Class Boo k -GrS Copy"nglit^ _ COPYRIGHT DEPOSm V MEDICAL DIAGNOSIS GREENE MEDICAL DIAGNOSIS FOR THE STUDENT AND PRACTITIONER BY CHARLES LYMAN GREENE, M. D., ST. PAUL LECTURER IN APPLIED ANATOMY, UNIVERSITY OF MINNESOTA, 1 892-4. PROFESSOR OF APPLIED ANATOMY AND INSTRUCTOR IN CLINICAL MEDICINE, 1 894-7. PROFESSOR OF CