 
jecting 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 dis- 
located the semilunar cartilages of the knee. This accident 
causes sudden sickening pain and effusion of fluid. 
Arthritis Deformans.-The more extreme degrees of arthri- 
tis, 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 move- 
ments of the terminal joints, and eventually the latter may 
become partially dislocated to one side or the other, or even 
ankylosed. 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 RHEUMATOID ARTHRITIS 
223 
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 disappear 
almost entirely with treatment. The normal curvatures 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 ankylosed 
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 disability. 
The hip and knee are the joints usually affected. In the 
former case the head of the bone becomes flattened like a 
mushroom and the joint cavity shallow. On account of 
the destruction of the cartilage there is grating, 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 weak- 
ening of the joint predisposes to intracapsular fracture (hip). 
Rheumatoid Arthritis.-Rheumatoid arthritis is character- 
ized by a chronic progressive course, with atrophy and 
deformity of many joints (hence the term chronic, progres- 
sive, polyarticular arthritis). It is accompanied by wasting 
of the muscles and atrophy of the skin. The disease is by 
some thought to be due to disturbances of metabolism, or by 
others to disease of the nervous system with trophic changes. 224 
DISEASES OF MUSCLES, BONES AND JOINTS 
The tendency at the present day is to attribute these cases 
to chronic toxemia, the result of some cryptic (hidden), 
apparently trivial infection. The following are examples of 
such infections: Pyorrhea alveolaris, sinus disease, pyelitis, 
and chronic endometritis. 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 
articular 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 particu- 
larly involved, and during the inflammatory 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 anky- 
losed 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 hos- 
pitals, homes and almshouses harbor scores of these unfor- 
tunate patients (chiefly females). In children there is a 
special form distinguished by more acute symptoms and by 
enlargement of the glands and spleen. 
Infectious Arthritis.-The types of chronic arthritis which 
we have been considering hold an obscure, although an impor- 
tant, relation to infection. In other types the symptoms 
may be almost identical, but the relation to 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. NERVOUS ARTHROPATHIES 
225 
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 characteristic in its manifestations. 
It involves most frequently 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 
Fig. 46.-Hands showing marked late deformity. (McCrae.) 
bones of the skull is common, sometimes with loss of sub- 
stance 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 anteroposteriorly like saber 
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 rheumatism, 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). 226 
DISEASES OF MUSCLES, BONES AND JOINTS 
Pulmonary Osteo-arthropathy.-Hypertrophic pulmonary 
osteo-arthropathy or clubbing of the fingers is seen character- 
istically in chronic ulcerative tuberculosis, bronchiectasis 
(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 insofar as they interfere with digestion and 
nutrition. Phenacetine may also be used for the same pur- 
pose but with greater caution. Locally, at the same stage, 
evaporating lotions, magnesium sulphate in saturated solu- 
tion, raw cotton, and similar dressings are of use. In the 
more acute forms and in infectious arthritis splints at times 
give considerable relief. In infectious arthritis incision into 
drainage of the joint is sometimes necessary. The diet, if 
there is fever, may be moderately restricted, but in the inter- 
vals it should be generous, with an abundance of fat and pro- 
tein (meat, eggs, and milk). It is only fair to state, however, 
that some physicians of wide experience obtain excellent 
results by a restricted regimen, especially as regards sugar 
and starches. 
After the acute attack is over or in cases in which the dis- 
ease 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 possible of all 
the muscles and joints. This will tend to prevent distressing 
contractures w7hich so frequently cripple these patients en- 
tirely and prevent them from walking or even from feeding 
themselves. The writer has seen remarkable improvement in 
the use of the hands and arms following a prolonged course of 
passive movements, exercises, and massage. Baths are not 
of much use; occasionally patients derive benefit from sul- 
phur 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. 
Cocaine Habit. 
Lead Poisoning. 
Food Poisoning. 
Auto-intoxication. 
Arsenic, Mercury, Antimony, 
Phosphorus, etc. 
Atropine and Strychnine. 
DISEASES DUE TO PHYSICAL CAUSES. 
Sunstroke.-Sunstroke or insolation results from exces- 
sive heat and exposure to the direct rays of the sun. Alco- 
holic 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 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. Con- 
vulsions sometimes occur. 
Symptoms.-When the patient is admitted to the hospital 
the skin is red, hot, and dry, the pulse rapid, full, and strong, 
and the temperature extremely high-108°, 110° or more. 228 
DISEASES DUE TO HEAT AND POISONS 
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 comparatively 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 insolation. 
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 con- 
fusion. I have seen patients 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 exhaus- 
tion 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 probably due to special 
exposure. 
After prolonged residence in the tropics, natives of the 
temperate zone, particularly women and children, suffer from 
anemia, loss of appetite, poor nutrition, and general weakness 
and lassitude. Some physicians who have had large experi- 
ence in the tropics believe that the intense light, indepen- 
dently of the heat, is in itself deleterious to blond races. 
Treatment. - Cases of sunstroke should be given cold 
baths to reduce the temperature as promptly as possible. CAISSON DISEASE 
229 
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, strychinine, atropine, etc. Cases of sunstroke 
and heat exhaustion are usually treated in tents rather than 
in hospital wards. If the tents are well ventilated, which is 
not always the case, they are much cooler than the wards 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 beneath the water, for the purpose of constructing 
bridge piers, etc., pressure is used to exclude water from 
the workings. At the depth of 100 feet this may amount 
to 50 to 60 pounds to the square inch. The workmen gain 
access to the working chamber through intermediate com- 
partments in which the pressure is raised. By gradually 
increasing the pressure when going in and still more gradually 
(one-half 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 paralysis. 
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 circulation 
in those suffering from cardiovascular disease, or in normal 
persons who overexert themselves. Nosebleed is a common 230 
DISEASES DUE TO HEAT AND POISONS 
symptom. These symptoms are probably due to deficiency 
of oxygen in the rarefied air. Physicians are loath to send 
patients with myocardial disease to lofty altitudes, particu- 
larly 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. A table of the commoner poisons and their 
treatment is here given. For details the reader is referred 
to books on "materia medica," "first aid," etc. 
Poison. 
Treatment. 
Ammonia. 
Diluted vinegar; lemon juice; olive oil; castor 
oil. 
Arsenic. 
Ferri hydroxidum cum magnesii oxido, 3 oz.; 
later castor oil. 
Atropine (belladonna). 
Tannic acid; morphine in not too large doses. 
Carbon monoxide (coal 
gas). 
Oxygen. 
Hydrochloric acid. 
Lime water; magnesia. 
Mercuric chloride. 
Raw eggs and albumin water. 
Opium and its derivatives. 
Tannic acid; atropine; wash stomach with 
potassium permanganate solution 1 to 1000. 
Phenol (carbolic acid). 
Sodium sulphate in solution. 
Silver salts. 
Sodium chloride. 
Snake bites. 
Potassium permanganate. 
Sulphuric acid. 
See hydrochloric acid. 
(In each case excepting coal gas and snake bites gastric lavage may be 
employed together with proper supportive measures as the case may indi- 
cate.) 
Alcohol and Alcoholism.-Ethyl alcohol is the essential 
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 carbohydrates (sugars and 
starches), but theoretically has a much higher fuel value, 
the factor being 7 calories per gram as compared with 
4 for carbohydrates (see Part VI). A controversy has 
ranged for many years between those who assign a food value 
to alcohol and those who regard it as a poison pure and 
simple. Conservative opinion inclines to the view that ALCOHOL AND ALCOHOLISM 
231 
small quantities 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). As 
a stimulant alcohol is now much less favorably regarded than 
formerly. Its principal action is to dilate the superficial 
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 prescrip- 
tion 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 con- 
centrated solution (spirit) there is no question but that 
alcohol causes catarrh of the gastrointestinal canal and cir- 
rhosis 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 cardiovascular system 
seems to be hardly less striking. Statistical inquiries appear 
to show, however, that it is not an important cause of arterio- 
sclerosis. 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 nervous diseases. 
Acute alcoholism is too familiar a condition to require 
description. It does not lead to delirium tremens, alcoholic 
neuritis, or other serious complications, unless the bout is 
unduly prolonged, or the acute excess associated with chronic 
overindulgence. Its chief importance in internal medicine 
is as a predisposing cause of pneumonia and rheumatism on 
account of the incidental exposure. At times there is some 
difficulty in distinguishing acute alcoholism from opium 
poisoning, apoplexy, uremia, diabetic coma, and "status 
epilepticus." Mistakes are most likely to happen in ambu- 
lance and police work, with scanty histories and small oppor- 
tunities for careful examination. When treatment is neces- 
sary the most effectual mode of relief is the administration 232 
DISEASES DUE TO HEAT AND POISONS 
of a hypodermic injection of apomorphine hydrochloride, or 
better still, lavage of the stomach. 
Chronic alcoholics are of two general types-those who 
indulge in moderately large or excessive quantities (a pint or 
more daily), continuously or almost continuously, and those 
in whom periods of excessive indulgence alternate with 
periods of complete abstention from, and even disgust 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 show very few signs of 
alcoholic excess, perhaps a little squeamishness in the morn- 
ing, 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 develop delirium 
tremens. I have seen this most often in pneumonia and in 
fractures of the lower extremities. Chronic periodical 
drinkers and alcoholic subjects generally after a prolonged 
spree may also develop delirium tremens. The symptoms 
most suggestive of impending delirium tremens are anorexia, 
tremor of the hands, tongue, and lips, restlessness, and 
obstinate insomnia. The tongue is heavily coated and often 
dry and brown. The characteristic delirium has been des- 
cribed previously (see page 21). The patients are often 
difficult to control and struggle violently to escape from their 
terrifying hallucinations. 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 which may persist 
for weeks (alcoholic wet brain). 
Neuritis, gastritis, cirrhosis of the liver, bronchitis, and 
bronchopneumonia, are complications of alcoholism which 
are described in their appropriate sections. 
Treatment.-The curative treatment of chronic alcoholism 
under ordinary conditions is not hopeful. At the Philadel- 
phia General Hospital we had patients who had been admit- 
ted for alcholism more than one hundred times and many 
others with records almost equally bad. Periodic drinkers ALCOHOL AND ALCOHOLISM 
233 
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 sur- 
rounded 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 legiti- 
mate method is by institutional supervision and by the pro- 
longed use of full doses of atropine and strychnine. 
In threatening delirium tremens free lavage at the begin- 
ning may ward off serious symptoms. Delirium tremens is 
sometimes treated as an "acidosis" by intravenous injections 
of sodium bicarbonate solution. (See Diabetes.) Once 
symptoms have appeared sedatives and physical restraint 
become necessary. It is very 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 seda- 
tive drugs most in use are: Bromides, paraldehyde, chloral, 
hyosine, and morphine. Physicians differ as to the wisdom 
of stopping the alcohol immediately, or cutting it off grad- 
ually, though the former practice tends to prevail. Stimu- 
lants such as strychnine 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 nourishing as possible, 
e. g., milk and eggs. 
Wood alcohol will produce an acute intoxication not 
unlike that due to ordinary alcoholic beverages, but even 
moderate doses may cause atrophy of the retina and partial 
or complete blindness. Poisoning may be due to the fraudu- 
lent substitution of wood alcohol for grain alcohol in whisky 
and other liquors, or topers may deliberately make use of it 234 
DISEASES DUE TO HEAT AND POISONS 
when other supplies are exhausted. Even external applica- 
tions 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 morphine or laudanum. 
These may be taken in overdose by mistake or with suicidal 
intent. The leading symptoms are somnolence, stupor, 
slow respiration, stertor, and pin-point pupils. The respira- 
tion may fall to 10 or 12 or less and if the patient is allowed 
to sleep, may stop entirely. 
Treatment.-The treatment consists in getting rid of the 
drug so far as possible by repeated lavage (because morphine 
is eliminated into the stomach even when taken subcutan- 
eously), in the administration of moderate doses of atropine 
and caffeine (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 flicking with a towel, 
by the electric brush (painful), and by alternate hot and cold 
douches. Walking and whipping, used without judgment, 
sometimes cause death from physical exhaustion. On the 
other hand, I have seen excellent results, without harmful 
incidental effects, following the use of electricity, hot and 
cold water, etc. 
Opium Habit.-The opium habit is induced by the above- 
mentioned preparations by opium itself, by laudanum, by 
paregoric, by heroine, and rarely by codeine. Opium is 
smoked, paregoric and laudanum are taken by the mouth, 
morphine is usually taken by hypodermic injection, and 
heroine is used as a snuff. Indulgence in opium (smoking) 
and heroine, and to a less extent in morphine, may be a purely 
vicious habit; many cases of morphine addiction, however, 
follow the prolonged therapeutic use of the drug for pain and 
discomfort. Nurses as well as physicians are likely to acquire 
the habit if they prescribe for their own aches and pains. 
It should be an invariable rule with 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 LEAD POISONING 
235 
and freedom from pain, but increasing doses are required to 
get an effect. As much as a dram of morphine a day may 
be taken by addicts without fatal results. In the intervals 
between doses the patient suffers from gastrointestinal symp- 
toms, irritability, restlessness, and insomnia. Thege symp- 
toms 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. 
Treatment.-The opium may be withdrawn immediately or 
gradually. I luring the first few days of treatment the patient 
suffers intensely from nausea, vomiting (green), and insom- 
nia. It is necessary to have the patient in an institution, 
otherwise 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 administration of belladonna and hyoscyamus, 
and by the gradual withdrawal of the drug. 
Cocaine Habit.-Cocaine ("coke") addiction is even more 
deleterious than the morphine habit. It acquired a foothold 
largely through the use of the drug in nose and throat practice 
before its dangerous nature was known. The stringent laws 
that have been enacted are limiting its use so that cases of 
the habit are not very frequently observed in hospital prac- 
tice. It is usually taken as a snuff arid is frequently com- 
bined with heroine. 
Acute symptoms are sometimes seen after the use of the 
drug as a local anesthetic-rapid pulse, excessive restlessness, 
insomnia, and the like. The habitue after his dose is said 
to experience a most delightful sense of satisfaction in his 
own ability, both mental and physical, but subsequently 
becomes irritable, morose, jealous, and vindictive. Terri- 
fying hallucinations are common. The treatment is similar 
to that suggested for the opium habit. Immediate with- 
drawal of the drug is usually practised. 
Lead Poisoning.-Lead is the most important of the indus- 
trial poisons. More than a hundred occupations have been 236 
DISEASES DUE TO HEAT AND POISONS 
known to occasion "plumbism." Those in whom it most 
frequently occurs are white-lead workers, makers of storage 
batteries, painters, smelters, plumbers, printers, etc. The 
large incidence of the disease in white-lead workers is to a 
great extent due to neglect of well-known precautions by 
the manufacturers, by the workmen, or by both. Poisoning 
may also occur from medicine ("lead and opium pills"), 
water 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 navel and 
are very intense. Obstinate constipation is associated with 
the pain. I have seen a case which simulated perfectly renal 
colic. There is a "blue" line near the free border of the gums, 
but this is absent when the teeth are missing. Anemia is 
rapid and severe and a peculiar granulation of the red blood 
cells is demonstrable by "basic" staining. The latter is 
very suggestive, but not in itself diagnostic of lead poisoning. 
Palsy may develop with or without preceding attacks of 
colic. Wrist-drop and foot-drop are the types of paralysis 
ordinarily seen, but multiple 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. 
Treatment.-Prophylactic treatment is most important. 
White lead may be made by a wet process which does away 
with the dangerous dust, or the workmen may wear respira- 
tors (because of discomfort they seldom do). In other 
instances, ventilating hoods may be used to protect those 
working with dusty lead compounds. Good nutrition and 
the free use of milk is thought to be of value. Thorough 
washing of the hands before handling food is the simplest 
and most generally applicable precaution, though not suffi- 
cient in itself. 
In a subacute attack, with colic, rest, purgation by Epsom 
salt, morphine, 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, A UTO-INTOXICA TION 
237 
perhaps with the addition of strychnine, and also local meas- 
ures such as massage and electricity. 
Food Poisoning. -Formerly, symptoms resulting from the 
eating of foods which had undergone putrefaction were 
known as "ptomaine poisoning," a name applied to sub- 
stances resulting from the splitting of proteins. Many of 
the ptomaines, however, are not toxic, and are not now con- 
sidered important in bacterial disease. Many of these cases 
were no doubt due to the Bacillus botulinus producing putre- 
factive changes in canned vegetables and fruits (ripe figs), 
sausages, etc. 
The general symptoms of food poisoning are those of acute 
gastroenteritis: Fever, severe pain, vomiting, purging, and 
collapse. Nervous symptoms may be prominent 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 within 
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 which are 
presumably due to poisonous products formed in the intes- 
tinal tract by the action of putrefactive bacteria. An excess 
of indican in the urine is suggestive of excessive intestinal 
putrefaction. 
The symptoms of the latter condition are indefinite- 
headache, vertigo, disinclination to work, flatulence, consti- 
pation, diarrhea. Some of the best authorities deny the 
existence of intestinal auto-intoxication in adults and 
attribute the symptoms to a nervous reflex from an over 
distended rectum. 
Treatment consists in dietetic restrictions of various kinds 
and in the administration of buttermilk (Bulgarian bacillus), 
or Bacillus acidophilus milk. The last mentioned prepara- 
tions are given with the idea of altering the intestinal flora 
(i. e., substituting harmless acid producing organisms for 
putrefactive bacteria). Constipation should be combated 
by diet, enemas, mineral oil, etc. 238 
DISEASES DUE TO HEAT AND POISONS 
Arsenic, Mercury, Antimony, Phosphorus, etc.-Arsenic, 
mercury, antimony,- and phosphorus may give rise to chronic 
poisoning in those who have been exposed to these poisons 
at their work or who have received medicinal doses. Acute 
poisoning arises when large doses have been taken by acci- 
dent or with suicidal or homicidal intent. Arsenic frequently 
causes slight gastrointestinal and renal irritation, and less 
often multiple neuritis, when administered in large doses or 
over a prolonged period for syphilis (arsphenamine), chorea, 
and pernicious anemia. Mercury under similar conditions 
causes ptyalism, loosening of the teeth, and gastrointestinal 
irritation, but these symptoms are now infrequent except in 
susceptible persons. In former times when mercury was 
used with greater freedom they were very common. Anti- 
mony and phosphorus are seldom used in medicine and toxic 
symptoms are extremely rare. Industrial poisoning from 
mercury occurs in smelters, in chemical workers, in makers of 
physical apparatus, in hat makers, etc. It is said to cause 
tremor, painful convulsions without unconsciousness, 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 have been 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 accompanied 
by severe irritation and inflammation of the gastrointestinal 
tract. It is difficult to control and commonly fatal either 
immediately or ultimately. In the middle ages arsenic was 
a favorite with poisoners, on account of its tastelessness 
and insidious effects, but it has lost its evil 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 concealing the criminal use of the drug. Acute arsenical 
poisoning may be treated by immediate lavage and the ATROPINE AND STRYCHNINE 
239 
administration of the antidote (ferric hydroxide with mag- 
nesium oxide, 4 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 gastrointestinal 
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 white 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 syn- 
copal 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. 
Atropine and Strychnine.-Atropine very commonly occa- 
sions toxic symptoms even in therapeutic doses. This is due 
in part to the varying susceptibility of different individuals. 
Serious results are rare because of the care with which the 
drug is employed and the distinctive character of the mani- 
festations. I have seen marked dilatation of the pupils and 
rapid pulse after the use of an ordinary belladonna plaster. 
The author 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. 
Strychnine poisoning is characterized by severe tonic con- 
vulsions without loss of consciousness. In a case which I 
saw many years ago fatal asphyxia was induced by an attenlpt 
to wash out the stomach. Considering the reckless freedom 
with which the drug is used by all classes of persons the rarity 
of acute poisoning is remarkable. PART X. 
INFECTIOUS AND PARASITIC DISEASES. 
CHAPTER I. 
GENERAL CONSIDERATIONS. 
Infectious and Contagious Dis- 
eases. 
Modes of Transmission in Infec- 
tions. 
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 diseases 
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 distinction was made between contagious and 
infectious diseases on account of supposed differences in mode 
of A contagious disease was thought to be 
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." 242 
INFECTIOUS AND PARASITIC DISEASES 
Thus the atmosphere in the neighborhood of smallpox hos- 
pitals was supposed to be "catching." "Contagion" in this 
sense is a myth, as is also "infection" in the sense of a miasma 
arising from swamps. Present-day authorities prefer the 
terms transmissible or communicable to either of those men- 
tioned, but the older terms will doubtless continue to be used 
-infectious in a broad comprehensive sense and contagious 
with a narrower 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). 
Modes of Transmission in Infections.-Infection may be 
acquired: (1) By direct contact with patients or infected 
animals; (2) by indirect contact; (a) by indifferent objects; 
(6) through human or animal carriers; (c) through intermedi- 
ate hosts; (d) by drinking water; (e) by food; (/) through the 
medium of air, or (g) soil. Some of these expressions require 
explanation and amplification. Infection by direct contact 
implies close association with patients or infected animals or 
direct exposure to "contagious" discharges. Infectious mate- 
rial 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, 
as well as dust, may convey infection by indirect contact. 
Thus dried up and pulverized excreta 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 reduce this 
danger to a minimum. It may be further diminished by the 
employment of damp sweeping and dusting and vacuum 
cleaning. Objects which have been merely exposed to air 
infection are probably very slightly dangerous. By the 
term "carriers" we designate: (a) Individuals who, following 
exposure to contagion, harbor dangerous organisms some- 
where in the economy (throat, intestine,) without being 
themselves attacked by the disease, and (6) persons who, 
having recently or long since convalesced from an acute MODES OF TRANSMISSION IN INFECTIONS 
243 
illness, still distribute organisms from some persistent focus 
of infection. Diphtheria 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 broad- 
cast, 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 
with disease (typhus fever is carried from person to person 
by lice), or from the lower animals to man (the plague is 
sometimes carried from infected rats to human beings by 
the agency of fleas). Animals also act as intermediate 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 intestine and scatters its eggs in the 
fecal discharges. Cattle become infected by eating grass, 
hay, or other food contaminated by these eggs. The eggs 
develop into embryos in the gastrointestinal canal of these 
animals, and then penetrate into the voluntary muscles in 
which they become encapsulated (larvae) as minute oat-like 
bodies. When infected beef, either raw or insufficiently 
smoked, is eaten by man the parasites quickly develop again 
into the adult state and the cycle is complete. If no raw 
meat were eaten the disease would die out without further 
precautions. Impure drinking-water and infected foods 
(including milk) are important in the spread of infections 
involving the gastrointestinal tract and in the propagation 
of animal 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 was formerly called air infection is 
now attributed with certainty to insects or carriers. The 
soil is of importance as a vehicle for conveying infectious 
matter to air (dust) or water. In tetanus (and similarly in 
gas bacillus infection) and hookworm disease, infectious 
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"). 244 
INFECTIOUS AND PARASITIC DISEASES 
Classification of Infections.1-With these preliminary 
explanations we may proceed to a classification of infectious 
and parasitic diseases, arranged primarily in accordance with 
the mode of transmission, and only secondarily in harmony 
with other criteria. Diseases which are transmissible in 
several ways are included under what seems to be the most 
important division, while diseases concerning whose trans- 
mission 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. 
(а) Infections due to pyogenic bacteria: Toxemia, septi- 
cemia, erysipelas, gonococcus infection. 
(б) A variety of infections, most of which are acquired by 
contact with domestic animals. (1) Bacterial: Tetanus, 
anthrax, glanders. (2) Due to fungi: Actinomycosis and 
sporotrichosis. (3) Due to a filterable virus: Rabies. 
(c) An infection (primarily human) due to a protozoan 
parasite: Syphilis. 
General Prophylaxis.-General prophylaxis in this group 
depends on the 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, silver 
solutions, and calomel ointment are often used on mucous 
membranes to prevent infection. Wounds may be treated 
according to circumstances by simple aseptic methods or by 
incision, drainage, cauterization, and antiseptics (bichloride 
of mercury, chloramine-T). In certain diseases special pre- 
ventive 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 "pro- 
phylactic" measures) to limit gonorrhea and syphilis. Most 
of these special measures will be mentioned again under the 
individual diseases. Accidental transmission of these infec- 
1 After Rosenau with material modifications. CLASSIFICATION OF INFECTIONS 
245 
tions to others is unlikely if 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 solutions, bichloride of mercury 1 to 1000, 
phenol 1 to 20, "formalin" (i. e., 40 per cent formaldehyde 
solution) 1 to 10 ( 40 4- 10 = 4 per cent formaldehyde gas), 
or compound solution of cresol 1 to 100. Isolation is the 
rule in erysipelas; partial quarantine in gonococcus infection 
with discharge, tetanus, rabies, and syphilis (active). 
Class II. Characteristics.-In this group infection is dis- 
seminated 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. 
(6) By Flies: African lethargy and other mainly tropical 
affections. (Typhoid fever, dysentery, and the exanthemata, 
in which flies play an important but secondary role in the 
transmission of infection, are classified elsewhere.) 
(c) By Lice, Ticks, Fleas or Bed-bugs: Typhus fever, Rocky 
Mountain fever, relapsing fever, trench fever, and the plague 
(bacterial). Rats and squirrels are susceptible to the latter 
disease and keep the infection alive in the intervals between 
epidemics. Fleas carry the infection from the rodents to 
man. 
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 
swamps, and similar measures of sanitation. Disinfection 
in the ordinary sense is useless, but "delousing" and the use 
of larvacides and insecticides (e. g., sulphur, carbon tetrachlo- 
ride, and kerosene) are important. The systematic ferreting 
out and treatment of infected persons 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 respira- 
tory tract (in which for the purposes of this classification, I 246 
INFECTIOUS AND PARASITIC DISEASES 
include the tonsils) and is disseminated by discharges from 
the same region-sputum, nasal and aural discharges (the 
middle ear is in intimate relation with the pharynx by way 
of the Eustachian tube). Desquamating epithelium is a 
possible source of contagion in some exanthemata, and, while 
not so important as formerly believed, should not be entirely 
disregarded. 
(d) Due to Specific Bacteria: Diphtheria, cerebrospinal 
fever, pneumonia, whooping-cough, tuberculosis, leprosy. 
(6) Diseases of Uncertain Origin: 
(1) Probably due to various types of streptococci: Rheu- 
matic fever, follicular tonsillitis, quinsy, scarlet fever. 
(2) Due to filtrable viruses or ultra-microscopical organ- 
isms: Infantile paralysis, encephalitis lethargica, influenza (?), 
glandular fever, mumps, measles, German measles, smallpox, 
chicken-pox. 
General Prophylaxis.-The general prophylaxis of this group 
consists in the avoidance of direct contact (in many cases 
partial or absolute quarantine), and in the disinfection or 
destruction of discharges. "Droplet" and dust infection are 
particularly common in diseases of this class. Screens and 
cubicles tend to limit droplet infection in contagious wards; 
the general use of gauze masks has not proved useful. Car- 
riers play an important role, as in diphtheria, pneumonia, and 
tonsillitis. Old linen, gauze, or paper napkins, should be 
used instead of handkerchiefs to receive nasal discharges or 
sputum. Soiled pieces should be put into paper bags and 
the whole burned at suitable intervals. With the same end 
in view sputum may be received into paper containers, or 
enamel cups containing antiseptic fluids may be substituted. 
The best fluids for the cups are strong lye, phenol (carbolic 
acid), 1 to 20, and "formalin." Cups in permanent use 
should be frequent 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 convalescent period 
with petrolatum, plain or medicated, to prevent the diffusion 
of scales. Other special methods of prophylaxis include COMMUNICABLE DISEASE 
247 
vaccination for smallpox, removal of focal infection in 
rheumatism, and the prophylactic use of toxin-antitoxin in 
diphtheria. 
Class IV. Characteristics.-In this group the infectious 
agent enters by the mouth (the hookworm is ordinarily an 
exception) and as a rule multiplies in the gastrointestinal 
tract. 
(а) The infection, generally bacterial, is disseminated prin- 
cipally by the intestinal discharges: Typhoid fever, para- 
typhoid fever, colon infection, Malta fever, cholera, bacillary, 
or amebic dysentery. 
(б) Infestations by higher animal parasites, disseminated 
(1) by intestinal discharges: Threadworms, round worms, 
hookworm; (2) through the agency of intermediate hosts: 
Trichina and Trichinosis, tapeworms, cysticercus, and echino- 
coccus. 
General Prophylaxis.-General prophylaxis in this group is 
principally concerned with the protection of the food and 
water supply. For the attainment of this end disinfection of 
discharges (particularly urine and feces), sanitary privies, 
regulation of sewage disposal, provision of pure water (filtra- 
tion), and the inspection and control of meat, milk, and other 
foods are essential. Carriers, both insect and human, play 
an important part (typhoid). Dust infection is occasionally 
a source of danger. 
Urine and feces may be disinfected by adding an equal 
quantity of some strong disinfectant, mixing, and allowing 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 disinfection of bedpans 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 communicable, 
and thereby come under the supervision of local health 
officers. The list of reportable diseases varies in different 248 
INFECTIOUS AND PARASITIC DISEASES 
localities and is determined in part by considerations of 
expediency. The following is an official list set forth by the 
Public Health Council of the State of New York: Anthrax, 
botulism, chicken-pox, cholera (Asiatic), diphtheria (mem- 
branous croup), dysentery, (amebic and bacillary), enceph- 
alitis lethargica, epidemic cerebrospinal meningitis, epidemic 
influenza, epidemic (septic) sore throat, German measles, 
glanders, malaria, measles, mumps, ophthalmia neonatorum, 
paratyphoid fever, plague, pneumonia (a) lobar, (6) bron- 
chial or lobular, poliomyelitis, acute anterior (infantile para- 
lysis), puerperal septicemia, rabies (person bitten by rabid or 
supposedly rabid animal), scarlet fever, smallpox, tetanus, 
trachoma, tuberculosis (report on special card), typhoid fever, 
typhus fever, Vincent's angina, whooping-cough.1 
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 w'hich 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 various 
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 unlikely. 
Cases may develop, however, very much earlier; diphtheria, 
e. g., frequently wdthin two days. 
1 The Pennsylvania law (September 21, 1923) includes in addition the 
following diseases: Bubonic plague, erysipelas, leprosy, pellagra, relapsing 
fever, paratyphoid fever, and yellow fever. ISOLATION AND DISINFECTION 
249 
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 twelve days after 
the appearance of the eruption and* until the crusts have 
fallen and the scars are completely healed; diphtheria (mem- 
branous 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 have 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 thirty days after the development of the disease 
and until all discharges from the nose, ears, and throat, or 
from suppurating glands, have ceased; smallpox, until four- 
teen days after the development of the disease and until the 
scabs have all separated and the scars completely healed; 
whooping-cough until eight weeks after the development of 
the disease and until one week after the last characteristic 
cough. 
Isolation and Disinfection.-Persons affected with com- 
municable diseases are usually isolated, and when 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 who do 
not come in contact with the patient or with the secretions 
or excretions may continue their usual vocations, provided 
such vocations do not bring them in close contract with 
children. Cases of smallpox must be removed to special 
hospitals and those who have been exposed must be vaccin- 
ated. 
A physician in attendance on any case suspected by him 
to be Asiatic cholera, dysentery, paratyphoid fever, 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 above, Class IV.) In 
cases of diphtheria, epidemic cerebrospinal meningitis, epi- 
demic or septic sore-throat, measles, poliomyelitis (infantile 250 
INFECTIOUS AND PARASITIC DISEASES 
paralysis), scarlet fever, smallpox, or whooping-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 above, Class III.) 
The physician or nufse or other necessary attendant upon 
a case of diphtheria, measles, or scarlet fever, after attendance 
upon the case, should take precautions and practise measures 
of cleansing or disinfection of his person or garments to pre- 
vent the conveyance to others 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. 
Some of the following recommendations follow the practice 
of the Philadelphia Bureau of Health: After recovery or 
death of a person affected with communicable disease ade- 
quate 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 bath 
and don entirely clean clothes. In cases of diphtheria one 
or more negative cultures from the throat or nose should be 
obtained. Clothing which has been contaminated should 
be disinfected by steam, by boiling water, or by formalde- 
hyde (gas or solution). If rooms are to be disinfected by for- 
maldehyde, three pints should be used for each 1000 cubic 
feet; all cracks and crevices should be closed with cotton or 
adhesive plaster. In addition there should be an ordinary 
thorough cleansing with soap and water and full exposure to 
fresh air and sunlight. Many authorities consider the latter 
measures almost sufficient in themselves. Articles such as 
mattresses and pillows, not readily cleaned, should be sent 
away and sterilized by steam. 
Hospital Quarantine.-In hospitals strict quarantine 
regulations are usually enfored differing according to the 251 
IMMUNITY 
character of the infections, and local conditions. 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 infections, such 
as diphtheria, in which certain specific precautions suffice. 
The nurse should be familiar with the regulations in her 
particular hospital or community. 
There is a tendency in many quarters to do away with all 
precautions based on the idea of air infection. In France 
and even in several parts of this country patients with various 
forms of infectious disease (including scarlet fever, e. g.) 
are treated in common wards, in some instances isolated 
from each other merely by tapes. In other hospitals com- 
partments (cubicles) separated by glass partitions are pro- 
vided 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 mediate contact have been carried out with 
scrupulous care ("aseptic nursing"). Carelessness on the 
part of physicians or nurses, e. g., hasty and insufficient dis- 
infection of the hands in passing from case to case, is fatal 
to the success of the plan. It should therefore be used only 
when specially trained nurses are available. 
Immunity.-Thus far we have considered only the causa- 
tive agents of infection. It is well known, however, that 
infection occurs only when the patient is unduly 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, rarely 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 who is immune to measles or smallpox may be suscep- 
tible to German measles or chicken-pox. Certain persons 
and even whole races appear to have an unusual degree of 
immunity against certain disease, or, on the other hand, an 
undue susceptibility to these or other diseases. In any given 
case this cannot be assumed without a thorough knowledge 252 
INFECTIOUS AND PARASITIC DISEASES 
of all the circumstances. Thus it was formerly believed 
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 prior 
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. 
Yellow fever. 
Measles. 
Whooping-cough. 
Scarlet fever. 
Infantile paralysis. 
Typhoid fever. 
Typhus fever. 
Chicken-pox. 
Mumps. 
Cerebrospinal meningitis. 
A previous attack of pneumonia, diphtheria, erysipelas, 
or malaria seems to predispose to subsequent attacks. 
Antitoxins.-The mechanism of immunity is too compli- 
cated 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 micro- 
organisms 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 growth, but the bacterial bodies 
contain endotoxins which will occasion symptoms when 
released by the death and disintegration of the microorgan- 
isms. Bacteria of this class mutliply, as a ride, in many 
localities in the body and call forth local reactions: Inflam- 
matory exudates, abscesses, peculiar forms of infiltration, 
softening, etc. To meet the first sort of infection the cells 
of the body manufacture a chemical antidote which is specific 
for the particular infection and is known as an antitoxin. PHAGOCYTOSIS AND VACCINES 
253 
If the patient can produce a sufficient quantity of this anti- 
dote to neutralize the toxins before irreparable injury has 
been inflicted on the vital 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 massive, an artificial immunity can be produced which 
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 
portion of his blood is withdrawn and the serum separated, 
purified, and concentrated. A portion of this serum injected 
into a healthy person will lend him a temporary passive 
immunity; if injected into a person in the early stages of 
diphtheria it will supplement the patient's own stock of 
antitoxin and bring about a rapid recovery in the vast major- 
ity of cases. Before antitoxin is marketed it is tested as to 
its power to neutralize definite quantities of toxin and its 
strength is then stated in "units;" an ordinary dose of diph- 
theria antitoxin is ten thousand units. 
The production of antitoxin is not the only resource of the 
body in its struggle with invading bacteria. Other sub- 
stances called "immune bodies" are also developed in the 
serum which cause the offending bacteria to clump together, 
to lose their motility, to precipitate, and finally to dissolve 
(agglutinins, precipitins, lysins). 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. 63). 
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), while bac- 
teria in the tissues are speedily surrounded by a host of these 
same white cells which endeavor to "devour" them (phago- 
cytosis). It is not an uncommon thing to see a half dozen 
bacteria inside a single leukocyte. If the outpouring is 254 
INFECTIOUS AND PARASITIC DISEASES 
excessive an abscess may result, but even this apparent 
defeat and sacrifice of countless leukocytes (pus cells) may 
lead to recovery by bringing about discharge of the invaders 
with the pus. In the more chronic infections (e. g., tubercu- 
losis) cells of other types are brought into action and tend 
to form a connective-tissue capsule about the bacilli and thus 
isolate them from the rest of the body (latent tuberculosis). 
Peculiar types of reaction are also produced by filtrable 
viruses; e. g., Negri bodies in rabies. If the reaction against 
invading bacteria is insufficient for lack of stimulus, as often 
happens in subacute and chronic infections, vaccines may be 
injected subcutaneously in ascending doses to provoke a more 
active resistance on the part of the defensive (immunizing) 
agencies. Vaccines are made by suspending in salt solution a 
pure culture of the offending microorganisms, previously killed 
by a sufficient application of heat. The vaccine is diluted 
so that each cubic centimeter contains a definite number of 
bacteria (one million 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 immu- 
nity. As is well known, the whole personnel of the United 
States Army during the late war was protected by antity- 
phoid 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 typhoid. 
Viruses.-The injection or inoculation of live cultures 
(viruses) is very commonly practised by veterinarians to 
develop immunity against certain animal diseases and partic- 
ularly against anthrax. The cultures are weakened or atten- 
uated, as the phrase is, by passing them through resistant 
animals, by growing them under unfavorable conditions, or 
by exposing them to heat or drying. In human beings the 
use of viruses is generally forbidden except in specific in- 
stances in which they are of proved value. The virus 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 very FEVER 
255 
long. The virus of vaccinia (cow-pox), or true vaccine, is 
used to develop an active immunity against smallpox. 
Vaccinia is merely a mild form of smallpox which has been 
permanently deprived of its virulence and contagiousness by 
implantation 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, how- 
ever, they consist of dead cultures, while the true vaccine 
is a living virus. As a result of the injection of serums and 
other protein substances some persons, after a lapse of ten 
days or two weeks, tend to develop a condition of hyper- 
susceptibility so that a second injection may cause acute 
collapse and even death (anaphylactic shock), or more fre- 
quently subacute skin manifestations such as urticaria 
(serum sickness). Other persons, fortunately few in number, 
are either congenitally hypersusceptible, or develop this 
condition in some obscure manner. In such persons, the 
injection of a full dose of serum may provoke fatal or unpleas- 
ant manifestations, which, however, may be forestalled by 
giving in advance one or more minute doses. This measure 
serves both to detect the condition, and in some cases to 
desensitize the patient. Anaphylaxis occurs in conditions 
other than infections as we have seen under hayfever and 
asthma. 
Summary.- To recapitulate: Immunity may be natural or 
acquired. Acquired immunity may be passive, 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 
virus, inoculation of a modified virus, vaccine injections, 
injections of antitoxic serums, injection of antibacterial 
serums. 
Fever.-Fever is the most striking evidence of the reac- 
tion of the body against invading microorganisms. Simple 
pyrexia (rise in temperature), however, may be due to other 
causes than infection, such as sunstroke, anaphylactic shock, 
and brain injuries, but is not then associated with the ordi- 
nary evidences of toxemia. The febrile state is accompanied 
by many symptoms, some of the more frequent of which are: 256 
INFECTIOUS AND PARASITIC DISEASES 
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, albumi- 
nuria, loss of strength, weakness, prostration. 
The degree of fever may be classified in accordance with 
the following simplified scheme (Rosenau): 
Subfebrile or high normal99° to 100° F. 
Low febrile100° to 101° F. 
Moderately febrile101° to 103° F. 
High febrile103° to 105° F. 
Hyperpyrexial105° F. and over. 
The normal daily (morning and evening) variation in 
temperature is less than one degree; in fevers it is frequently 
much greater. The pulse and respiration ordinarily 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 high tem- 
perature is usually maintained from a few days to two or 
three weeks; this stage is known as the "fastigium." In 
some eruptive fevers (e. g., smallpox, measles) the course of 
the temperature may be temporarily interrupted by a remis- 
sion. At the end of a fastigium the temperature 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 pseudocrisis of pneumonia. In 
convalescence from fevers there may be recrudescences, that 
is, temporary elevations caused by overfeeding, constipation, 
excitement, or there may be true relapses which repeat all 
the features of the original attack. Continued fever is char- 
acterized by sustained temperature with only slight diurnal 
variations. Croupous pneumonia and typhoid fever are 
characteristic types of continued fever. Remittent fever 
exhibits wider diurnal variation without, however, descending 
to normal. Typhoid fever is remittent during the stages of 
invasion and lysis. Estivo-autumnal malaria is a typical TYPES OF FEVER 
257 
Fig. 47.-Measles showing remission before appearance of eruption. 
(Musser.) 
Fig. 48.-Intermittent fever of tuberculosis. (Musser.) 258 
INFECTIOUS AND PARASITIC DISEASES 
remittent fever. In intermittent fever the temperature 
reaches the normal or even falls below it in the intervals 
between the febrile paroxysms. The most typical inter- 
mittent fever is that seen in ordinary malaria, in which there 
is a regular rise of temperature every day or every other 
day, with normal records in the interim. The hectic fever 
of advanced tuberculosis and the fever of septicemia and 
BLOOD EXAM. WIDAL REACT. ABSENCE OF LEUCOCYTOSIS 
ANAEMIA REDUCTION OF R.B.C. GREATER REDUCTION OF H/EMAGLOBIN. 
Fig. 49.-Typhoid fever. Course of fever and relation to symptoms. 
(Musser.) 
pyemia may be either remittent or intermittent. In pyemia 
the diurnal variations may be 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 deter- 
mined 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 instances they TYPES OF FEVER 
259 
may be entirely at sea. The best idea of internal temperature 
is obtained by taking the observation in the rectum. This 
method is in general use in tuberculosis sanatoria since slight 
febrile variations are of great importance in early or incipient 
Fig. 50.-Intermittent tertian fever. Malaria without chills. 
tuberculosis. It is also commonly used in infant practice. 
In ordinary cases the mouth and axilla are the most con- 
venient 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 between the two. Most thermometers, how- 
ever marked, give more accurate readings if left in the mouth 
for at least five minutes. This is of importance in detecting 
subfebrile rises in incipient tuberculosis. 
Fig. 51.-Estivo-autumnal fever. 260 
INFECTIOUS AND PARASITIC DISEASES 
Treatment of Fevers.-The reduction of temperature may 
be accomplished by drugs, antipyrine, acetophenetidin 
(phenacetin), acetanilid, quinine, salicylates, but this 
method is now largely discountenanced and abandoned except 
in acute fevers accompanied by headache, pain, and aching, 
in which most of these drugs serve a double purpose. For 
prolonged fevers hydrotherapeutic methods are preferable, as 
they not only reduce fever but stimulate the nervous system 
and improve the circulation in the peripheral vessels and the 
lungs. Cool or cold water is applied in many ways, the best 
known of which are tub baths, cold packs, sponging, and the 
application of cold compresses, ice-bags and caps. As these 
are sufficiently described in nursing manuals it is not neces- 
sary to dwell on them here. Cold air also tends to keep the 
temperature down and has a most beneficial and stimulating 
effect on many patients suffering with acute respiratory dis- 
ease, e. g., croupous pneumonia. Bronchitis in children, the 
weak, and the aged is more favorably influenced by warm, 
moist air, which, however, should be frequently changed (free 
ventilation). The air in the room may be moistened by 
boiling water over a gas flame or a spirit lamp. Sunlight is 
also a valuable aid in the treatment of chronic fevers. It 
should be avoided in many acute exanthemata in which the 
eyes are affected. In tuberculosis fresh, cold air, sunlight, 
rest, and diet are the physician's chief weapons. 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 work. 
The diet of fevers should be largely liquid or semiliquid 
and if the disease is prolonged should be more than adequate 
to supply the nutritive requirements of the patient. These 
questions are considered in more detail under Metabolism 
and in the section on Typhoid Fever. In fevers which do 
not involve the gastrointestinal tract or impair the function 
of the kidneys a rapid return to solid food may be instituted 
at the beginning of convalescence. CHAPTER II. 
INFECTIOUS AND PARASITIC DISEASES-CLASS I.1 
(a) 
Toxemia, Septicemia, and Pyemia. 
Erysipelas. 
Gonococcus Infection. 
Gonorrheal Arthritis. 
(h) 
Tetanus. 
Anthrax. 
Glanders. 
Actinomycosis. 
Rabies. 
(c) 
Syphilis. 
(a) INFECTION DUE TO PYOGENIC BACTERIA. 
Toxemia, Septicemia, and Pyemia.-Toxemia, septicemia 
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) organisms. 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 sur- 
geon 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 sec- 
tion. The investigations of recent years have tended to 
break down the sharp distinctions between these three mani- 
festations 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 state 
brought about by the circulation in the body of the poisons, 
specific and non-specific, produced by the growth of various 
1 See p. 244. 262 
INFECTIOUS AND PARASITIC DISEASES 
bacteria. The bacteria may themselves circulate in the 
blood or they may be confined to a limited area whence their 
toxic products may be distributed throughout the body as 
in tetanus and diphtheria. In septicemia the bacteria them- 
selves are carried by the blood to all the tissues and elaborate 
their poisons wherever they may become established. In 
this condition we are no longer able to cure the patient by 
removing 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 favorable 
locations by pus organisms circulating in the blood. The 
prognosis in these cases is usually very bad, but is dependent 
to a large degree on the type of organism. Thus, some 
varieties of streptococci (S. hemolyticus) are very virulent, 
while others (S. viridans) give rise to subacute or chronic 
manifestations. 
Symptoms.-The symptoms of toxemia in the specific 
infections are considered under the respective diseases, 
pneumonia, typhoid, etc. The general manifestations of 
toxemia as seen in pyogenic infections are: Chilliness, irregu- 
lar fever, rapid pulse, headache, restlessness, delirium, loss 
of appetite. In septicemia the chills are more severe, oft 
repeated, and associated with high remittent or intermittent 
fever, and correspondingly severe constitutional symptoms. 
In pyemia similar symptoms occur, but are frequently accom- 
panied by drenching sweats. The patient's mind may remain 
clear, but at other times confusion, disorientation, and 
stupor 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 Osler, carry off the "majority 
of cases of advanced arteriosclerosis and of Bright's dis- 
ease"), the symptoms are very 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 are accompanied by symp- 
toms of toxemia, septicemia, and pyemia: Septic endocar- TOXEMIA, SEPTICEMIA, AND PYEMIA 
263 
(litis, 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. At the 
time the culture is taken the physician paints the region of 
the vein with 5 per cent ticture of iodine. After a constrict- 
ing bandage has been applied to the upper arm, he plunges 
a large hollow needle into the distended vein and withdraws 
(usually with a syringe) as much blood as he requires. Before 
he removes the needle the constricting bandage should be 
completely relaxed, otherwise hemorrhage into the sub- 
cutaneous tissue is liable to occur. Measured quantities of 
the blood thus withdrawn are placed in tubes and flasks 
containing culture media. An alcohol lamp should be at 
hand for flaming the necks of the tubes and flasks. 
Treatment.-The treatment should aim to remove the 
original focus of infection when this can be discovered and is 
accessible. Teeth may need to be withdrawn or extensive 
surgical operations undertaken. At autopsy deep abscesses 
are occasionally discovered which, if properly opened, would 
have prevented pyemia and death. Recently, I saw two 
cases of this sort, one with a submammary abscess, the other 
with an abscess deep in the thigh. When cultures from the 
blood are obtained, special serums may be employed or auto- 
genous 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, sup- 
portive, and tonic. 
An abundant diet of high caloric value, including milk 
and eggs, is usually advisable and fresh air should be "admin- 
istered 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 264 
INFECTIOUS AND PARASITIC DISEASES 
factors, the most careful nursing is required to secure com- 
parative comfort to the patient, to avoid passive congestion 
of the organs, to prevent bed-sores, and to maintain a healthy 
condition of the mucous membranes. Mouth washes, dust- 
ing powders, etc., as described under Typhoid Fever, will 
be required. Prophylactic 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, which we do not fully understand, pro- 
duces a specific inflammation of the skin accompanied by 
symptoms of toxemia. The infection is 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 with 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 disin- 
fection, 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 abra- 
sions 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 symp- 
toms of infection develop from three to ten days after 
exposure. 
The disease begins with rigors or a severe chill followed 
by high fever which 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 fever are present-thirst, loss of appetite, coated tongue, 
scanty urine, headache, backache, general aching, and noc- 
turnal delirium. In alcoholics delirium tremens is frequent. ERYSIPELAS 
265 
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 
seal]), causes enlargement and thickening of the ears and 
infiltrates the neck. The inflammation of erysipelas is dis- 
tinguished 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" over a large part of the body. 
In traumatic cases the localization is determined by the site 
of the wound. In babies it begins in the umbilical stump. 
In some severe cases localized abscesses develop. In one 
instance I saw gangrene of both hands. Other complications 
that may be mentioned are phlebitis, arthritis, pneumonia, 
pleurisy, endocarditis, and nephritis. Relapse may occur 
and second attacks are common. The mortality in babies, in 
the aged, and in complicated cases is large, but in the vigor- 
ous it is small. The average hospital mortality is about 
7 per cent, which is less than that of typhoid. 
Treatment.-From what has been said the prophylactic 
treatment is easily deduced. Erysipelas cases in hospitals 
should be isolated completely from the surgical and obstet- 
rical wards. Nurses and physicians in charge of such cases 
should not come in contact with patients in the above-men- 
tioned wards. Care should also be taken to protect subjects 
of chronic disease, although the precautions may be less 
stringent when open wounds 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 when 
the patients are discharged. Similar precautions hold for 
private cases. The principal precaution should be against 
conveyance of infection by the hands or infected objects. 
The diet should be ample as the patients are often debili- 
tated. Milk with cereal additions, eggs, and broths will be 
the mainstay during the febrile period. 266 
INFECTIOUS AND PARASITIC DISEASES 
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 or iron and quinine in large doses 
are old-fashioned remedies still much used. Stimulation is 
frequent required. Local applications are employed in great 
variety, from simple cold-water dressings to ichthyol and 
collodion. A recent favorite has been saturated solution of 
Epsom salt applied on a thick gauze mask and covered with 
oiled silk. All applications should extend beyond the zone 
of inflammation. Hypodermic injections of antiseptic solu- 
tions (bichloride, carbolic), in advance of the border of 
inflammation are sometimes used. 
Gonococcus Infection. - The Micrococcus gonorrheae 
attacks with great frequency the mucous membranes of the 
urethra, cervix, etc., in adults and of the conjunctiva in the 
newborn. The conjunctivae are also occasionally involved 
in adults. It is one of the leading causes of blindness. These 
manifestations as well as those which follow direct extension 
from genital infections, such as prostatitis, pus tubes and 
pelvic peritonitis, 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 conveyed 
by sheets, night-dresses, napkins, wash-cloths and towels, 
as well as by nurses' hands. Usually it is necessary to isolate 
every case admitted with the slightest discharge until a 
bacteriological examination has been made, and in positive 
cases to continue the isolation until no gonococci are found 
on microscopical examination. The patients should wear a 
napkin of some sort to save their own hands from contamina- 
tion. 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 (r. i.). 
Gonorrheal Arthritis.-The general manifestations of 
gonorrhea with which we are directly concerned are of two 
principal forms: (1) A general septicemia in which fever GONORRHEAL ARTHRITIS 
267 
and other symptoms of a mild or severe degree may develop 
with or without ulcerative endocarditis. The symptoms 
and treatment of septicemia and endocarditis have been 
described elsewhere. 
2. Gonorrheal arthritis or "rheumatism." This may be 
of varying degrees of severity from a simple arthralgia or pain 
in the affected joints to a severe suppurative inflammation. 
Occasionally the tendons and periosteum alone are involved. 
The majority of cases are characterized by pain and swelling, 
frequently of one joint, as the knee, at other times of many 
joints. Unlike acute articular rheumatism the swelling 
tends to remain more or less persistently in the joints prima- 
rily affected instead of skipping about from one to another. 
Unusual joints such as those of the jaw or spine are also 
attacked. The constitutional symptoms such as fever and 
sweats are less marked than in rheumatic fever; sweats 
indeed are usually absent. The local symptoms moreover 
are obstinate, and do not yield readily to treatment by 
salicylates. 
Careful questioning will usually elicit a history of gonococ- 
cus infection, but in women and children the clue may be 
given by microscopical examination of vaginal or urethral 
discharges, the patient frequently being entirely ignorant of 
the existence of infection. To secure a specimen the labia 
should be separated and a fresh drop of pus as it exudes from 
the urethra or vagina collected on a sterile swab and spread 
on a cover-glass or slide. After the specimen has dried it 
should be sent to the pathologist for examination. Speci- 
mens from the cervix will always be obtained by the physi- 
cian 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 who 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. 268 
INFECTIOUS AND PARASITIC DISEASES 
Treatment.-The medicinal treatment of gonorrheal arthri- 
tis is unsatisfactory. • Salicylates and iodides are frequently 
employed, but the former are of use only in relieving pain. 
In severe cases splinting is of value in conjunction with moist 
compresses (saturated magnesium sulphate solution or lead 
water and laudanum) covered with oiled silk or wax paper. 
Passive hyperemia (congestion) 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 con- 
gestion produced by moist compresses as described above, or 
in the latter stages by baking, is a pleasanter form of treat- 
ment and often quite as effective. If stiffness develops in 
convalescence the nurse will be called upon to use passive 
movements and massage. 
Gonococcus vaccine has been found of use in obstinate 
arthritis as well as in the vaginitis of children. The vaccine 
should be thoroughly shaken to emulsify or mix the bacteria 
and the required amount injected into the subcutaneous 
tissue by means of a sterile syringe, filled directly from the 
container. A point should be selected where the connective 
tissue is loose and the needle should be plunged in vertically 
to avoid pain. A preliminary sterilization of the skin with 
alcohol or iodine is of course advisable. Some physicians 
plunge the needle through a drop of carbolic solution which 
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. 
(6) VARIOUS INFECTIONS MOST OF WHICH ARE 
ACQUIRED BY CONTACT WITH DOMESTIC 
ANIMALS. 
Tetanus.-Tetanus is primarily a disease of the lower 
animals and particularly of horses, and is due to a bacillus TETANUS 
269 
(Bacillus tetani) which is abundant about stables and in 
garden earth. The organisms flourish only when protected 
from the air and are therefore apt to infect punctured or 
contused wounds, but rarely or never open incised wounds. 
Birth injuries in women and umbilical infections in babies 
are occasional portals of entry. At times the site of inocula- 
tion is so slight as to be overlooked altogether. Vaccination 
wounds have occasionally been infected by this organism, 
but with very few 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 with great care to avoid 
any contamination, and as an additional safeguard animal 
injections are made to determine its freedom from the bacilli. 
Tetanus is very prevalent in tropical countries where condi- 
tions are favorable to its growth. In this country it almost 
always arises from wounds, and until the agitation for a 
"sane celebration" was 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 within a few days of injury are extremely fatal, while 
those which develop after several wTeeks are usually mild. 
The symptoms are due to a toxin which attacks the nervous 
tissues; the bacteria themselves do not invade the blood. 
Symptoms.-The first symptom is usually stiffness of the 
jaws which 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 mus- 
cles of the neck and back become stiff and the abdomen is 
board-like in its rigidity. The limbs are less rigid than the 
trunk. In severe cases the slightest irritation, 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 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. 270 
INFECTIOUS AND PARASITIC DISEASES 
Treatment.-When infection is suspected, antitetanic serum 
may be given to the patient with reasonable certainty 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 lacerated wounds which 
cannot be made aseptic amputation is sometimes a life-saving 
measure. I have several times seen lives sacrified in an 
attempt to save a badly crushed finger or hand. Deep punc- 
tured wounds, e. g., by nails incrusted with garden or stable 
soil, should be freely incised. The South Sea Islanders are 
said to have poisoned 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 pos- 
sible. 
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 meas- 
ures 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 pal- 
liate the symptoms and to permit of the administration 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 irreparable damaged. Recently 1 have seen good 
results in severe cases following the use of multiple antitoxin 
injections into the region of the wound, into the veins, into 
the nerves principally affected, and into the spinal canal. 
Anthrax.-Anthrax is a disease of sheep and cattle (par- 
ticularly in the Orient) but is occasionally communicated 
to man. The causative agent is a spore-bearing organism ACTINOMYCOSIS 
271 
known as the anthrax bacillus which is notable for its 
large size and its resistance to disinfectants. This organism 
is frequently used as a crucial test of the efficacy 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. Infec- 
tion in human beings generally results from handling hides, 
hair, and wool taken from animals that have died of the dis- 
ease. During the war a considerable number of cases were 
traced to shaving 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 gastrointestinal 
tract. In the former case it is often called woolsorter's dis- 
ease. A combination of internal and external anthrax may 
occur. 
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. 
In conjunction with these measures antianthrax serum may 
be administered, locally (by injection), intramuscularly, 
and intravenously. 
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 persons who come 
in close contact with diseased animals. It may affect either 
the skin (farcy) or the nose and respiratory tract, and in 
either case may assume an acute or a chronic form. 
Actinomycosis.-This, again, is a disease ("lumpy jaw") 
primarily of cattle and pigs, and only secondarily of man. 
It is due to the ray fungus, a vegetable parasite of a higher 
type than the bacteria. This fungus may gain entrance 
through wounds or abrasions of the skin or mucous mem- 
branes (although by what means is uncertain), or it may be 
conveyed by food. Various forms of the infection have been 
described affecting the skin, the digestive tract, the brain, 272 
INFECTIOUS AND PARASITIC DISEASES 
and the lungs respectively. The form last mentioned, which 
is the one we usually see in man, resembles chronic bronchitis 
and pulmonary tuberculosis. Fever, wasting, cough, con- 
solidation, and cavity formation in the lung occur just as in 
the latter disease. The diagnosis is made by the discovery 
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. 
Sporotrichosis.-This is another infection due to a some- 
what similar fungus. It is occasionally seen in this country. 
It is a chronic infection which produces localized indolent 
nodules which eventually form abscesses. The lesions sug- 
gest localized tuberculosis, and have frequently led to unnec- 
essary operations. Potassium iodide is supposed to be a 
specific. 
Rabies.-This disease, also known as hydrophobia and 
lyssa, occurs primarily in dogs and is communicated by them 
to human beings. In England, prior to the War, the disease 
was practically stamped out by rigidly muzzling all dogs for 
a period of ten months, and subsequently maintaining a strict 
quarantine against imported animals. Recently, due to war 
conditions, it has recurred. 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 wolves 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 bleed- 
ing and deep cauterization with 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 probable a microscopical animal parasite. 
The incubation is long, varying from two or three weeks to 
as many months or even longer. A very prolonged incuba- 
tion is suggestive 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, however, to deny the existence of the SYPHILIS 
273 
disease altogether which some persons, even 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 dread, with 
irritability of the special senses; a stage of excitement, occa- 
sionally 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 unconscious- 
ness announce the fatal outcome. 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 mentioned 
are largely governmental. It is vulgar superstition to sup- 
pose 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 avast 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 dis- 
ease, is of great importance in internal medicine on account 
of its far-reaching consequences. Even the primary lesion 
is occasionally "accidentally" and frequently innocently, 
acquired; in the latter case from infected husbands, wives or 274 
INFECTIOUS AND PARASITIC DISEASES 
parents (congenital form), as the case may be. It deserves 
therefore, to be considered from a purely medical point of 
view without any necessary reference to morals. The causa- 
tive agent is a spiral microorganism, the Treponema pallidum 
(Spirocheta pallida), which is generally considered to be of 
animal rather than of vegetable nature.1 The disease may 
be congenital, or acquired after birth, and develops in three 
stages-primary, secondary, and tertiary. In addition, 
there are certain late stages of the infection (paresis and 
tabes) which formerly were considered more or less distinct 
diseases (parasyphilitic). Recently, however, the treponema 
has been found both in paresis and tabes. 
Fig. 52.-Chancre. (Knowles.) 
The primary stage usually manifests itself about three 
weeks 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. 
1 Yaws: Another species of treponema causes a non-venereal disease 
known as the yaws which is prevalent in Central Africa and other tropical 
regions. It is characterized by nodular, often ulcerated, skin lesions. It 
yields readily to arsphenamine treatment. SYPHILIS 
275 
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 elsewhere, and 
falling of the hair. If the eruption is slight and no general 
examination is made the case may be dismissed as one of 
simple sore-throat. The mucous patches are covered with 
a grayish-white exudate. They frequently occur at the 
junction of the skin and mucous membrane and may transmit 
infection, as in kissing. 
Fig. 53.-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 eruptions 
in great variety, degenerative diseases of the bloodvessels 
in the brain and elsewhere, destructive bone disease, 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 the dermatologist, sur- 
geon, or physician as the case may be. A brief enumeration 276 
INFECTIOUS AND PARASITIC DISEASES 
of some of the principal conditions which may be due to this 
infection follows: Enlargement of the lymphatic glands, 
secondary anemia, general arteriosclerosis, atheroma and 
aneurysm, chronic valvular heart disease, myocarditis, ulcer- 
ation 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 
liver, venereal warts 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, perios- 
teitis, 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 much less than would be anticipated from the extent 
of the damage inflicted. The pains when present are often 
worse 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 
suggestive of syphilis. In the last few years the diagnosis 
of early and of late or obscure cases, has been greatly facili- 
tated by the Wassermann reaction. This is a complicated 
test for which five or more cubic centimeters of blood are 
desirable. This may be obtained by aseptic puncture of a 
vein as in making 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 resis- 
tance of the individual, the results of treatment, or other 
causes. In many persons the primary and secondary mani- 
festations may be so slight as to escape observation, and yet 
severe tertiary or parasyphilitic affections may develop, and 
vice versa. In the congenital form persistent rhinitis, skin 
eruptions, and fissures about the mouth and anus are the 
commonest manifestations. In later youth and early adult SYPHILIS 
277 
life, interstitial keratitis, deafness, destruction of the nasal 
bones (saddle-nose), bone disease, and nervous affections are 
perhaps the most common results. 
Treatment.-The treponema has been found in practically 
all the lesions of syphilis, so that care should be used in 
collecting and destroying nasal and other discharges or secre- 
tions from moist lesions. Dishes and other utensils liable 
to contamination should be kept separate or disinfected by 
boiling or by bichloride of mercury solution. In hospitals 
separate wards should be provided for active cases with 
external manifestations. Municipal or state control of pros- 
titution has not met with success, except perhaps in the army 
and navy, 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 or more states a medical 
examination, including a Wassermann reaction, is required 
by law before marriage. The most practical methods aside 
from moral instruction are: Education in regard to the 
dangers of the disease, the provision of adequate hospital 
facilities for the treatment, so far as possible, of all active 
cases, and compulsory notification to secure proper supervi- 
sion of the patients. Information thus obtained should of 
course be regarded as confidential in order to avoid unpleas- 
ant notoriety for the unfortunate victim. Even ordinary 
active treatment may be regarded in a real sense as pro- 
phylactic, 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 was by mercurial 
preparations-mercury ointment (inunction), gray powder 
(infants), calomel (inhalation), bichloride of mercury, yellow 
iodide and red iodide (by mouth), salicylate of mercury 
(hypodermically)- in appropriate doses, succeeded or com- 
bined with potassium iodide. The mercury was usually 
given in as large doses as the patient could tolerate without 
poisonous manifestations (salivation and diarrhea). The 
iodide was also given in ascending doses. For early cases a 
course of about two years was usually recommended. If the 278 
INFECTIOUS AND PARASITIC DISEASES 
treatment was taken up at a different stage it was variously 
modified. A few years ago Ehrlich's salvarsan, and later 
his neosalvarsan, (synonyms: Arsenobenzol, arsphenamine, 
neoarsphenamine) were introduced. Recently, a preparation 
known as tryparsamide has been advocated in the treat- 
ment of paresis. This is a powerful arsenical preparation 
which is administered in sterile solution, intravenously. All 
the apparatus used must be sterile and the arm should be 
prepared as for a blood culture. In the case of neoarsphena- 
mine cold sterile water is used for preparing the solution; for 
arsphenamine a more elaborate technic is necessary. CHAPTER III. 
INFECTIOUS AND PARASITIC DISEASES- 
CLASS II.1 
(a) 
Malaria. 
Filariasis. 
Yellow Fever. 
Dengue. 
(&) 
African Lethargy. 
(c) 
Typhus Fever. 
Rocky Mountain Fever. 
Relapsing Fever. 
Trench Fever. 
The Plague. 
(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 labeled malaria, but 
the discovery of the parasite in the blood has enabled physi- 
cians to diagnose the cases with 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 without 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 which has a 
special cycle of development in the red cells of the blood. The 
"tertian" organism ("Plasmodium or Hemameba vivax") 
completes its cycle within forty-eight hours. At the end of 
this period the parasite which now completely fills the red 
blood cells segments into eighteen or more spore-like bodies. 
1 See p. 245. 280 
INFECTIOUS AND PARASITIC DISEASES 
The latter penetrate fresh red cells and the cycle begins anew. 
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 in- 
fection paroxysms occur on alternate days (Fig. 49). This is 
the common form of malaria in this climate. The "quartan" 
parasite (Plasmodium malariae) reaches full development 
in seventy-two hours, producing a chill every third day. 
If there are mutliple infections there may be chills on two 
days with a free interval of one day, or with three infections, 
chills every day. This form of malaria is rare in this country 
Fig. 54.-Some of the principal forms assumed by the plasmodium of 
tertian fever in the course of its cycle of development. (After Thayer and 
Hewetson.) 
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 
between the febrile attacks (Fig. 50). 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 281 
MALARIA 
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 fever" 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 sexual cycle of 
development entirely distinct from the asexual which occurs 
in the human blood, 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 mos- 
quitoes, the same result would ensue, because there would be 
no means of transferring the disease from person to person. 
Preventive treatment accordingly concerns itself with 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 quinine in mala- 
rial 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 otherwise rendered harmless. 
Pools, swamps, and sluggish streams which cannot be filled 
up or drained are treated with petroleum and other insecti- 
cides. During the World War a combination of the use of 
quinine with measures of sanitation was successfully utilized 
to control malaria in the cantonments of the rice field dis- 
tricts. 
Symptoms and Treatment.-Ordinary tertian malaria is 
characterized by a regular succession of severe chills followed 282 
INFECTIOUS AND PARASITIC DISEASES 
by high fever and profuse sweats. Even 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 temperature falls and a state of com- 
plete or comparative comfort is restored, which persists until 
the onset of the following paroxysm twenty-four or forty- 
eight hours later. In untreated cases the chills tend to 
become less regular and to occur a few hours earlier than 
would be expected. During the paroxysms the patients 
frequently suffer from headache, backache, and general 
pains. Occasionally there is delirium or even stupor and 
coma. Loss of appetite, coated tongue, and disturbances of 
the bowels (diarrhea or constipation) are symptoms of com- 
mon occurrence in this disease. After a succession of severe 
chills there develops decided weakness, pallor, yellow or 
sallow hue, enlarged spleen, and albuminuria. Fever blis- 
ters on the lips and nose are very characteristic of this 
affection. In this form of malaria quinine is an absolute 
specific, acting in an almost miraculous manner. Usually 
15 to 30 gr. 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 explan- 
ations.) If there is a double infection a similar dose is 
required the following day. After that quinine is continued 
in decreasing doses and finally stopped. It is usual, however, 
to administer a large dose at intervals of a week or less until 
the possibility of recurrence has disappeared. 
The estivo-autumnal type, which is also occasionally seen 
in our hospitals runs a course 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 delirium, brown tongue. These cases also respond 
readily to quinine but not so rapidly as the ordinary "inter- 
mittent." Arsenic is frequently used as an adjuvant to 
quinine during convalescence. 
Malignant types of malaria, popularly known as "con- YELLOW FEVER 
283 
gestive chills," are marked by profound prostration, uncon- 
sciousness, and sometimes a fatal termination. In hot 
weather I have seen severe attacks of ordinary malaria with 
unconsciousness mistaken for sunstroke. Another grave 
malarial condition is the so-called black-water fever, seen in 
South Africa and elsewhere, in which the patients pass urine 
deeply stained with blood pigment. 
Filariasis.-Filiaria 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 occasionally seen in our hospitals. 
Yellow Fever.-Yellow fever is an acute infectious disease 
of warm climates, which occasionally invades northern lati- 
tudes. In the eighteenth and early nineteenth centuries 
severe epidemics occurred in Philadelphia and other Nor- 
thern cities, and prior to the Spanish-American War local 
epidemics were not at all uncommon in the South. The dis- 
ease in the latter case was imported from Cuba and Central 
and South American countries where it was formerly endemic 
(constantly present). Since the Spanish-American War, 
increased knowledge of the disease and improvements in 
sanitation have caused it to disappear in this country. This 
disease is probably due to a spirochete (Leptospira icteroides) 
and is undoubtedly transmitted by a particular variety of 
mosquito. The latter fact has led to a complete change in 
methods of prophylaxis, and for this reason the disease 
deserves some consideration in this place. Formerly when 
yellow-fever patients were brought to our ports elaborate 
disinfection of the ships and of all fomites, including infected 
clothing and linen, was insisted upon. The patients were 
isolated with precautions as elaborate as in the case of small- 
pox. At the present time infected patients are isolated in 
screened rooms and the mosquitoes, in the hold of the ship 
and elsewhere, are destoyed by fumigation. Exposed per- 284 
INFECTIOUS AND PARASITIC DISEASES 
sons are detained or kept under observation during the period 
of incubation (five 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 with a stage 
of remission, jaundice, vomiting, and frequently by renal 
complications. Sometimes there is vomiting 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 mentioned 
in this connection. It is due to a filtrable virus which is 
transferred by mosquitoes and occurs in epidemic form in 
warm climates. Its poular name is due to the intense head- 
ache, backache, and general pains which are present during 
the fever which 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. 
(6) INFECTION SPREAD BY FLIES. 
African Lethargy.-This disease is indigenous to equatorial 
Africa, and is mentioned merely as a type of diseases trans- 
mitted by flies. In this instance, 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 dis- 
covered a special drug containing arsenic which is very effec- 
tual in curbing the disease. This affection is characterized 
by a prolonged course (months and even years), general 
mental hebetude or sleepiness ("sleeping sickness"), and a 
fatal termination. It has no relation to lethargic encephali- 
tis, the sleeping sickness which has recently sprung into 
prominence in Europe and America. 285 
TYPHUS FEVER 
(c) INFECTION SPREAD BY LICE, TICKS, FLEAS, OR 
BED-BUGS. 
Typhus Fever.-Typhus fever, also known as ship fever 
and jail fever, is a disease due to a filtrable virus which is 
transferred from patient to patient by lice. At one time it 
was 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 eruptive 
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 typhus there is an eruption 
which does not disappear (like that of typhoid) on pressure 
because it is hemorrhagic in character. The points of resem- 
blance in the two diseases are mainly the stupor, low mutter- 
ing delirium, brown tongue, and other so-called "typhoid" 
symptoms (really symptoms of toxemia). The disease is 
readily transmissible, probably not so much by direct con- 
tagion as through the agency of the formerly ubiquitous 
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 war-ridden countries of Europe, particularly in 
Russia, Austria, and Serbia. In Serbia the epidemic was 
checked largely through the heroic efforts of American physi- 
cians and nurses. Prophylaxis in this disease is strictly in 
the line of improved sanitation-cleanliness, destruction of 286 
INFECTIOUS AND PARASITIC DISEASES 
vermin, "delousing," and prevention of overcrowding in 
tenements, lodging-houses, jails, etc. 
Rocky Mountain Fever.-Several diseases of minor impor- 
tance are transmitted from horses and cattle to man by ticks, 
for example Texas fever and Rocky Mountain Fever. Ac- 
cording to Osler 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 symp- 
toms of the disease, including the hemorrhagic rash are not 
unlike those of typhus fever. Prophylaxis consists in "dip- 
ping or scouring" tick infested horses and cattle. 
Relapsing Fever.-There are several forms of relapsing 
fever, the best known being due to the spirochete of Ober- 
meier. Though rare in this country it may be mentioned as 
an example of a definite infection transmitted by vermin, in 
this instance by bed-bugs, lice, and fleas. Another disease 
characterized by relapsing fever was prevalent in the British 
Army, under the name of Trench Fever, during the late war. 
The disease was probably caused by a filtrable virus, ami 
was certainly transmitted by lice. 
The Plague.-The plague is a very fatal infectious disease, 
indigenous to the East, which occasionally spreads to the 
temperate zone. In recent years there have been local out- 
breaks 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 enlargement of the lymphatic glands with abscess 
formation (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 known as the "bacillus pestis." The disease 
appears to be actively contagious in the pneumonic form, but 
is usually conveyed through the agency of fleas. These not THE PLAGUE 
287 
only carry the disease from one person to another but also 
from rats and other rodents to human beings. The incuba- 
tion is from two to ten days. 
The prophylaxis of the disease is largely concerned with 
the destruction of infected animals, principally rats and squir- 
rels, and of the insect carriers. The disease is therefore 
controlled in part by general sanitary improvements, and in 
particular by a campaign directed against vermin. The 
difficulty in exterminating rats is greater than anyone not 
conversant with 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. CHAPTER IV. 
INFECTIOUS AND PARASITIC DISEASES- 
CLASS III.1 
Diphtheria. 
Laryngeal and Nasal Diphtheria. 
Treatment. 
Cerebrospinal Fever. 
Treatment. 
Pneumonia. 
Course of Disease. 
Complications. 
Treatment. 
Whooping-cough. 
Tuberculosis. 
Leprosy. 
(a) BACTERIAL DISEASES. 
Diphtheria.-The term diphtheria is derived from a Greek 
word meaning a membrane and is applied to a disease 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 conjunctiva and 
on wound surfaces. The causative 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 discovery of the bacillus, diphtheria 
of the larynx was commonly known as membranous or 
psuedomembranous 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 con- 
tagious principally for those who come in close contact with 
the patients and are exposed to what is known as "droplet" 
infection. Infection may also occur through the medium 
of "carriers" or of objects soiled with secretions. "Carriers" 
1 See p. 245. LARYNGEAL AND NASAL DIPHTHERIA 
289 
are immune persons who have been exposed to the disease 
and carry virulent bacilli in their throats, or convalescents 
whose throats have not been freed from the infection. There 
is probably 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 backache, not 
severe, but the pulse is weak and often irregular, and album- 
inuria almost the rule. As the disease progresses prostration 
becomes marked, but delirium is not a prominent feature. 
Deposits are 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 week or 
two convalescence is well 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 tem- 
porary rise caused by the injection of antitoxin. In other 
cases toxemia is intense and delirium and prostration 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 insufficiency causes a fatal 
outcome. 
Laryngeal and Nasal Diphtheria.-In the laryngeal form 
the constitutional symptoms may be slight, but the obstruc- 
tive symptoms, although they may show remissions, do not 
disappear, but tend to increase until serious or fatal inter- 
ference with respiration occurs, or until the loosening and 
coughing up of the membranes bring relief. The chief symp- 
toms 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 290 
INFECTIOUS AND PARASITIC DISEASES 
intubation or tracheotomy has been necessary are often febrile 
and are prone to develops severe bronchitis and broncho- 
pneumonia. The nasal form, while occasionally very severe, 
is more commonly mild and its character might not be sus- 
pected except for the presence of the disease in the throat. 
Cases of this kind are likely if unrecognized to act as danger- 
ous 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 selective action of the diphtheria 
toxin on the heart muscle, the kidney, and the nervous struc- 
tures leads to characteristic and often serious sequelte. 
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 convalescence. Nephritis is sug- 
gested by a pasty pallor and its presence is confirmed by 
the urinary examination. The nerves which 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 frequently involved. The throat paral- 
yses cause difficulty in swallowing and regurgitation of food 
through the nose. 
Treatment.-The prophylactic treatment of diphtheria is 
an interesting one. Non-immune persons, particularly 
children in hospitals or homes who have been exposed, should 
receive prophylactic injections of antitoxin, 1000 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 recurring epidemics may require subsequent injections. 
These might be unobjectionable except for the very rare occur- 
rence of anaphylactic shock and the more common serum sick- 
ness which is manifested by hives and other eruptions. A 
lasting active immunity against diphtheria may be obtained 
by the use of a mixture of toxin and antitoxin in definite pro- 
portions, "toxin-antitoxin." Doses, containing from 1 to 3 LARYNGEAL AND NASAL DIPHTHERIA 
291 
antitoxin units and the proper amount of toxin, are injected 
subcutaneously or intramuscularly at intervals of one week. 
The series may consist of three or more injections. At the 
same time most of the objections to prophylactic injections 
have been met by the introduction of the Schick test1 which 
enables us to distinguish immune from non-immune persons. 
The latter alone require protection. In diphtheria a strict 
quarantine should be maintained until two or more succes- 
sive cultures have been reported negative. Sputum, nasal 
and aural discharges should be collected and destroyed; all 
utensils should be boiled or otherwise sterilized; 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 them- 
selves 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 given 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 administration 
of adequate doses of antitoxin at the earliest possible moment 
and its repetition when 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 
subcutaneously (back, abdomen), intramuscularly (thigh, 
buttocks) 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 treat- 
ment consists of stimulants, diuretics etc., as indicated by 
the condition of the patients. Strychnine, caffeine, atro- 
pine, 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 Loffler's 
solution which contains toluol and chloride of iron. After 
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. 292 
INFECTIOUS AND PARASITIC DISEASES 
preliminary drying of the mucous membrane 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. If obstruc- 
tion 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 con- 
sists 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 
Fig. 55.-O'Dwyer tube, obturator and handle. (Koplik.) 
tube, which is usually made or hard rubber or gold-plated 
metal maintains a passageway of sufficient size to permit of 
easy respiration. Cyanosis is usually immediately relieved. 
A silk thread is tied to the intubation tube on introduction 
and left hanging out of the mouth. If difficulty in respira- 
tion occurs within ten to fifteen minutes the tube may be 
withdrawn by means of the thread, otherwise the thread is 
cut and removed. Sometimes soft "piano" wire is used and 
allowed to remain "permanently." Otherwise the subse- 
quent removal of the tube requires a special pair of curved 
forceps, known as an "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. When Fig. 56.-Introduction of the tube along the index finger. (Koplik.) 
Fig. 57.-Introduction of the tube into the chink of the glottis. (Koplik.) 294 
INFECTIOUS AND PARASITIC DISEASES 
the dyspnea has permanently disappeared (after two or 
three days to a week),' the intubation tube may be removed, 
but it is sometimes necessary to replace it after removal or 
after accidental displacement (cough). Sometimes the tube 
becomes clogged and must be removed for cleansing. A 
small percentage of children-usually of nervous tempera- 
ment 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 meningitis 
(also known as cerebrospinal fever and spotted fever) is due 
to the Diplococcus intracellularis meningitidis, 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 
comparatively long intervals, an important one being that 
which had its chief centers in New York and Boston in 1904 
and again in 1905. A large number of cases also occurred in 
the American Army in the years 1917 to 1919. As a rule 
cases are seen late in the winter 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 infection occurs principally, if not 
entirely, by direct contact either with the patient or with 
"carriers," as in diphtheria. Infected objects (handkerchiefs, 
pillow cases) may occasionally convey the disease, but the 
meningococcus is fortunately very susceptible to drying, 
sunlight, and simple disinfectants. 
The disease affects the delicate membranes (leptomeninges) 
which closely invest the brain and spinal cord. The furrows, 
or sulci, on the lateral aspect and the depressions at the base 
of the brain, as well 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 with pus cells. 
The spleen is enlarged, but no other organs show any char- 295 
CEREBROSPINAL FEVER 
acteristic changes unless complications have 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. In these forms except the last, the symp- 
toms 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 meningitis 
cases in childhood, Holt), and its terrible mortality (nearly 
100 per cent), has been described elsewhere (page 54). 
Epidemic meningitis is characterized by a sudden onset, 
with severe headache, vomiting, fever, sensitiveness to touch, 
light, and sound, and general rigidity. Tremor and con- 
vulsions are common. In typical cases the head is held 
stiffly or drawn backward, the spine is rigid, the thighs 
flexed on the abdomen, the hands clenched, and the feet 
extended. The patient generally lies on his side. Irrita- 
bility 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 admin- 
ister 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 weak, but may be slow at the last; the bowels are con- 
stipated. Intervals of seeming improvement occur and the 
fever which is at first high becomes very irregular. Irregu- 
lar respiration or Cheyne-Stokes respiration, with which we 
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 we 
may notice inequality of the pupils, herpes on the lips, and 
occasionally scattered hemorrhagic spots on the chest and 
extremities. In the Philadelphia epidemic of 1917 the spots 
(petechiae) were seldom observed, while in France (1918) 
they were a striking feature of the disease. Cases were 
even described in which hemorrhages were the only distinc- 
tive evidence of the infection. If the finger is drawn sharply 
across the skin a red line bordered by two white lines shortly 296 
INFECTIOUS AND PARASITIC DISEASES 
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 conditions, 
but only too frequently paralysis, chronic hydrocephalus, or 
mental impairment is the sad legacy of the disease. There 
are rapidly fatal cases wdiich terminate by death in a few days 
or hours, and cases which linger for several months. In the 
basilar meningitis of infants the duration is especially long. 
In these cases extreme retraction of the head is the most 
noticeable symptoms. (Plate II.) Mild cases also occur and 
in these the diagnosis 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 lum- 
bar puncture, an important method of diagnosis and treat- 
ment in this and other diseases. (See p. 27.) 
The prophylaxis of the disease consists in a careful disin- 
fection of the discharges or washings from the ear, nose, 
throat, and mouth, avoidance of direct exposure in case of 
cough, disinfection 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 who have been in intimate 
contact with the patient immediately prior to the onset of 
symptoms should be kept under observation until negative 
throat cultures have 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 30 cc 
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. PNEUMONIA 
297 
This destroys the micrococci and, when the changes in the 
brain and cord have not gone too far, accomplishes remark- 
able results. Serums prepared for particular strains of men- 
ingococci are frequently even more effective. Lumbar punc- 
ture 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. The patient must 
be frequently turned and otherwise cared for to avoid con- 
gestion 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 blad- 
der and bowels will also need attention, as the patients are 
frequently unconscious. Sometimes the nurse will be able 
to administer 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 ("tube 
feeding''). 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 way, is preferable. A pint or more of milk fortified 
with 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 we speak of pneumonia we usually 
mean lobar or croupous pneumonia, a malady which is 
caused by the pneumococcus1 and is now regarded as a gen- 
eral infectious disease with its most prominent manifestation 
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 bronchopneumonia (catarrhal or lobular pneumonia) 
and other irregular types which are not specific infections 
but may be caused by a great variety of organisms as well 
1 Various types (Types I, II, III, etc.) of pneumococci are described 
which produce corresponding types of disease. 298 
INFECTIOUS AND PARASITIC DISEASES 
as by the pneumococcus (croupous pneumonia is rarely due 
to other organisms). Croupous pneumonia is common from 
late infancy to middle age, while bronchopneumonia is ordin- 
arily most prevalent at the extremes of life and in debilitated 
persons. During the great influenza epidemic of 1918 
bronchopneumonia of a very fatal type attacked patients of 
all ages-particularly 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 hospitals about 20 per cent, while in insti- 
tutions which receive 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 tas the presence 
of the pneumococci themselves which are often tolerated by 
the healthy throat without apparent harm. In institutions 
and elsewhere the disease at times becomes actively infectious 
with deplorable results. The most recent explanation for 
these variations is that there are several distinct races of pneu- 
mococci with varying degrees of virulence and infectivity. 
At autopsy in typical cases an entire lobe is found con- 
solidated. 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 grayish in color, and the 
exudate has begun to soften preliminary to absorption. Only 
a small part of the exudate is ever expectorated. 
The typical signs of pneumonia are caused by the conges- 
tion and consolidation. Crepitant rales are "sticky" sounds 
caused by the air entering and separating the walls of the 
congested air cells. The dulness on percussion is due to 
the physical state of the lung. A similar "note" may be COURSE OF DISEASE 
299 
brought out by tapping a large piece of 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 constitutes a 
complication or sequel of some gravity. With convalescence 
the consolidated lung softens and is rapidly absorbed. Dur- 
ing 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. Pneumonia most com- 
monly 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 somewhat 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. Fol- 
lowing this, high fever, rapid respiration, cough, and severe 
pain in the affected side supervene. The pain is sharp or 
stabbing and occurs with 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 brought up which adheres to the lips 
and is expectorated with difficulty. On microscopical exam- 300 
INFECTIOUS AND PARASITIC DISEASES 
ination 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 when taken is found to be well sustained and the 
leukocytes are markedly increased (leukocytosis). The appe- 
tite, as in all fevers, is diminished and slight delirium is 
present, at least at night. The skin is flushed and it is com- 
monly 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 leukocytes are counted a few 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 weakness 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 untoward symptom. Sometimes in otherwise 
typical cases there is a fall of temperature of a temporary 
nature just preceding the crisis (pseudocrisis). Convales- 
cence proceeds rapidly and in another week the patient may 
be up and about. The signs of consolidation also disappear 
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. Excessive pain on res- 
piration is common in extensive pleurisy or pleuropneumonia. 
Brown or "prune-juice" sputum is found in severe alcoholic 
pneumonias. Jaundice is common in some epidemics, but 
does not in itself add to the gravity of the case. Abdominal 
distention is a condition that frequently develops and COMPLICATIONS 
301 
demands assiduous attention 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 aggravated. 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 wide 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 convalescence 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 fever 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 roentgen-ray. 
Early treatment of empyema by efficient drainage, followed 
later by lung exercises to prevent the development of chronic 
empyema (Fig. 30) usually leads to good results, but neglected 
cases often develop septicemia and either die, or are "oper- 
ated" late and recover with deformity of the chest and a 
crippled lung. In empyema complicating epidemic broncho- 
pneumonia, the results of radical operation are less happy. 
Repeated aspirations are often preferred in these cases. 
Exploratory puncture is usually made with a large antitoxin 302 
INFECTIOUS AND PARASITIC DISEASES 
syringe or with an aspirator. A small hypodermic needle 
which 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 also may 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, meningitis, and arthritis are 
a few of the other complications that may develop. As 
mentioned at the beginning pneumonia 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 exten- 
sive epidemics of bronchopneumonia both in the military and 
civilian population. As a rule the disease followed measles 
or influenza but was often seemingly independent. It was 
characterized by a high degree of contagiousness, extensive 
pulmonary involvement and high mortality (50 per cent and 
upward). Both streptococci (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 out, and after con- 
valescence 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 prac- 
tice to keep them in separate rooms, both for the protection 
of susceptible subjects and the more efficient carrying out of TREATMENT 
303 
the fresh-air treatment. This is the practice in the Philadel- 
phia General Hospital and other large institutions where 
many cases are almost constantly under observation. Dur- 
ing the pneumonia (postinfluenzal) epidemic of 1918 it was 
the rule in military hospitals to isolate patients in temporary 
cubicles improvised from sheets. Gauze masks, consisting 
of three or more layers of fine gauze, were also worn by atten- 
dants, 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 the various types of pneumococci already mentioned 
have been used with better results. That for Type I, the 
commonest form, has been found most useful; that for Type 
II is less satisfactory, while the others are probably useless. 
If this form of treatment is to be used it is necessary for the 
laboratory to determine the type of organism by injections 
into mice. Meanwhile, injections of Types I and II serum 
may be given. Some physicians employ venesection in 
robust patients if they are seen at the onset. Quinine and 
other drugs have also been lauded as specifics, but the 
majority of physicians use a treatment, which is largely 
expectant ("watchful waiting"). Simple diuretics (including 
water) are used to encourage elimination and stimulants are 
administered when needed, particularly at the time of the 
crisis. At present many physicians "digitalize" their patients 
from the outset. Expectorants are not required in croupous 
pneumonia, though they have a place in bronchopneumonia. 
Sedatives are used, when other means fail to relieve pain or 
to check excessive cough. 
For the pleuritic pain the ice-bag, dry cups, and strapping 
are most efficient; poultices, and their modern equivalents 
made of clay or chalk and glycerine, 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 oil, and blisters. A light woolen shirt 
is probably as efficient as the cotton jacket and is decidedly 304 
INFECTIOUS AND PARASITIC DISEASES 
more comfortable; frequently nothing but a muslin night- 
gown is worn. 
For the distressing tympanites which often threatens the 
patient's life by interfering with respiration, the hot-water 
bag, turpentine stupes, rectal tube, and enemas are used. 
A change in diet-omission of milk-and certain drugs (such 
as dilute hydrochloric acid, pituitrin, and eserine salicylate) 
are also beneficial. 
To control excessive temperature and to stimulate the 
respiration and the nervous system, sponging and packing 
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 with comfort. Hydro- 
therapy is hardly practicable in improvised open-air rooms 
or wards but may be employed if there is a warm retiring 
room. If the patient is treated indoors the room must not 
merely be ventilated, but there must be an unlimited supply 
of pure, cold air streaming through it. In bronchopneu- 
monia, as seen in the aged and in children, on the other 
hand, the temperature should perhaps be kept up to 65° 
and good ventilation provided. Other methods which 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 with severe 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 bedpan and the administration of a liquid diet 
with a great abundance of water, lemonade, or similar bever- 
ages. 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. 
Whooping-cough.-Whooping-cough or pertussis, is an 
infectious disease of early childhood, although adults and 
particularly the aged are occasionally attacked. It is prob- 
ably 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 contagious and WHOOPING-COUGH 
305 
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 sur- 
charged with suspended droplets after a "kink." The incu- 
bation is from one to two weeks. There are no distinctive 
pathological changes in the organs. 
After a week or two of apparently simple bronchitis, which 
may be accompanied by slight fever and associated symp- 
toms, the cough becomes spasmodic and soon develops its 
typical character. This second or paroxysmal stage may last 
for a month or more. The paryoxysms may only be occa- 
sional 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 lasting two weeks or longer. During this period the 
cough usually retains some spasmodic element. The total 
duration 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 complica- 
tions. This may take the form of nosebleed, it may be 
subconjunctival, the whole 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 situation of the blood-clot. I recall 306 
INFECTIOUS AND PARASITIC DISEASES 
a case in which paralysis of one arm was due to this cause. 
Bronchitis and bronchopneumonia are the most fatal com- 
plications and are all too common in young children. Vomit- 
ing and emaciation have been mentioned. Convulsions may 
also complicate pertussis and may be a cause of death. 
Prophylaxis and Treatment.-Children attacked by whoop- 
ing-cough should be isolated at once, as the disease is con- 
tagious from the beginning. Quarantine should be main- 
tained at least until the end of the paroxysmal stage. The 
child, however, should not be kept in the house, but should 
be allowed to go out of doors and only restricted as regards 
its association with 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 main- 
taining the nutrition. When practicable, city children should 
be sent to the country but in winter time the fresh-air treat- 
ment 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 underclothing 
as in other catarrhal affections. Some physicians find a 
tight abdominal belt of benefit in [limiting the paroxysms. 
Vaccines prepared from the causative organism and serums 
obtained from convalescent patients are now being used to 
prevent or cut short the course of the disease. Medicinal 
treatment is almost wholly sedative and should be confined 
to those cases in which the number of paroxysms is excessive. 
Drugs such as antipyrine, bromides, and monobromate of 
camphor are types of those ordinarily employed. CHAPTER V. 
INFECTIOUS AND PARASITIC DISEASES- 
CLASS III. 
(a) BACTERIAL DISEASES (Continued). 
Tuberculosis. 
Distribution of Tuberculosis in the 
Body. 
Glandular Tuberculosis. 
Miliary Tuberculosis. 
Galloping Consumption. 
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, prac- 
tically 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 tuberculosis 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, secon- 
dary infection as we shall see is frequently responsible for 
the high fever, sweats, and chills often regarded as peculiarly 
characteristic of tuberculosis itself. The secondary invaders 
are the ordinary pus organisms, the pneumococcus, and per- 
haps the influenza bacillus: Two 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 for 
certain structures. The human type is the one commonly 
found in tuberculosis of the lungs, and is communicated 
from person to person. The bovine type is ingested with the 308 
INFECTIOUS AND PARASITIC DISEASES 
food and particularly with milk, and probably gives rise to 
much of the glandular tuberculosis in children. 
Tuberculosis is rarely congenital, and probably never 
hereditary; the prevalence of the disease in certain families 
is more reasonably accounted for by the inheritance of a frail 
constitution and by exposure to infection in childhood. Dis- 
semination of the tubercle bacillus is principally due to the 
sputum, only occasionally to the urine and feces. 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. 
Another source of infection is from the milk and meat of 
tuberculous cows, and although this is not as important as it 
was once believed to be, nevertheless, meat should always be 
well cooked, and milk for children should be obtained from 
tuberculin-tested herds (pasteurization, however, kills the 
tubercle bacillus). It is now thought that most infections 
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 tuberculous 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. Furthermore, the chronicity 
of ordinary phthisis is by some authorities attributed to the 
patient's acquired resistance. Before taking up pulmonary 
tuberculosis in its various aspects, a brief summary of the 
other forms that tuberculosis may assume will be given. 
Distribution of Tuberculosis in the Body.-Gastrointestinal 
tuberculosis occurs principally in the form of tuberculous 
ulcers in the small intestine. Occasionally the cecum is 
affected, leading to the formation of a tumor-like mass. 
Tuberculosis of the intestine is frequently, but by no means 
invariably associated with intractable diarrhea. It is com- 
monly an accompaniment of advanced pulmonary tubercu- 
losis. In intestinal 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 susceptible DISTRIBUTION OF TUBERCULOSIS IN THE BODY 
309 
to cure by operative interference. Tuberculosis of the kid- 
ney is another common manifestation, one kidney being 
usually more diseased than the other. It may be associated 
with stone. Bladder tuberculosis is also found in these 
cases. Tuberculosis of the ovary is a 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 most frequent in 
childhood. In the large joints it is known as "white swell- 
ing." Pott's disease (tuberculosis of the spine) and hip 
disease ("coxalgia"), belong to this group. In these cases 
the bone frequently breaks down with the formation of 
"cold abscesses" (e. g., psoas abscess). Glandular tuber- 
culosis is most often observed in childhood and attacks by 
preference the glands of the neck. The infection in many 
cases enters through the tonsils. The glands, which are at 
first discrete tend to fuse together as the disease progresses, 
to undergo cheesy degeneration, 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 roentgen-ray 
treatment or excision. 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 known as "tabes mesenterica." These 
lesions of the bones, joints, and glands, were formerly spoken 
of as scrofula. They are discussed in works on surgery. 
The heart and bloodvessels are infrequently attacked by 
tuberculosis. Tuberculous pericarditis is, however, not 
uncommon and is often associated with tuberculosis of the 
peritoneum and pleura. Pleurisy, wdiich is generally tuber- 
culosis, has been discussed elsewhere. Tuberculosis of the 
nervous system is usually manifested as tuberculous menin- 
gitis. Tuberculosis of the skin occurs in two principal forms: 
The anatomical wart which is due to accidental inoculation 
in the performance of autopsies, etc., and lupus. The latter 
is an extremely disfiguring and mutilating disease of the 
skin which pursues a decidedly chronic course. 310 
INFECTIOUS AND PARASITIC DISEASES 
The following forms of tuberculosis will 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 which 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 with invasion of the bloodvessels or lym- 
phatics. Sometimes a bronchial lymphatic gland will open 
into a small bloodvessel and the patient who has hitherto had 
few or no symptoms, will 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 tuberculosis (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 pin-head-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 
symptoms are predominantly those of meningitis. In the 
ordinary 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 
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 impossible for 
many weeks 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 we 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 persistently negative exclude 
typhoid. CHRONIC FIBROID PHTHISIS 
311 
Galloping Consumption.-Another form of rapidly fatal 
tuberculosis is phthisis florida or "galloping consumption." 
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 disease. At 
the end of a week or ten days the so-called pneumonia does 
not clear up, the temperature is persistent 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 distinct 
form of the disease, but the early stage of the chronic ulcera- 
tive 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 sus- 
picion of tuberculosis should be awakened by a persistent 
cough, even of slight degree, loss of weight, digestive dis- 
turbances, or anemia without obvious cause. Suspicion in 
these cases will be strengthened if the temperature is found 
to show a slight evening rise. 
Chronic Fibroid Phthisis.-In patients who recover from 
tuberculosis the focus of disease is surrounded by connective 
tissue and the actual lesion itself may be converted into a 
calcareous or chalky nodule. In persons with more extensive 
involvement but with a high degree of resistance, fibroid 
induration of a whole lobe or lung may occur. This may limit 
the spread of the disease, but does not bring about complete 
recovery or latency. In these cases chronic bronchitis per- 
sists 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 com- 
monly, from some complicating or intercurrent condition. 312 
INFECTIOUS AND PARASITIC DISEASES 
Chronic Ulcerative Tuberculosis.-Chronic ulcerative phthi- 
sis is the ordinary form of pulmonary tuberculosis. It is 
characterized by more or less extensive areas of consolida- 
tion in the lung, which tend to break down with the for- 
mation 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 (pneumo- 
thorax or pyopneumothorax). 
The destructive process in the lungs is prone to involve the 
smaller bloodvessels 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 some instances hemorrhage may be the 
first manifestation of the disease; these cases are usually 
favorable and often recover. 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 in- 
volved, the course is usually rapidly downward. Tuber- 
culous ulceration of the small intestine is also a common 
complication in advanced cases. This is not invariably 
attended by distinctive symptoms, so 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 infec- 
tion, are to be attributed to secondary infection with other 
bacteria. 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 tuber- 
culosis in its widest sense would include almost the whole 
domain of preventive medicine, as tuberculosis is favored by TREATMENT OF TUBERCULOSIS 
313 
almost all unhygienic conditions: Overcrowding, lack of sun 
and fresh air, lack of cleanliness, insufficient and improper 
food, lack of exercise in the open air, etc. It has been found 
that the incidence of tuberculosis is considerably greater in 
certain houses in which sunlight and ventilation are particu- 
larly 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 mention 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 were formerly advised to go into the open, 
and live a life of active exertion-riding horseback, camping, 
tramping, etc. According to our present ideas this treatment 
was bad and suited only to a few exceptional cases. At 
present patients with fever or rapid pulse are kept absolutely 
at rest in bed. When the acute symptoms disappear greater 
activity is gradually permitted 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 without unusual fatigue. In 
some instances work is prescribed with the idea of causing 
a slight febrile reaction (auto-inoculation with the tuberculous 
toxin). 
In recent years, the principle of local rest has been applied 
to pulmonary tuberculosis with considerable success "in 
cases in which everything else has been tried and found 
wanting" (Fishberg). Measured quantities of air or nitro- 
gen are introduced into the pleural cavity through a needle, 
attached to a special apparatus, causing partial or complete 
collapse of the affected or most seriously affected lung. 
Extensive adhesions interfere with this treatment and 
advanced disease in the opposite lung would also be a contra- 314 
INFECTIOUS AND PARASITIC DISEASES 
indication. It is usual to give repeated insufflations of 100 
to 300 cc every few days until complete collapse is obtained, 
and later supplementary injections as necessary. Under 
this form of treatment intractable hemorrhage is controlled 
large cavities are emptied, cough and expectoration are 
Fig. 58.-Robinson's modification of the Brauer apparatus for inducing 
pneumothorax. (Fishberg.) 
decreased, and fever is reduced The disease in the treated 
lung tends to enter a latent stage while the healthy or little 
affected lung assumes the function of respiration which it is 
often capable of fulfilling satisfactorily. Rarely, operative 
measures are employed to attain the same end. TREATMENT OF TUBERCULOSIS 
315 
Fresh air is a very important agent in the treatment of this 
disease. Where it is possible, a well-screened sleeping porch 
or tent should be arranged in the yard or on a roof or balcony. 
When the weather conditions permit the shelter should be 
completely opened at least on two sides so as to allow a free 
circulation of fresh air. Tents closely battened are worse 
than ordinary rooms. Cold, dry air is undoubtedly more 
beneficial than warm or damp air, except perhaps in tuber- 
culous 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 quarters, 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. Even the beneficial 
effects of Alpine sunlight may now be imitated by the ultra- 
violet lamp (heliotherapy). 
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 
2000 calories, half a dozen eggs representing nearly 500 calor- 
ies, and a substantial meal making up the total to 3000. 
Very often 4000 or 5000 calories a day are administered, but 
the advisability of excessive hypernutrition is being ques- 
tioned. More difficult to arrange but 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 main- 
tenance of nutrition and increase in weight 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 
minimal doses of tuberculous toxins obtained by grinding 
and suspending killed tubercle bacilli. When tuberculin was 
first introduced, many years ago, comparatively large doses 
were employed with results which in most cases were far from 
happy. This led to its temporary abandonment except for 
diagnosis. The injection of a moderately large dose of 316 
INFECTIOUS AND PARASITIC DISEASES 
tuberculin in a person or animal possessing a focus of infec- 
tion anywhere in the body causes a sharp febrile reaction. 
Fig. 59.-Outside sleeping room. (T. S. Carrington.) 
This is constantly used in the case of cattle in order to 
diagnose the presence of the infection. In human beings it TREATMENT OF TUBERCULOSIS 
317 
is employed for the same purpose, but less often than formerly 
on account of the discovery of less troublesome modes of 
applying the test. Von Pirquet found that if a little tuber- 
culin was rubbed into an abrasion on the arm, a local reaction, 
with redness and slight swelling, would appear in a day or 
two if the patient were infected with tuberculosis. Calmette 
employed a similar reaction in the conjunctiva, but this is 
now little employed on account 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, 
which consists in the use of very minute doses administered 
hypodermically at suitable intervals over 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 reaction. In this manner the patient 
develops a resistance to the tuberculous toxins which may 
enable him to overcome and localize the infection. Large 
doses on the other hand tend to overwhelm the defensive 
forces of the body and to facilitate the rapid progress of the 
disease. Tuberculin therapy is little used in this country, but 
is very popular in England. Patients with active tubercu- 
losis who indulge in excessive exercise probably absorb similar 
poisons from their own diseased tissues and so encourage 
the progress of the disease. 
The medicinal treatment of tuberculosis is disappointing. 
Innumerable drugs have been proposed as specifics, but 
none of them has held a permanent place except cod-liver 
oil and perhaps cresote. The former is not only good as a 
food but is a valuable source of vitamins (q. ®.). The latter 
administered in small doses may relieve both dyspepsia and 
bronchitis. Enormous doses of creosote were formerly pre- 
scribed, but these are now little used. Iodine preparations 
of various kinds are credited by some with curative proper- 
ties; they are frequently administered by inunction. Other 
drugs are used symptomatically, e. g., codeine for excessive 
cough, nux vomica for anorexia, iron for anemia, etc. 318 
INFECTIOUS AND PARASITIC DISEASES 
These and other methods of treatment may be carried out 
in the patient's home or in a sanatorium. 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 treat- 
ment at home can remain with 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 we now call leprosy is probably 
not identical with that described in the Old Testament, 
which, according to the best authorities, included other skin 
conditions, and particularly 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 Hawaii 
and the Philippines. The leper colony in the former place is 
particularly famous. The disease is due to an organism 
which in many respects resembles the tubercle bacillus, and 
is possibly transmitted in a similar manner.1 The popular 
exaggerated dread of contagion is unwarranted, as physicians, 
priests, "sisters," etc., have lived for years in comparatively 
close contact with cases without acquiring the disease; not 
all have been so fortunate. Its contagiousness is probably 
on a par with that of tuberculosis. Leprosy occurs in two 
forms, which are, however, 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 designation 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 intractable 
1 Some authorities suspect that the bed-bug is responsible for the transfer- 
ence of this disease, while others hold that infection enters through abrasions 
of skin or mucous membranes. LEPROSY 
319 
ulcers occur. The disease is extremely chronic and has 
hitherto been considered incurable. Chaulmoogra oil is of 
Fig. 60.-Anesthetic leprosy with mutilating results. (From a photograph 
of a leper in the Sandwich Islands.) (Ormsby.) 
considerable value given over a period of years with inter- 
missions. It is used internally beginning with a dose of 
5 min. three times a day, and increasing to one teaspoonful. CHAPTER VI. 
INFECTIOUS AND PARASITIC DISEASES- 
CLASS III. 
(6) DISEASES OF UNCERTAIN ORIGIN. 
1. Probably Due to Various 
Types of Streptococci. 
Rheumatic Fever. 
Course. 
Diagnosis and Prognosis. 
Treatment. 
Follicular Tonsillitis and Quinsy. 
Scarlet Fever. 
Course. 
Prophylaxis and Treatment. 
2. Probably Due to Filtrable 
Viruses or Ultramicroscopic 
Organisms. 
Infantile paralysis. 
Encephalitis Lethargica. 
Influenza. 
Glandular Fever. 
Mumps. 
Measles. 
German Measles. 
Smallpox or Variola. 
Vaccinia. 
Chicken-pox. 
(1) DISEASES PROBABLY DUE TO VARIOUS TYPES OF 
STREPTOCOCCI. 
Rheumatic Fever.-Rheumatic fever, which is also known 
as acute articular or inflammatory rheumatism, is an infec- 
tious disease of uncertain causation. It is probably due to 
streptococci which have acquired a special predilection for 
the joints and other serous surfaces (endocardium, pericar- 
dium, pleura). Prolonged growth in the crypts of the 
tonsils or in other hidden places seems to modify the strep- 
tococci so that they attack these special structures and lose 
their power to produce general inflammatory conditions. 
This hypothesis is worthy of mention, because it may explain 
the frequent incidence of rheumatism in persons who have 
been repeated victims of follicular tonsillitis. Although the 
disease is infectious and is present in epidemic proportions 
in the late winter and early spring, we do not know enough of RHEUMATIC FEVER 
321 
its transmission to take any precautionary measures, aside 
from the avoidance 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 have 
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 fre- 
quently simulated by the various forms of arthritis which are 
so common at that age period. Males (particularly coach- 
men, 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 themselves rheumatic, though 
here there is much uncertainty on account of the failure to 
distinguish gout, rheumatisms, arthritis, muscular "rheu- 
matism," etc. 
Course.-Rheumatic fever usually begins suddenly after a 
chilling or thorough wetting. I remember sleeping in a long- 
unoccupied, chill, "spare-chamber" at a farm house where 
I visited in childhood and waking in the morning with joints 
so swollen and tender that I was barely able to crawl down 
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 fever and by 
sweats. The large joints are successively involved, shoulders, 
elbows, wrists, knees, ankles, hips, and occasionally smaller 
joints. When new joints are involved those first affected 
tend to clear up and when 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 and valve leaflets (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 pericarditis, if all 322 
INFECTIOUS AND PARASITIC DISEASES 
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 cardiac enlargement. Peri- 
carditis is recognized by its special physical signs, to-and-fro 
rub, etc. Pleurisy, pneumonia, and very high temperature 
are other complications of rheumatism. Sometimes joint 
symptoms are associated with 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 valvular 
heart disease its ultimate consequences are very serious in 
many cases. The forms of valvular 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 whether there is any such 
condition as chronic rheumatism in the sense of a direct 
sequence to the acute disease. Cases so described are forms 
or mild arthritis or inflammation of the joints, due to a 
variety of causes. Some of them are mild forms of rhema- 
toid arthritis, others have nothing more behind them than 
flat-feet for example. Acute articular rheumatism may be 
confused with gout, with the acute forms or stages of rheu- 
matoid arthritis, with infectious arthritis (particularly gonor- 
rheal 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 be 
largely fluid with cereal additions, but later a simple but 
abundant diet should be given. 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 physi- 
cians, however, would limit the meat more strictly than I 
have indicated. 
The medicinal treatment of rheumatism usually consists 
of suitable doses of salicylic acid or some of its derivatives. 
Alkalies are also used, either separately or in combination FOLLICULAR TONSILLITIS AND QUINSY 
323 
with salicylates, and recently vaccines and serums have been 
employed by some clinicians. The local treatment is more 
important from the nurse's standpoint. If no local medica- 
tion 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 prevent 
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 wintergreen, medicated 
ointments, etc. When the swelling and stiffness of the joints 
are persistent, massage and baking are often of use. After, 
or better, before, an acute attack an effort should be made to 
eliminate all possible sources of focal infection not only 
because of the danger of recurrence of the arthritis, but more 
particularly on account of the great risk of endocarditis. 
The tonsils, lingual and faucial, are most often responsible, 
but focal infections in the teeth, sinuses, gastrointestinal and 
urinary tracts, should not be overlooked. 
Follicular Tonsillitis and Quinsy.-Acute tonsillitis is an 
infection which is probably due to a modified streptococcus, 
similar to or identical with that which causes acute articular 
rheumatism. The close relation which exists between recur- 
ring follicular tonsillitis and rheumatism is a medical truism. 
The various forms of tonsillitis may be due to distinct micro- 
organisms, or to microorganisms of the same kind but of 
varying virulence (streptococci). The marked variations in 
the severity of the disease and particularly in its communica- 
bility are sufficient evidence of this statement. Most cases 
are only slightly contagious while others deserve the designa- 
tion of epidemic or "septic sore-throat" (the pharynx is also 
involved). 
Tonsillitis is of three general types, features of all of which 
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 with a yellowish- 
white exudate which may be limited to them or may spread 324 
INFECTIOUS AND PARASITIC DISEASES 
over the whole surface of the tonsil. Unlike the membrane 
of diphtheria it does not spread beyond the tonsil and is 
easily detached with a probe or applicator. In a second 
type (parenchymatous) the tonsil is diffusely swollen and 
infiltrated, while in a third, quinsy, the inflammation involves 
the tissues which surround 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 with severe 
headache, backache, and general pains in the limbs. There 
may be a decided initial chill. The temperature rises imme- 
diately 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 
well 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 two or three days to 
a week the temperature falls by crisis and the patient rapidly 
recovers. In the parenchymatous type the local symptoms 
are more pronounced. The follicles are not especially in- 
volved, but there may be small abscesses in the substance of 
the tonsil or tonsils. 
Quinsy (peritonsillar abscess) is a much more distressing 
affection. It may complicate or follow an ordinary attack 
of acute tonsillitis or it may arise independently. 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 distress. 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, and involves the tissues about the tonsil more than 
the tonsil itself. The temperature is moderate but irregular 
and disappears when the abscess has opened, whether spon- 
taneously or following incision. The duration is indefinite- 
a week more or less. SCARLET FEVER 
325 
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 
followed 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 indicated. An ice-bag or hot applica- 
tions externally are grateful to many patients. In quinsy 
more active local treatment is required. A free use of 
alkaline sprays, gargles, and mouth washes aids the patient 
in getting rid of the large quantities of mucus. When sup- 
puration has occured, incision into the peritonsillar tissue 
shortens the attack. 
Persons who have had repeated attacks of tonsillitis and 
quinsy may exhibit glands which are pitted with deep un- 
healthy follicles and deformed by scar tissue. In these 
cases operation may remove cryptic (hidden) infections which 
are responsible for acute (rheumatic) or chronic articular 
disease (arthritis deformans). 
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 princi- 
pally young children. The infectious material is present in 
the discharges from the nose, ears and throat (or from suppu- 
rating 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 fever wards, after ordinary cleaning and airing, 
were utilized by influenza cases without any resulting cross 
infection. It can probably be carried by a third person and 
such persons (carriers) may harbor the infecting organism in 
their throats. The causal microorganism is unknown but is 
probably a modified form of the streptococcus. A filtrate 
made from cultures of these organisms is now being used as 
an intracuticular diagnostic test (Dick), in a manner not 
unlike that previously described for diphtheria. It is hoped 326 
INFECTIOUS AND PARASITIC DISEASES 
that a satisfactory antitoxin may be developed. The incu- 
bation is short, 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 vomit- 
ing or convulsions, headache, and sore-throat. The face is 
flushed, but the eruption appears first on the neck and chest 
and then spreads downward involving the limbs last. There 
is no real eruption 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 associated 
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 infec- 
tious disease, and at the same time are not expected to exclude 
or mistake other conditions. In addition to measles, German 
measles, and even smallpox, all of which may closely simulate 
scarlet fever, there are deceptive rashes due to food idiosyn- 
crasies, to serum injections, to drugs, and even to enemas. 
Drug rashes due to belladonna, quinine, sodium salicylate, 
and copaiba are well known. 
Course.-The period of invasion lasts, as a rule, only 
twenty-four hours and is characterized by headache, vomit- 
ing, sore-throat fever, and rapid pulse. At the end of 
twenty-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 weeks. The latter varies in character 
from a fine powder-like deposit to large sheets of skin which 
may form perfect casts of hands or feet. In mild cases in 
which 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 with the onset, 
maintains its height during the acme of the disease, and falls 
rapidly, though not by crisis, with the disappearance of the SCARLET FEVER 
327 
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 
always 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 inflam- 
mation of the throat there is an associated enlargement of 
Fig. 61.-Desquamation in scarlet fever. (Welch and Schamberg.) 
the glands of the neek. The tongue is at first heavily coated 
with white, but at the time of the appearance of the eruption 
the papillae become red and swollen and project through the 
white, giving the tongue a 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 328 
INFECTIOUS AND PARASITIC DISEASES 
the enlarged red papillae are the characteristic features. 
With these more typical symptoms are associated the usual 
concomitant phenomena of fever: Thirst, loss of appetite, 
gastrointestinal 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, 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 important from the point of view of 
prophylaxis, as the discharges are prone to convey the disease 
and to prolong the period of infectivity. The onset of 
nephritis should be immediately revealed by routine examina- 
tion 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 week of convalescence or later. 
Diphtheria is common after scarlet fever, especially in insti- 
tutions, but if it is recognized promptly and treated with 
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 which 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 enlargement 
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 complications 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 PROPHYLAXIS AND TREATMENT 
329 
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 vaccination in smallpox. In view of these 
facts the patient should be rigidly quarantined with an atten- 
dant, and the quarantine 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 dissemina- 
tion of scales, and the nose and throat should receive atten- 
tion. Slight desquamation need not be a bar to raising the 
quarantine, but aural or nasal discharge is of more impor- 
tance. Some authorites (Ker) advise that discharged 
patients should avoid intimate contact (kissing, 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 convalescence, 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 avoidance of aural and respiratory complications. 
In case of nephritis the usual measures (see Acute Nephritis) 
to secure elimination will be in order. Drug treatment is 
purely symptomatic. 330 
INFECTIOUS AND PARASITIC DISEASES 
(2) DISEASES PROBABLY DUE TO FILTRABLE VIRUSES 
OR ULTRAMICROSCOPICAL ORGANISMS. 
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 infectious features have come 
more and more into prominence. As an evidence of this 
change of viewpoint the paralyses are now regarded as 
frequent complications rather than essential or invariable 
accompaniments of the disease. 
In 1909 the disease was reproduced experimentally in 
monkeys by the inoculation of material from patients dead 
of the disease. Since that time the virus has been success- 
fully 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 bacterial filters. The virus is 
easily destroyed by ordinary antiseptics-e. g., 1 per cent 
peroxide of hydrogen or 1 per cent menthol in oil-but like 
vaccine virus resists the action of glycerine (Rosenau). The 
infectious agent is found on the mucous membranes of the 
nose and throat and of the gastrointestinal tract, as well 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 fiy) has been suspected. Healthy "con- 
tacts," 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 through adults are occasionally 
affected. INFANTILE PARALYSIS 
331 
Symptoms.-Iii typical cases of poliomyelitis the course 
of the disease is sharply divided into two stages (compared 
to the humps of a dromedary by Draper) separated by a 
longer of shorter interval (a few hours to a few days) of 
apparent health. In some cases the symptoms 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 characteristic. 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 of the extremities. In fatal cases paralysis of the 
respiratory 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 would be expected at 
first. The muscles permanently paralyzed undergo atrophy. 
One attack of the disease gives a high degree of immunity. 
Treatment.-Prophylaxis should be principally directed to 
the disinfection of discharges from the nose and throat and 
to the isolation of contacts and convalescents. Disinfection 
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 exan- 
themata. Nurses and other contacts may spray the nose 
and throat with peroxide solution, one part to two 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 who have passed through an attack of the disease, is 
frequently injected into the spinal canal after lumbar punc- 
ture and in some cases seems to have a favorable effect. 
Occasionally severe headache, respiratory distress, etc., may 332 
INFECTIOUS AND PARASITIC DISEASES 
follow such an injection. Under these circumstances the 
physician should be immediately summoned and needles 
made ready for lumbar puncture. 
After the acute stage has passed the physician will make 
use of measures designed to restore the greatest possible 
degree of function to the paralyzed muscles. These include 
strychnine, massage, passive movements, gymnastic exer- 
cises, electricity, and hydrotherapy (salt baths). Among 
the poor the mother may be taught to use massage and em- 
ploy suitable movements, but in the well-to-do this task will 
fall to the nurse or masseuse. Faradic (electric) stimulation 
is often of great use in restoring the affected muscles. Occa- 
sionally the galvanic current may be required. In the later 
stages, when complete atrophy has occurred, orthopedic 
procedures are in order. In a general way these include the 
use of various forms of apparatus and operations. In the 
last few years surgeons have been successful in restoring 
partial or complete use of paralyzed limbs by the transplan- 
tation of tendons. This is possible because not all the 
muscles of a part are affected. 
Encephalitis Lethargica (Sleeping Sickness).-This disease 
in its present manifestation first appeared in Vienna (1916), 
later in France (1918), and subsequently (1919) in this coun- 
try where it has since been epidemic in various localities. 
A similar or identical disease has been associated with 
previous pandemics of influenza, but the latter disease is 
probably at most a predisposing cause. Encephalitis bears 
a strong resemblance to poliomyelitis, but differs in that it 
exerts its principal effects upon the brain rather than upon 
the cord. 
As the name (encephalitis) implies, the pathological changes 
are in the brain and more particularly in the nuclei of the 
cranial nerves and in the great ganglia at the base of the 
brain. The spinal cord may also be affected to a less extent. 
The causative factor has not been definitely determined, 
but it probably is a filtrable virus similar to that referred to 
under infantile paralysis. In contrast to the latter disease, 
adults are chiefly affected, but cases are by no means uncom- 
mon in children and even in infants. ENCEPHALITIS LETHARGICA 
333 
Symptoms.-The most typical symptoms are lethargy, 
varying from sleepiness to stupor, double vision, difficulty 
in swallowing, and other evidences of cranial nerve involve- 
ment, weakness, headache, dizziness, fever, loss of memory, 
tremor, muscular rigidity, and constipation. In other cases 
there may be restlessness and insomnia. The wealth of 
symptoms exhibited seems only limited by the functions of 
the affected cranial nerves, nuclei, and basal ganglia. In 
some types of the disease, the symptoms are principally in 
the distribution of the spinal nerves. Some patients, for 
example, show inveterate unilateral jerking movements of 
the abdominal muscles (clonic type). 
The disease begins with fever, sometimes slight, often 
high, but usually irregular, and is accompanied by sweats, 
headache, vertigo, weakness, and lassitude. The course 
may be very stormy resulting in death before the more 
typical symptoms are manifested. In most cases, the early 
course of the disease is prolonged, and convalescence is accom- 
panied by distressing complications and sequelae, some of 
which are very persistent or even permanent. It is believed 
by many that the disease is chronic and progressive, and 
that there is a high mortality late in the disease. In children, 
there is often an associated change in character with behavior 
difficulties, and in some cases criminal tendencies. In 
adults, after a few months, or even years, a group of symp- 
toms frequently develops which resembles that seen in 
Parkinson's disease ("shaking palsy"). The face has a 
mask-like appearance, often with a fixed smile; the limbs are 
held stiffly, and the movements are awkward. A tremor of 
variable degree which decreases or disappears on effort to 
control may also be present. Loss of control of the emotions 
is also common.1 
Treatment.-No specific treatment has as yet been discov- 
ered. Experiments with intravenous injections of solutions 
1 Physical sequelae-such as symptomatic paralysis agitans, choreiform 
movements, cranial nerve palsies (especially of the oculomotor and facial 
nerves), hemiplegia, monoplegia, etc.-are more common in adults and 
adolescents; mental sequelae-defective memory, loss of concentration, 
drowsiness, change of temperament, mental depression and even insanity 
-are more common in young children. 334 
INFECTIOUS AND PARASITIC DISEASES 
of some of the synthetic dyes are being tried, and are prom- 
ising. Meanwhile, rest and symptomatic treatment in the 
early stages, and physical and orthopedic measures in the 
late stages are useful. 
Influenza (Grippe).-Several diseases are probably con- 
fused under the term influenza. True influenza occurs in 
widespread epidemics which are often world-wide and are 
therefore known as pandemics. These pandemics occur at 
comparatively long intervals (twTenty-five to thirty years), 
but may be followed by local epidemics. True influenza is 
probably due to a filtrable or ultramicroscopical organism. 
The "influenza bacillus" which was formerly considered the 
specific cause is now generally thought to be a secondary 
invader. The influenza bacillus and other common organ- 
isms (pneumococci, streptococci) may be of importance in the 
causation of the non-specific influenzal colds, "grippe," etc., 
so common in the cold, seasons of the year. 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 atmos- 
pheric condition, 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 would 
explain (Osler). The epidemic of 1918, which was associated 
with epidemic (streptococcic) bronchopneumonia, is believed 
to have caused upward of 400,000 deaths in the United States 
during the months of September, October and November. 
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 respira- 
tory system, but nervous and gastrointestinal forms are 
described in which the principal stress seems to fall upon those 
systems. 
The disease begins suddenly and is attended with symp- 
toms of extreme prostration, severe headache, backache, and MUMPS 
335 
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, infection of the conjunctiva, 
and in the gastrointestinal form, vomiting or diarrhea. In 
the course of a few days, in uncomplicated cases, the symp- 
toms subside and convalescence begins. In spite of the 
apparent mildness of the disease recovery of health and 
strength is often slow. Complications are frequent, par- 
ticularly 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 sensitive. 
On this account it is well 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 condi- 
tion of the patient's stomach will permit. The pains in the 
acute stages may be relieved by the use of hot-water bags or 
other local applications, and by the administration of sali- 
cylates, phenacetin, and codeine. These remedies are to be 
used with 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 isola- 
tion may be effectual is proved by the fact that prisons and 
other institutions have frequently escaped infection, even in 
widespread epidemics. 
Glandular Fever.-Glandular fever is an acute febrile 
affection occasionally seen in children, which is characterized 
by fever of short duration, mild constitutional symptoms, 
and general glandular swelling. Very little, if any, treatment 
is necessary. 
Mumps.-Mumps (epidemic parotitis) is an infectious dis- 
ease which attacks children and young adults particularly. 
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 336 
INFECTIOUS AND PARASITIC DISEASES 
not known; mumps may be due to a filtrable virus. 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 ear and overlaps the angle of the jaw, which serves 
to distinguish it, as a rule, from simple lymphatic enlarge- 
ments, which are below 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 pancreas. 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 symp- 
toms 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 laudanum, 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 infec- 
tious disease characterized by catarrhal symptoms, fever, 
and later, a diffuse, patchy eruption. It is doubtless 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 epidemics 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 MEASLES 
337 
mistaken for measles. The disease is infectious from the 
first catarrhal symptoms and is transmitted directly from 
patient to patient, rarely by second persons or infected 
objects. The infection seems to be principally contained 
in the discharge from the eyes, nose, and ears, seldom if at 
all, in the scales. It is extremely active, but does not stand 
drying or other unfavorable influences. Infection is there- 
fore not air-borne except within short range, as from coughing 
and sneezing. The period of incubation before the appear- 
ance of the first symptoms is usually ten days, and before 
the appearance of the eruption, two weeks. 
The disease begins with 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 white 
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 two in the fever and other symptoms 
on account of which the patient might be considered conval- 
escent, but with the appearance of the eruption the fever 
again rises (see Fig. 47). The eruption usually appears 
first in the edges of the hair, or on the forehead, or below 
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 fever 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 week 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 
responsible for the large mortality of this disease in infants 
or unprotected adults. Bronchitis and tuberculosis are also 338 
INFECTIOUS AND PARASITIC DISEASES 
common respiratory complications, the former being serious 
from its liability to terminate in pneumonia. Other sequels 
are defects of vision, deafness, and chronic enlargement 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 fever 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 determined by these and the 
previously named complications. Uncomplicated measles 
is not a serious disease but the frequency of bronchopneu- 
monia and of other grave complications 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, 
but recently immunization by means of serum from convales- 
cing cases has given promising results. Notification, quar- 
antine, 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 well-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 cloth- 
ing exposed to contamination. The attendants should wear 
gowns and caps and disinfect their hands and faces before 
leaving the room. Quarantine should be maintained for 
"ten days after the appearance of the rash and until all dis- 
charges from the nose, ears, and throat have disappeared 
and until all cough has ceased." The scales are not impor- 
tant, but their diffusion should be limited by the use of 
ointments and the usual antiseptic bath at the end of the 
illness. GERMAN MEASLES 
339 
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 fever has disappeared soft 
diet may be given and later solids. As said before the eyes 
should be protected without limiting the ventilation. 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 bronchitis 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 symp- 
toms, but these are so mild that they are frequently over- 
looked. 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 else- 
where 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 dis- 
appears in a few days and the patient is convalescent. The 
temperature seldom rises above 100°. There are no compli- 
cations, 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. 340 
INFECTIOUS AND PARASITIC DISEASES 
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 was very 
fatal and even those who recovered were frequently disfigured 
by excessive scarring. At the present time owing to the 
efficiency of vaccination, it is a relatively rare affection; 
during seventeen years of practice, the writer has encoun- 
tered only two or three cases. Many cases moreover are 
modified by vaccination and are very mild (varioloid). 
Small epidemics occur from time to time, principally in 
unprotected persons or in adults who have outgrown their 
childhood immunity (from primary vaccination). In coun- 
tries where revaccination is systematically practised the 
disease is almost non-existent. On the other hand, where the 
scruples of individuals are allowed to defeat the purpose of 
vaccination laws, serious epidemics have occurred. In this 
disease, as in many other diseases in this chapter, a filtrable 
virus is probably the causative factor. In the pustular stage 
ordinary pus organisms occur as secondary invaders. 
After an incubation of about twelve days the disease sets 
in suddenly with high fever, loss of appetite, sleeplessness, 
delirium, severe headache and backache, chills, and perhaps 
nausea and vomiting. Sometimes a diffuse rash occurs 
which may mislead the physician and suggest scarlet fever 
or other infections. With the appearance of the eruption 
on the third day the "initial" fever disappears. The stage 
of remission lasts about four days. The eruption appears as 
little reddish, "shot-like" elevations or papules about the 
wrists and in the edge of the hair. The face, forearms, and 
wrists show the most profuse eruption while 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 
with clear fluid. This gradually becomes milky and finally, 
about the sixth day of the disease, the vesicles are converted 
into "uinbilicated" pustules. Finally the pustules rupture 
and form crusts which separate after a period of weeks to 
leave the characteristic pitted scars. During the pustular 
stage there is a secondary irregular fever which varies in 
degree and duration in accordance with the profuseness of PLATE VI 
Notice the eruption on face is crusting while the remainder is at 
its height. (Knowles.) 
Smallpox (Typical Distribution). VACCINIA 
341 
the eruption. In mild cases or in varioloid there may 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. The 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 compara- 
tively 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 prevalent all 
who have not been recently vaccinated should undergo the 
operation again. Otherwise vaccination in infancy and again 
on entering schools 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 affec- 
tion is found in horses) which manifests itself as pustules on 
the udders. The local and constitutional symptoms 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 cus- 
tomary 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 contagion, was replaced by this new 
and practically harmless method. In Jenner's time, and even 
down to the last quarter of the nineteenth century, it was 342 
INFECTIOUS AND PARASITIC DISEASES 
customary to take the scab from a healthy child and preserve 
it for future vaccinations. While this was on the whole a 
satisfactory plan it occasionally led to unfortunate conse- 
quences on account of the simultaneous inoculation of other 
disease, particularly of syphilis. However, objections 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 with glycerine and kept until free from 
contaminating organisms. The calves are killed and exam- 
ined for tuberculosis or other disease and the vaccine is tested 
for freedom from tetanus. Serious infections due to the 
lymph itself are now of the rarest occurrence, although a 
vaccination wound, like any scratch if carelessly treated, may 
serve as an avenue of entrance for some chance infection such 
as erysipelas. The nature of vaccinia 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 depriving it of its specific protective power against 
smallpox. 
In persons who have been vaccinated and are still immune 
revaccination does not "take," but on the second day a 
small area of redness appears which 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 vesiculation 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 two 
with local induration and swelling. More severe reactions 
are usually due to mixed infection with pus organisms. 
These seldom prove serious and are treated on general anti- 
septic principles. Enlargement 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 outerside of the leg near the head of the CHICKEN-POX 
343 
fibula, the choice being determined by the freedom of these 
regions from movement. 
Chicken-pox.-Chicken-pox or varicella is one of the least 
serious of all the infections and one that rarely requires treat- 
ment. As already stated it is of most importance on account 
of its resemblance to varioloid. The incubation is approxi- 
mately two weeks and the eruption 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 chiefly con- 
fined 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 
with 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 contagious 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. Prophylaxis by 
means of serum from convalescent patients has recently 
been introduced. 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. 
Hydrotherapy. 
Malta Fever. 
Cholera. 
Dysentery, 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 desig- 
nate 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 degenerative changes in the heart, liver, and 
other organs; clinically: By a prolonged febrile course (com- 
monly three to six weeks), an eruption of rose spots, bron- 
chitis, 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 ulceration may involve small blood- 
vessels, causing serious or fatal hemorrhage, or the bowel 
1 See page 247. TYPHOID OR ENTERIC FEVER 
345 
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 into contact with active living 
Fig. 62.-Ileum from a case of typhoid fever, showing ulceration of 
solitary follicles (6) and of a small Peyer's patch (a). (Adami and McCrae.) 
typhoid bacilli in pure culture, of checking their movements 
and causing them to clump. This is the basis of the valuable 
and diagnostic 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. 
Many obscure epidemics, particularly in institutions, have 
been traced to carriers. When these persons are employed 346 
INFECTIOUS AND PARASITIC DISEASES 
in the kitchen the danger is of course increased. Lettuce 
and other "truck" vegetables are frequently fertilized with 
"night soil" and this may lead to obscure sporadic or epi- 
demic outbreaks. Oysters are open to contamination on 
account of the custom of "fattening" them in fresh water 
(often contaminated with sewage) after their removal from 
the salt water. 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 fre- 
Fig. 63.-Positive Widal test showing clumping of bacilli (magnified.) 
(Simon.) 
quent 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 water. 
Wells and springs in the country are very often badly placed 
and open to contamination from surface drainage or from 
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 347 
TYPHOID OR ENTERIC FEVER 
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 
important of acute infections both for the nurse and the 
physician. 
Course of the Disease.-There are a great many variations 
in the course of typhoid cases, some of which will be described 
below. The following sketch will serve to illustrate the 
course of an ordinary case unmodified by treatment (see 
Fig. 49). The incubation is on the average ten days. The 
symptoms at first are indefinite: "Generally 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. Con- 
stipation is almost as frequent at this stage as diarrhea. At 
the end of a week the temperature 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 aggravated degree. The fever is 
high and continuous with a slight morning remission. Hydro- 
therapy has little or only a temporary effect on the tempera- 
ture. The pulse is relatively slow but soft and dicrotic. 
(See pages 78 and 79.) 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 known as "sordes." Diarrhea may be severe with 
stools of a "pea soup" consistency and musty odor. In the 
third week, or in prolonged cases perhaps in the fourth or 
fifth week, the morning temperature begins to show very 
marked remissions and reacts readily to measures adopted to 
lower it. This period corresponds to that of ulceration in 
the bowel, and perforation or hemorrhage is to be dreaded. 
Stupor and delirium continue and emaciation and weakness 
are progressive. Bronchitis which is often marked in the 
early stages is replaced by congestion in the dependent 348 
INFECTIOUS AND PARASITIC DISEASES 
portions of the lungs. In the fourth or final week of fever, 
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 constipation, overfeeding, 
or other slight causes, by relapse, in which the whole course 
of the disease is repeated, usually in an abbreviated and 
milder form, but occasionally with greater severity, or by one 
of the many unfortunate sequels. 
Occasional cases occur with 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. Paratyphoid 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 variations. 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 known 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 with acute 
nephritis and uremia, with croupous pneumonia, with violent 
delirium, or with severe chills. 
Complications and Sequelae of Typhoid.-The complications 
and sequelae of typhoid are legion. Some of them consist 
merely in an exaggeration of ordinary symptoms of the disease 
such as bronchitis and diarrhea. It will save time, how- 
ever, to take them up systematically. 
Mild delirium 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 muttering delirium associated 
with picking at the bedclothes or at imaginary objects, 
twitching of the tendons (subsultus), dry, brown tongue, 
sordes on the teeth, general muscular relaxation (slipping 
down in the bed), and incontinence of urine and feces. COMPLICATIONS AND SEQUELAE OF TYPHOID 
349 
When these symptoms of extreme prostration ("typhoid 
state'') develop in other diseases they are sometimes described 
as "typhoid," irrespective 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 symp- 
toms 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 29) the 
prognosis is usually favorable for ultimate recovery. Neu- 
ritis with paralysis occurs occasionally 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 char- 
acteristic leukopenia is replaced by a leukocytosis. 
Valvular heart disease is not common, but myocardial 
weakness is the rule in severe cases. In convalescence, 
patients sometimes have a rapid, but more often an extremely 
slow, soft pulse. One of the common complications 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 with 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 when it extends to the finer bron- 
chioles or alveoli (bronchopneumonia). In severe cases there 
is almost always passive congestion at the bases of the lungs 
revealed by dulness and fine rales ("moist" bubbling sounds 
on auscultation). The patient's position should be changed 
from time to time to obviate this condition so far as possible. 
Croupous pneumonia may complicate the disease at the 
onset, as already mentioned, or later during its course. 350 
INFECTIOUS AND PARASITIC DISEASES 
Loss of appetite is more or less constant in all severe cases 
during the febrile stage, but in convalescence the appetite 
is inordinately great. Gaseous distention of the abdomen 
or tympanites is often a serious complication. Sometimes it 
appears to be due to the diet (milk), although it may be due 
in part to a toxic paralysis of the bowel wall. Diarrhea is a 
regular symptom of the disease, but when excessive, is a very 
serious complication. Constipation is common in convales- 
cence; 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 hemorrhage 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 appearance. In 
the presence of hemorrhage the patient should be kept abso- 
lutely quiet and if there is any mental or physical agitation 
a hypodermic of morphine (gr. 1) should be administered. 
Many physicians will not allow even a bedpan 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 bowel unless specificially ordered. 
Astringents by the mouth, although of doubtful efficacy, are 
sometimes used by the physician. Gelatine may be given 
freely by the mouth to favor clotting; its employment by 
subcutaneous injection has proved too hazardous (tetanus) 
and painful to encourage its further use. Calcium lactate 
by the mouth and blood serum administered subcutaneously 
are now 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 COMPLICATIONS AND SEQUELA? OF TYPHOID 
351 
and rigidity of the abdomen, etc. Any symptoms in the least 
degree suggestive should be immediately reported to the 
physician. Sudden severe pain in the lower abdomen is very 
characteristic, but is often masked by the apathetic state of 
the patient. The patient should be kept absolutely quiet 
and the pain relieved if necessary by an ice-bag. 
Inflammation of the gall-bladder is a common complication 
or sequel of typhoid fever. The bile is a very favorable 
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 very common in the course of this disease 
and severe nephritis occasionally occurs. I have 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 convalescence the patient be- 
comes 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 vessels should be allowed to stand for some time before 
being emptied. In some large hospitals double-jacketed 
receivers are provided for sterilization by live steam. Bed- 
ding, 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. 352 
INFECTIOUS AND PARASITIC DISEASES 
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 thoroughly 
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 for 
nurses and attendants as an additional prophylactic, but the 
security against infection thus afforded does not excuse care- 
lessness in other respects. The prophylaxis of typhoid in the 
hospital is simplified when the patient can be treated in 
special wards. 
Symptomatic Treatment.-The patient suffering from 
typhoid should be kept at absolute rest. This necessitates 
the use of the bedpan and urinal. A soft but firm mattress 
is sufficient in the majority of cases but with severe emacia- 
tion or a tendency to bed-sores an air- or water-bed is prefer- 
able 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 constantly 
on the back, but should be turned frequently from side to 
side. The backs and buttocks should be frequently cleansed, 
sponged with alcohol, and thoroughly powdered. (Com- 
pound stearate of zinc or talcum powder.) These precau- 
tions 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 with running cold water, or ice compresses. 
If the latter are used the patient will need to be well pro- 
tected with water-proof linen or silk. Special attention 353 
SYMPTOMATIC TREATMENT 
should be given to the care of the mouth, teeth, and tongue 
which should be rinsed after every feeding, and cleaned with 
pledgets of cotton, moistened in a mild antiseptic solution 
with or without glycerine.1 A dry, brown, fissured tongue, 
and teeth heavily coated with sordes are usually due to 
defective nursing as much as to the condition of the patient. 
Diet-The traditional diet in typhoid consists of milk 
with the occasional addition of broth, beef-juice, and egg- 
water. This regimen (c. g., a glass of milk every two hours 
for ten feedings) seldom yields more than 1500 calories and 
frequently much less, about 800, if broth is given alternately 
with milk. The advantages of this diet are the sense of 
security which it gives against hemorrhage and perforation, 
its simplicity, and its ease of digestion. Its chief disadvan- 
tages are the marked loss of nutrition, the tendency to 
meteorism (distention), and the impossibility of satisfying 
the patient's appetite as convalescence approaches. Dis- 
turbances due to milk diet are sometimes attributable to 
an impure supply (high bacterial "count") and not to the 
milk in itself. Few physicians now adhere to this rigid 
dietary throughout. Raw or soft-boiled eggs, junket, corn- 
starch, and other semisolid foods are commonly added as 
convalescence approaches. Other physicians, while employ- 
ing a diet which is largely liquid (milk), increase its caloric 
value enormously by the addition of milk-sugar, cream, 
eggs, cereals, etc. (up to 5000 or 6000 calories). The aim is 
to furnish sufficient food to maintain completely the nutri- 
tion 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 shown 
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 shown the fallacy 
of some of the older theories. The nurse should of course 
follow the method dieting favored by the physician in 
1 Equal parts of a saturated solution of boric acid and glycerine, to which 
a little lemon juice may be added. Liquid petrolatum is useful for moistening 
the lips. 354 
INFECTIOUS AND PARASITIC DISEASES 
attendance. Whatever the diet, water, lemonade, and other 
fluids should be offered to the patient at frequent intervals 
to promote a free excretion of toxins. 
Ilydrotherapy.-Hydrotherapy occupies a very prominent 
place in the treatment of typhoid. It has been found that 
the application of cold water not only reduces the tempera- 
ture temporarily but has a most stimulating 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 deepened, and the kidney secre- 
tion is increased. Cold water may be applied in many ways, 
but is most frequently employed in the form of full cold 
baths, wet packs, or sponges. The full or Brand bath is 
by far the most effectual method of treatment. In hospitals 
it is usual to give a bath every three hours, when the tempera- 
ture reaches a certain height (e. g., 103°). Most physicians 
do not give 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 temperature 
alone, but in ward work some routine procedure is necessary 
as a basis and may be modified to suit individual cases. In 
mild cases or in the presence of complications which 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 contraindicated, largely on 
account of the necessary disturbance to the patient. 
Drugs, etc.-Typhoid vaccine is now frequently used in 
the treatment as well as in the prevention of typhoid fever. 
It is claimed that it shortens the febrile period. Otherwise 
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 purgatives should be 
avoided (this opinion is by no means universally held). 
Many antiseptic and antipyretic drugs have been employed 
from time to time, but no general agreement has been reached 
as to the value of any one in particular. Salol is perhaps 
most frequently used. Whisky was formerly given as a 
routine in the course of typhoid, because it was thought to 
serve both as a food and a stimulant. As we have seen, it 355 
CHOLERA 
serves the former purpose only when 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 while rare in this country has 
recently broken out in Arizona and Texas. Its ordinary 
habitat is in the Mediterranean region and particularly in 
Malta. It is due to a bacillus which is found in the milk 
of infected goats and is acquired by using milk or milk 
products derived from this animal. The prophylaxis is 
therefore evident. It is characterized by fever which 
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 wave-like fever). 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 bacillus" 
(sprillum) of Koch and is disseminated by drinking-water in 
much the same manner as typhoid fever. Its natural habitat 
is the tropics whence it spreads to the temperature zone in 
epidemic form, when faulty hygiene or a vulnerable water 
supply affords it an opportunity. It is now 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 which the writer was, by the way, an innocent 
victim, the disease was excluded. In Arabia, India, etc., 
the disease is endemic and is spread by the annual pilgrim- 
ages 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 own 
tropical possessions, at Manila and elsewhere. 
The incubation is brief, from two to five days, and is fol- 
lowed by diarrhea. The stools at first resemble those of 
ordinary enteritis, but soon become very frequent, thin, and 
watery ("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 356 
INFECTIOUS AND PARASITIC DISEASES 
the excessive loss of fluid. Collapse rapidly ensues. Sup- 
pression of urine is usual. 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 epi- 
demic 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 infected 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 incubation. 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 inocu- 
lation has also been used during epidemics. 
The treatment of cholera consists in irrigation of the bowels 
with tannic acid or other astringent solutions, large doses of 
kaolin, liberal intravenous saline injections, and symptomatic 
measures. 
Dysentery, Bacillary and Amebic.-There are two prin- 
cipal types of dysentery: One due to the Bacillus dysenteriie 
and related organisms, the other to an animal or protozoan 
parasite, the Entameba histolytica. The former is the com- 
mon 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 dysentery of the tropics and it frequently 
gives rise to liver abscesses. Americans and Europeans 
whose work carries them to the tropics are frequently 
invalided home on account of the latter form of the disease. 
The typical symptoms of dysentery are the passage of DYSENTERY, BACILLARY AND AMEBIC 
357 
frequent small stools, consisting largely of mucus and blood 
with painful straining (rectal tenesmus). These symptoms 
distinguish it from ordinary enteritis, in which 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 painless. Acute dysentery 
may be mild and of brief duration, but usually the 
movements are frequent, and fever and constitutional symp- 
toms marked. Even 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 intercurrent complications. Per- 
foration 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 recurrence from quite trivial causes, such as unsuitable 
diet or change of temperature. Persistent cases are often 
relieved by removal 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 temper- 
ate 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, medicated 
fluids containing tannic acid, nitrate of silver, quinine, etc., 
are used to irrigate the lower bowel. In the bacillary type 
bismuth and similar drugs with opium are frequently em- 
ployed, while in the amebic form ipecac or emetine which is 
derived from it, is administered in large doses with remark- 
ably good results. Abscess of the liver is treated by incision 
and drainage usually, with good success. CHAPTER VIII. 
INFECTIOUS AND PARASITIC DISEASES- 
CLASS IV (Continued). 
1. Disseminated by Intestinal 
Discharges. 
Threadworms. 
Round or Lumbricoid Worms. 
Hookworms and Hookworm 
disease. 
2. Disseminated through the 
Agency of Intermediate Hosts. 
Trichina and Trichinosis. 
Tapeworms. 
Cysticercus. 
Echinococcus. 
INFESTATIONS BY HIGHER ANIMAL 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 conven- 
ience, however, to consider these so called infestations in this 
connection, because of a certain similarity in modes of propa- 
gation and prophylaxis. Parasites of all kinds and particu- 
larly intestinal parasites are far more common in the tropics 
than in the temperate zone; we can refer only to the more 
common varieties observed in this latitude. 
1. Threadworms.-Of the general class of roundworms the 
most familiar is the threadworm (Oxyuris vermicularis) 
which is so commonly found in the rectum of children. These 
worms are very small, from one-fifth to two-fifths of an inch in 
length, and have a habit of wandering 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 scratching. In children with sus- 
ceptible nervous system they occasion muscular twitching, 
disturbed sleep, and similar manifestations. Reinfection 
may occur by the introduction of the eggs into the mouth. 359 
THE ROUNDWORM 
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 worms (e. g., to the 
vagina) are sometimes prevented by placing a ring of mercury 
ointment about the anus. The parasites are removed by 
flushing the lower bowel with simple salt or with some medi- 
cated solution. An infusion of quassia made by pouring a 
quart of water on one or two ounces of the chips is the most 
popular remedy. 
Fig. 64.- 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 6 to 
16 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 symp- 
toms are ordinarily extremely vague: Picking at the nose, 
grinding of the teeth, and even convulsions are attributed to 
the presence of this parasite. The diagnosis is made by 
finding the eggs in the stools. Under the microscope the 
eggs, with their rough envelope, are quite distinctive. Treat- 
ment is usually by santonin. It is given in to 2-grain 
doses, combined with calomel. The patient should fast 360 
INFECTIOUS AND PARASITIC DISEASES 
for some time before treatment is begun and subsequently a 
purgative should be administered. 
Hookworms and Hookworm Disease.-This disease, until 
a few years ago considered to be rare, has come to be recog- 
nized 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 investigation by the govern- 
Fig. 65.-New World male hookworm. Natural size. (Stiles.) 
Fig. 66.-New World female hookworm. Natural size. (Stiles.) 
Fig. 67.-The same, enlarged to show the position of the mouth (m), the 
anus (a) and the vulva (v). (Stiles.) 
ment authorities since our recent conquest of the island. 
The New World variety (Necator Americanus) is about twice 
as large as the ordinary threadworm. 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 larvae gain access to the THE TRICHINA AND TRICHINOSIS 
361 
body by burrowing through the skin, causing inflammatory 
symptoms known as "ground-itch" in those who go barefoot. 
Once within the body, the parasites make their way 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 prove fatal. 
The prophylactic treatment consists in proper sanitary 
arrangements (well-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 sus- 
pected 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 
chenopodium, carbon tetrachloride, thymol, or other vermi- 
fuges in suitable doses, preceded by fasting and saline purga- 
tives and followed by renewed 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 worm deposits the 
embryos in the intestinal wall so that they immediately reach 
the lymph or bloodvessels and by these paths reach the mus- 
cles all over the body, where 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 larvae develop in the intestine into the full-grown 
worm, and the cycle begins anew in the new host. In 
human beings infection usually results from eating smoked, 
imperfectly cooked, or raw ham (after the German fashion). 
The ingestion of the infectious food at first induces few or 
no symptoms (sometimes mild gastroenteritis) but at the end 
of one or two weeks the migration of the embryos into the 
muscles causes severe pains, high fever, and a train of symp- 
toms not unlike those of typhoid. Quite commonly there is 
edema of the eyelids. These symptoms-fever, severe 362 
INFECTIOUS AND PARASITIC DISEASES 
muscle pains, and edema-in a person who admits indulgence 
in raw or insufficiently cooked pork, are very suggestive of 
trichinosis. If in addition, examination of the blood shows 
a leukocytosis with an unusual proportion of certain white 
Fig. 68.-Trichinella spiralis in muscle, greatly magnified. (Simon.) 
blood cells known 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 suffer- 
ings of the patient. The preventive treatment is evident; TAPEWORMS 
363 
no pork except that which is known to be thoroughly cooked 
should be eaten. 
Tapeworms.-Of the many varieties of tapeworms only 
one is common in the eastern United States. This is the 
beef tapeworm (Tenia saginata). 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 membrane of the intestine 
by four suckers. The segments near the head, in which situ- 
ation 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 detecting the eggs 
in the stools by microscopical examination. In the ox the 
parsite is found in the muscles in the larval stage (cysti- 
cercus). Infection may be prevented by eating only well- 
cooked meat, and avoiding beef and sausage which have 
merely been smoked or dried. 
The pork tapeworm (Tenia solium) is very similar to the 
beef tapeworm. The head is armed with booklets as well as 
suckers, the uterus is not so finely divided, and the length 
of the worm is somewhat less. It is found in countries where 
pork is eaten in a more or less uncooked condition. Self- 
infection may occur, but the pig is the usual intermediate 
host. 
The fish tapeworm, or Dibothriocephalus latus, is common 
in countries in which fish forms an important part of the 
diet, and especially in Scandinavia. Imported cases are not 
unusual in this country. This worm is even longer than the 
beef tapeworm, the segments are broad and short, and the 
uterus resembles a rosette. This is a much more serious 364 
INFECTIOUS AND PARASITIC DISEASES 
infestation than those previously described, as it frequently 
leads to a very high degree of anemia resembling the perni- 
cious type. 
Fig. 69.-Tenia saginata: a, natural size; b, head, much enlarged; c, ova, 
much enlarged. (Simon.) 365 
ECHINOCOCCUS DISEASE 
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 larvae 
developing in the tissues or organs produce enormous cysts 
filled with 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. 
Tapeworms are treated by fasting, purgation, and vermi- 
fuges. The vermifuges in common use are the oleoresin of 
aspidium (male fern) and the tannate of pelletierin (from 
pomegranate). Pumpkin seeds are sometimes used. Echino- 
coccus cysts when large enough to be diagnosed with certainty 
should be incised and drained. INDEX. 
A 
Abscess, brain, 59 
of liver, 178 
in dysentery, 356 
peritonsillar, 324 
perinephritic, 213 
Achylia, 156 
Actinomycosis, 271 
Acromegaly, 76 
Addison's disease, 76 
Adenoids, 112 
"Air hunger," 106 
African lethargy, 284 
Alcohol, 230 
wood, 233 
Alcoholic cirrhosis of liver, 176 
neuritis, 45 
Alcoholism, 230 
acute, 231 
chronic, 232 
delirium tremens, 232 
Alien's treatment in diabetes melli- 
tus, 193 
Amoebic dysentery, 356 
Anemia, 64 
pernicious, 65 
splenic, 66 
Anesthesia, 23 
Aneurysm, 85 
Angina pectoris, 92 
Vincent's, 137 
Angioneurotic edema, 24 
Animal diseases in man, 268 
Anorexia, 129 
Anthrax, 270 
Antidotes, 230 
Antimony poisoning, 238 
Antitoxin, 252 
diphtheria, 291 
tetanus, 270 
Aortic disease, 99 
Aphasia, 22 
Aphonia, 106 
Apoplexy, 56 
Appendicitis, 170 
acute, 170 
chronic, 171 
Arsenic poisoning, 238 
Arsphenamine and neoarsphena- 
mine, 278 
administration of, 278 
Arteriosclerosis, 83 
Arthritis, acute, 221 
chronic, 221 
deformans, 222 
gonococcus, 266 
gonorrheal, 224, 266 
infectious, 224 
irritative, 221 
monarticular, 223 
rheumatoid, 223 
syphilitic, 224 
traumatic, 221 
tuberculous, 224 
Arthropathies, nervous, 225 
Articular rheumatism, 221 
acute, 320 
Ascaris lumbricoides, 359 
Ascending infection of urinary pas- 
sages, 209 
Ascites, 180 
Aseptic nursing, 251 
Asiatic cholera, 355 
Aspiration of chest, 125 
Asthma, 121 
Ataxia, 25 
locomotor, 50 
Atheroma, 83 
Atonic constipation, 163 
Atony of stomach, 156 
Atrophic cirrhosis of liver, 175 368 
INDEX 
Atrophy, progressive muscular, 46 
Atropin poisoning, 239 
Auto-intoxication, 237 
B 
Bacillary dysentery, 356 
Bacteria and parasites, anthrax 
bacillus, 271 
ascaris lumbricoides, 359 
bacillus of Bordet, 304 
dysenteriae, 356 
mallei, 271 
of Malta fever, 355 
pestis, 286 
tetani, 269 
typhosus, 344 
comma bacillus, 355 
dibothriocephalus latus, 363 
diplococcus intracellularis 
meningitidis, 294 
Entamoeba histolytica, 356 
filaria sanguinis hominis, 283 
influenza bacillus, 334 
Klebs-Loffler bacillus, 288 
micrococcus gonorrhea?, 265 
necator americanus, 360 
oxyuris vermicularis, 358 
plasmodium falciparum, 280 
malaria, 280 
vivax, 270 
pneumococcus, 297 
pyogenic bacteria, 261 
ray fungus, 271 
spirillum of Obermaier, 286 
streptococcus pyogenes, 264 
tamia echinococcus, 265 
saginata, 363 
solium, 363 
treponema pallidum, 274 
trichina spiralis, 361 
trypanosome, 284 
tubercle bacillus, 307 
Bacterial diseases, 288 
Class IV, 247, 344, 358 
Banti's disease, 66 
Bardny test, 22 
Bed-bugs, infection disseminated 
by, 285 
Belching, 130 
Bell's palsy, 43 
Benedict test in diabetes mellitus, 
194 
Beriberi, 200 
Bile passages, diseases of, 173 
Binet test, 32 
Black death, 286 
Blood, diseases of, 61 
general consideration, 61 
examination of, 61 
Blood-pressure, 79 
in nephritis, 207 
Bloodvessels, diseases of, 77, 83 
Bones, diseases of, 221 
"Botulinus" poisoning, 237 
Break-bone fever, 284 
Bright's disease, 214 
Brill's disease, 285 
Bronchitis, 116 
Bronchopneumonia, 119, 337, 361 
in measles, 337 
in whooping-cough, 306 
Bubonic plague, 286 
C 
Caisson disease, 229 
Calories, 185 
in diet, 186 
Cancer. See Carcinoma. 
Carcinoma of esophagus, 141 
of gall-bladder, 178 
of intestine, 168 
of liver, 178 
of peritoneum, 182 
of stomach, 148 
Carriers, 242 
Casts in urine, 206 
Catarrh, chronic gastric, 143 
Catarrhal enteritis, 158 
jaundice, 173 
pneumonia, 119 
Catheterization, 207 
Cerebrospinal fever, 294 
meningitis, 294 
syphilis, 53 
Chest, aspiration of, 125 
Cheyne-Stokes respiration, 82 
in nephritis, 207 
Chicken-pox, 343 
varioloid, 340 
Chlorosis, 64 
Cholelithiasis, 174 
Cholera, 384 
asiatica, 355 
infantum, 356 369 
INDEX 
Cholera morbus, 356 
nostras, 356 
Chorea, 39 
Choreiform movements, 25 
Cirrhosis of liver, 175 
Cocaine habit, 235 
Colic, 130 
gall stone, 175 
Colon bacillus infection, 348 
Coma, 21, 192, 215 
Comma bacillus, 355 
Communicable diseases, 247 
Confusion, 20 
Congestion of liver, 179 
Congestive chills, 282 
Constipation, 131 
chronic, 163 
atonic, 163 
spasmodic, 163 
Consumption, 311 
galloping, 311 
Contagious diseases, 241 
Continued fever, 250 
Contractures, 25 
Convulsions, 24 
epileptic, 38 
infantile, 37 
uremic, 215 
Cough, 106 
Crescents, malarial, 280 
Cretinism, 72 
Crises, 50 
Croup, membranous, 115, 289 
spasmodic, 115 
Croupous pneumonia, 297 
Cyanosis, 82 
Cyst of kidney, 213 
Cysticercus, 263 
Cystitis, 210 
Cystoscope, 208 
D 
Delirium, 21, 29 
tremens, 232 
Dementia, 31 
precox, 31 
Dengue, 284 
Descending infection of urinary 
passages, 208 
Diabetes insipidus, 196 
mellitus, 192 
Benedict test, 194 
Diabetes mellitus, causes of, 192 
Diaphragmatic pleurisy, 122 
Diarrhea, 131, 158 
in adults, 160 
fermentative, 159 
infantile, 159 
in typhoid fever, 344 
Debothriocephalus latus, 363 
Diet, calories of, 186 
in chronic gastritis, 144 
in diabetes, 195 
in nephritis, 217 
in typhoid fever, 353 
Digestive tract, diseases of, 129 
general consideration, 129 
Digitalis, 102 
Dilatation of heart, 93 
of stomach, 150 
Diphtheria, 288 
conjunctival, 290 
laryngeal, 289 
nasal, 289 
intubation in, 292 
Diplococcus intracellularis men- 
ingitidis, 294 
Disinfection, 249 
Disseminated sclerosis, 49 
Diverticulitis, 171 
Droplet infection, 242 
Dropsy, 82 
Dry pleurisy, 122 
Ductless glands, diseases of, 70 
Duodenal tube, Einhorn's, 134 
Rehfuss', 134 
Duodenum, ulcer of, 145 
Dysentery, 356 
abscess of liver in, 356 
amoebic, 356 
bacillary, 356 
Dyspepsia, gall stone, 175 
nervous, 156 
Dysphagia, 130 
Dyspnea, 82, 106 
E 
Echinococcus disease, 365 
Edema in nephritis, 216, 217 
pulmonary, 120 
Einhorn's duodenal tube, 134 
Elephantiasis, 288 
Embolism, 87 
cerebral, 56 
Emphysema, 121 370 
INDEX 
Empyema, 123 
in pneumonia, 301 
Encephalitis lethargica, 332 
Endocarditis, acute, 96 
chorea and, 39 
chronic, 97 
gonococcus, 267 
malignant, 96 
rheumatic, 321 
Enteric fever, 344 
Enteritis, 158 
Enteroclysis, 134 
Enterocolitis, 159 
Enuresis, 208 
Epidemic parotitis, 335 
poliomyelitis, 330 
Epilepsy, 38 
Epistaxis, 107 
Erysipelas, 264 
Esophagus, cancer of, 141 
diseases of, 140 
stricture of, 140 
hemorrhage of, 141 
malignant, 141 
simple, 140 
spasmodic, 140 
syphilitic, 140 
tumors of, 140 
Exophthalmic goiter, 74 
Exhaustion delirium, 29 
F 
Facial palsy, 43 
Fainting, 81 
Famine edema. 189 
Farcy, 271 
Feeble-minded, the, 32 
Feeding, rectal, 135 
Fermentative diarrhea, 159 
Fever, 255 
classification of, 256 
treatment of, 260 
trench, 286 
types of, 256 
Fibroid tuberculosis, chronic, 311 
Filaria sanguinis hominis, 283 
Filariasis, 283 
Fissures, 169 
Fistulas, 169 
Fleas, infection disseminated by, 
285 
Flies, infection disseminated by, 
285 
Follicular tonsillitis, 323 
Food poisoning, 237 
values, 185 
Fractional test-meals, 134 
Fulness and distress, 130 
functional diseases of nervous sys- 
tem, 33 
G 
Gall-bladder, cancer of, 178 
Gall-stone colic, 175 
disease, 174 
dyspepsia, 175 
Gangrene, 192 
and noma, 137 
and erysipelas, 20 
and Raynaud's disease, 23 
pulmonary, 120 
Gangrenous stomatitis, 137 
Gastralgia, 130, 155 
Gastric pain, 130 
Gastritis, 142 
Gastro-enteritis, 142 
Gastroptosis, 152 
Gavage, 297 
German measles, 339 
Glanders, 271 
Glands, ductless, diseases of, 70 
lymphatic, diseases of, 70 
Glandular enlargement in measles, 
338 
fever, 335 
tuberculosis, 309 
Goiter, adenomatous, 71 
cystic, 71 
exophthalmic, 74 
simple, 71 
Gonococcus arthritis, 266 
endocarditis, 267 
infection, 266 
rheumatism, 267 
septicemia, 266 
vaccine, 268 
vaginitis, 266 
Gonorrheal. See Gonococcus. 
Gout, 196 
Graves' disease, 74 
Grippe, 334 
Ground-itch, 261 
Gummata, 275 INDEX 
371 
H 
Hay-fever, 111 
Headache, 22 
Heart area, 83 
dilatation of, 93 
disease of, 92 
causation of, 94 
valvular, 96, 98 
hypertrophy of, 93 
insufficiency of, 94 
soldier's, 93 
Heartburn, 130 
Heat, effects of, 228 
exhaustion, 228 
Heberden's nodes, 222 
Hectic fever, 258 
Hematemesis, 131 
Hemiplegia, 54 
Hemophilia, 69 
Hemorrhage, cerebral, 56 
of esophagus, 141 
subdural, 58 
in tuberculosis, 312 
in typhoid fever, 350 
Hemorrhoids, 169 
Hernia, 166 
Heroin habit, 234 
Herpes, 47 
in pneumonia, 300 
zoster, 47 
Hip disease, 309 
Hodgkin's disease, 67 
Hook-worm disease, 360 
Hospital quarantine, 250 
Hydatid cysts, 365 
Hydrocephalus, 59 
chronic, 60 
Hydropericardium, 91 
Hydrophobia, 272 
Hydropneumothorax, 124 
Hydrothorax, 124 
Hyperacidity, 156 
Hyperesthesia, 23 
Hypertrophic cirrhosis of liver, 177 
Hypertrophy of heart, 93 
Hypodermoclysis, 63 
Hypostatic pneumonia, 119 
Hysteria, 35 
I 
Idiots, 32 
Immunity, 251 
infections affording, 252 
without, 252 
Inanition, 189 
Incipient tuberculosis, 311 
Incontinence of urine, 208 
Incubation, period of, 248 
maximum, 248 
Industrial poisoning, 238 
Infantile convulsions, 37 
paralysis, 330 
scurvy, 199 
Infantilism, 76 
Infarct, pulmonary, 120 
Infarction, 87 
Infections, 241 
due to pyogenic bacteria, 261 
transmission of, 242 
Infectious diseases, 241 
classification of, 244 
Class I, 244, 261 
Class II, 245 
Class III, bacterial, 245, 288 
uncertain causation, 320 
Class IV, 247, 344, 358 
immunity in, 251 
incubation of, 248 
isolation of, 249 
quarantine in, 250 
Infestations, 358 
Inflammatory rheumatism, 250 
Influenza, 334 
bacillus, 334 
Insanity, 29 
Insolation, 249 
Insomnia, 20 
Insufficiency, cardiac, 94 
Insulin, 194 
Intermittent fever, 258 
Interstitial nephritis, 217 
Intestinal parasites, 358 
tuberculosis, 308 
Intestine, carcinoma of, 168 
diseases of, 158 
obstruction of, 166 
strangulation of, 167 
tumors of, 168 
Intravenous infusion, 63 
Intubation, operation of, 292 
Intussusception, 166 
Isolation, 249 
period of, 249 
J 
Jail fever, 285 
Jaundice, 173 372 
INDEX 
Jaundice, catarrhal, 173 
Joints, diseases of, 221 
tuberculosis of, 307 
K 
Kernig's sign, 296 
Kidneys, cyst of, 213 
diseases of, 211 
functional tests of, 206 
general considerations, 211 
movable, 213 
stone in, 211 
tumors of, 213 
Klebs-Loffler bacillus, 288 
L 
Lacunar tonsillitis, 323 
Laryngeal diphtheria, 289 
Laryngismus stridulus, 115 
Laryngitis, 114 
Lavage, 131 
Lead colic, 235 
neuritis, 43, 45 
palsy, 235 
poisoning, 235 
Leprosy, 318 
Lethargic encephalitis, 332 
Leukemia, 66 
Leukoplakia, 137 
Leukocytosis, 253 
Lice, infection disseminated by, 285 
Liver, abscess of, 178 
in dysentery, 356 
cancer of, 178 
cirrhosis of, 175 
alcoholic, 175 
atrophic, 175 
hypertrophic, 177 
portal, 175 
syphilitic, 177 
congestion of, 179 
diseases of, 173 
gin-drinker's, 175 
Lobar pneumonia, 297 
Lobular pneumonia, 119 
Lockjaw, 2G8 
Locomotor ataxia, 50 
Lues. See Syphilis. 
Lumbago, 219 
Lumbar puncture, 27, 296 
Lumpy jaw, 271 
Lungs, diseases of, 119, 271 
Lymphatics, diseases of, 70 
M 
Malaria, 279 
estivo-autumnal, 280 
malignant, 282 
parasite of, 280 
quartan, 280 
quotidian, 280 
tertian, 279 
Malignant pustule, 270 
Malnutrition, 189 
Malta fever, 355 
Manic depressive psychosis, 30 
Measles, 336 
bronchopneumonia in, 337 
German, 339 
glandular enlargement in, 338 
noma in, 137 
Melancholia, 30 
Membranous croup, 115, 289 
Meningitis, 54, 244 
cerebrospinal, 294 
influenzal, 295 
pneumococcic, 295 
pyogenic, 295 
secondary, 295 
syphilitic, 53 
tubercular, 295 
Mental deficiency, 32 
diseases, 17, 29 
Mercurial stomatitis, 137 
Metabolism, diseases of, 188 
principles of, 188 
Micrococcus gonorrhea;, 266 
Miliary tuberculosis, 311 
Milk, certified, 162 
pasteurized, 162 
pure, prophylactic value of, 162 
sterilized, 162 
Mitral disease, 99 
Morbilli, 336 
Morons, 32 
Morphine habit, 234 
Mosquitoes, infection disseminated 
by, 279 
Motor tracts, 19 
Mountain sickness, 229 
Mouth, diseases of, 136 
Movable kidney, 213 373 
INDEX 
Mucous patches, 275 
Multiple neuritis, 45 
sclerosis, 49 
Mumps, 335 
orchitis in, 336 
Murmurs, 83 
Muscles, diseases of, 219 
Muscular rheumatism, 219 
Myalgia, 219 
Myelitis, 48 
Myocarditis, 95 
Myositis, 219 
Myxedema, 72 
N 
Nasal diphtheria, 289 
Nauheim baths, 104 
Necator americanus, 360 
Neoarsphenamine and arsphena- 
mine, 278 
administration of, 278 
Nephritis, 214 
acute, 216 
blood-pressure in, 207 
Cheyne-Stokes respiration in, 207 
chronic, 216 
interstitial, 217 
parenchymatous, 216 
edema in, 216, 217 
in scarlet fever, 328 
trench, 216 
Nervous diseases, 17 
organic, 43 
symptoms and signs of, 20 
anesthesia, 23 
aphasia, 21 
ataxia, 25 
choreiform movements, 25 
coma, 21 
confusion, 20 
contractures, 25 
convulsions, 24 
delirium, 20 
headache, 22 
hyperesthesia, 23 
insomnia, 20 
pain, 23 
paralysis, 24 
reflexes, 26 
spasticity, 25 
special senses, 27 
sphincter disturbances, 23 
Nervous diseases, symptoms and 
signs of, stupor, 21 
tremors, 26 
trophic disturbances, 23 
vasomotor disturbances, 
23 
vertigo, 22 
dyspepsia, 156 
system, functional diseases of, 33 
Neuralgia, 40 
Neurasthenia, 33 
Neuritis, 43 
alcoholic, 45 
facial, 43 
lead, 43 
multiple, 45 
pressure, 44 
toxic, 44 
Neuro-circulatory asthenia, 93 
Neurons, 17 
Neuroses of stomach, motor, 155 
secretory, 155 
sensory, 155 
Nitrate of silver poisoning, 239 
Noma, 137 
Nystagmus, 50 
O 
Obesity, 188 
Obstruction of intestines, 166 
Opisthotonos, 24 
Opium habit, 234 
poisoning, 234 
Orchitis in mumps, 336 
Organic diseases of nervous system, 
43 
Orthopnea, 82 
Osteo-arthritis, 222 
Osteo-arthropathy, pulmonary, 226 
Osteomalacia, 200 
Oxyuris vermicularis, 358 
P 
Pain, 23 
gastric, 130 
precordial, 92 
Palsy, Bell's, 43 
Pancreas, diseases of, 172 
Pancreatitis, 172 
Paralysis, 24 374 
INDEX 
Paralysis, agitans, 40 
facial, 43 
infantile, 330 
lead, 43 
pressure, 44 
in whooping-cough, 305 
Paranoia, 32 
Parasites, 358 
intestinal, 358 
Parasitic diseases, 274, 358 
Parasyphilitic diseases, 274 
Paratyphoid fever, 348 
Paregoric habit, 234 
Parenchymatous nephritis, 216 
Paresis, 50 
general, 52 
Parkinson's disease, 40, 333 
Parotitis, 139 
epidemic, 335 
Pellagra, 201 
Perforation in typhoid fever, 350 
Pericarditis, 89 
adhesive, 89 
fibrinous, 89 
rheumatic, 321 
tuberculous, 308 
with effusion, 89 
Pericardium, diseases of, 89 
Perinephritic abscess, 213 
Peritoneum, cancer of, 182 
diseases of, 180 
tuberculosis of, 308 
tumors of, 382 
Peritonitis, 181 
Pernicious anemia, 65 
Pertussis, 304 
Phagocytosis, 253 
Pharyngeal diphtheria, 288 
Pharyngitis, 112 
Phosphorus poisoning, 239 
Phthisis, 311 
fibroid, 311 
florida, 311 
ulcerative, 312 
Physical causes, diseases due to,227 
Piles, 169 
Plague, 286 
bubonic, 286 
pneumonic, 286 
Plasmodium falciparum, 280 
malaria:, 280 
vivax, 279 
Pleura, diseases of, 122 
Pleurisy, 122 
Pleurisy, diaphragmatic, 122 
dry, 122 
purulent, 123 
with effusion, 123 
Pleurodynia, 219 
Pneumococcic meningitis, 295 
Pneumococcus, 297 
Pneumonia, 297 
broncho-, 119, 302 
catarrhal, 119 
croupous, 297 
empyema in, 301 
herpes in, 300 
hypostatic, 119 
lobar, 297 
lobular, 119 
plague, 286 
Pneumothorax, 124 
artificial, 313 
Poisoning, antimony, 238 
arsenic, 238 
atropin, 239 
botulinus, 237 
food, 237 
habit, 234 
industrial, 238 
lead, 235 
mercury, 238 
nitrate of silver, 239 
opium, 234 
phosphorus, 239 
ptomaine, 237 
strychnine, 239 
wood alcohol, 233 
Poisons, 230 
antidotes, 230 
diseases due to, 230 
Poliomyelitis, acute, 330 
chronic, 46 
epidemic, 330 
Polycythemia, 66 
Portal cirrhosis of liver, 175 
Psychosis, postinfectious, 29 
senile, 30 
manic-depressive, 30 
Pott's disease, 309 
Pressure paralysis, 44 
Progressive muscular atrophy, 46 
Pro toelysis, 134 
Protozoan infections, 279 
Psychasthenia, 32 
Ptomaine poisoning, 237 
Pulmonary edema, 120 
gangrene, 120 375 
INDEX 
Pulmonary infarct, 120 
tuberculosis, 307 
Pulsations, 82 
Pulse, 77 
capillary, 83 
tracings, 81 
Purpura, 67 
hemorrhagica, 69 
rheumatic, 69, 321 
Pyelitis, 211 
Pyemia, 261 
Pyloric stenosis, 150 
Pyogenic bacteria, 261 
infection due to, 261 
Pyopneumothorax, 124, 312 
Pyorrhea, 138 
Pyrosis, 138 
Q 
Quarantine, 250 
absolute, 250 
cubicles, 250 
hospital, 250 
partial, 250 
special, 250 
Quinsy, 324 
R 
Rabies, 272 
Railroad spine, 34 
Ray fungus, 271 
Raynaud's disease, 23 
Rectal feeding, 135 
Rectum, stricture of, 168 
Reflexes, 26 
Rehfuss' duodenal tube, 134 
fractional method, 134 
Relapsing fever, 286 
Remittent fever, 256 
Reportable diseases, 247 
Respiratory disease, physical signs 
of, 108 
bronchial breathing, 108 
dulness, 108, 
frictions, 108 
rales, 108 
movements, 105 
Rhinitis, 108 
Rheumatic fever, 320 
endocarditis in, 321 
heart in, 321 
Rheumatic fever, pericarditis in, 
321 
purpura in, 321 
purpura, 67, 322 
Rheumatism. See also Rheumatic 
fever. 
articular, acute, 320 
chorea and, 39 
gonorrheal, 266 
inflammatory, 320 
intercostal, 219 
muscular, 219 
syphilitic, 225 
tonsillitis and, 320 
Rheumatoid arthritis, 223 
Rickets, 198 
Rocky Mountain fever, 286 
Roseola, 339 
Round-worm, 359 
Rubella, 339 
Rubeola, 336 
S 
St. Vitus' dance, 39 
Salivary glands, diseases of, 136 
Salvarsan and Neosalvarsan. See 
Arsphenamin and Neoarsphen- 
amin. 
Scarlet fever, 324 
nephritis in, 328 
Schick test, 291 
Sclerosis, disseminated, 50 
multiple, 50 
spinal, 50 
Scrofula, 309 
Scurvy, 199 
Senile psychosis, 30 
Sensory tracts, 19 
Septicemia, 261 
gonococcus, 266 
varieties of, 261 
Serositis, multiple, 182 
Shell shock, 34 
Ship fever, 285 
Sleeping sickness, African, 284 
encephalitis, 332 
Smallpox, 340 
Soldier's heart, 93 
Spasmodic constipation, 163 
croup,115 
Spasticity, 25 
Special senses, 27 376 
INDEX 
Sphincter disturbances, 24 
Spinal sclerosis, 50 
Spirillum of Obermeier, 286 
Splenic anemia, 66 
Spondylitis deformans, 222 
Sporotrichosis, 272 
Spotted fever, 294 
Sputum, 107 
Stenosis, pyloric, 150 
congenital hypertrophic, 151 
Stomach, atony of, 156 
cancer of, 198 
dilatation of, 150 
diseases of, 142 
functional, 155 
organic, 142 
secretory disturbances of, 155 
ulcer of, 145 
Stomatitis, 156 
gangrenous, 137 
mercurial, 137 
simple, 136 
ulcerative, 137 
Stone, 211 
in bladder, 211 
in kidney, 211 
Strangulation, intestinal, 167 
Strawberry tongue, 327 
Streptococcus hemolyticus, 262 
pyogenes, 264 
viridans, 262 
Stricture of esophagus, 140 
of rectum, 168 
Stroke, 56 
Strychnine poisoning, 239 
Stupor, 21 
Subacidity, 156 
Sugar in urine, 194 
Sunstroke, 227 
Suppurative tonsillitis, 324 
Syncope, 81 
Syphilis, 273 
acquired, 273 
cerebrospinal, 53 
congenital, 274 
diseases due to, 276 
primary, 274 
lesions, 274 
secondary, 275 
tertiary, 275 
Wassermann reaction in, 276 
Syphilitic arthritis, 224 
cirrhosis of liver, 177 
rheumatism, 225 
T 
Tabes, 50 
mesenterica, 309 
Taenia echinococcus, 365 
saginata (beef tapeworm), 363 
solium, 363 
Tapeworm, 363 
beef, 363 
fish, 363 
pork, 363 
Teething, 139 
Test breakfast, 133 
meals, 133 
fractional, 134 
Tetanus, 268 
antitoxin, 270 
Thermometry, 258 
Thread-worm, 358 
Thrills, 83 
Thrombosis, 87 
cerebral, 56 
Thrush, 137 
Thymus, diseases of, 75 
Ticks, infection disseminated by, 
285 
Tongue, appearance of, 138 
diseases of, 138 
strawberry, 327 
Tonsillar diphtheria, 289 
Tonsillitis, 112 
acute, 323 
chorea and, 39 
chronic, 325 
follicular, 323 
parenchymatous, 323 
rheumatism and, 320 
suppurative, 324 
Toxemia, 261 
Toxic neuritis, 44 
Toxin-antitoxin, 290 
Tracts, motor and sensory, 19 
Transfusion of blood, 63 
Transmissible diseases, 242 
Transmission of infections, 242 
Traumatic arthritis, 221 
Tremors, 25 
Trench fever, 286 
nephritis, 216 
Treponema pallidum, 274 
Trichina spiralis, 361 
Trinchinosis, 361 
Trophic disturbances, 24 
Trypanosome, 284 INDEX 
377 
Tubercle bacillus, 307 
bovine type, 308 
human type, 307 
Tubercular meningitis, 295 
Tuberculosis, 307 
distribution of, in body, 308 
fibroid, chronic phthisis, 311 
glandular, 309 
incipient, 311 
miliary, 310 
ulcerative, chronic, 312 
Tuberculous arthritis, 224 
Tumors of brain, 59 
of esophagus, 140 
of gall-bladder, 178 
of intestines, 168 
of kidney, 213 
of liver, 178 
of lung, 122 
of peritoneum, 182 
Typhoid fever, 344 
complications and sequelae of, 
348 
hemorrhage, 350 
perforation, 350 
Widal reaction in, 253, 345 
spine, 351 
state, 349 
vaccine, 352 
Typhus, 344 
abdominalis, 344 
exanthematicus, 295, 344 
fever, 285 
Mexican, 285 
U 
Ulcer of duodenum, 145 
of stomach, 145 
complications of, 146 
hemorrhage in, 147 
perforation in, 147 
Ulcerative stomatitis, 137 
tuberculosis, chronic, 311 
Undulant fever, 355 
Upper air passages, diseases of, 109 
Uremia, 215 
Uric acid, 196, 204 
Urinary passages, diseases of, 208 
infection of, ascending, 209 
Urinary passages, infection of, 
descending, 209 
Urine, 203 
incontinence of, 208 
laboratory examination of, 203 
V 
Vaccines, 253 
gonococcus, 208 
typhoid, 254, 352 
Vaccinia, 341 
Vaginitis, gonococcus, 266 
Valve lesions, aortic, 99 
individual, 98 
mitral, 99 
multiple, 100 
Valvular heart disease, 96 
Varicella, 343 
Variola, 340 
Varioloid, 340 
Vasomotor disturbances, 23 
Venesection, 102 
Vertigo, 22 
Vincent's angina, 137 
Virus, 254 
anthrax, 254 
rabies, 254, 272 
vaccine, 255 
Visceral parasites, 361, 365 
Vitamines, 183 
Volvulus, 166 
Vomiting, 131 
W 
Wassermann reaction, 276 
Waterbrash, 130 
Weil's disease, 173 
Whooping-cough, 304 
bronchopneumonia in, 306 
Widal reaction, 253, 345 
Woolsorters' disease, 271 
Writer's cramp, 25 
¥ 
Yaws, 274 
Yellow fever, 283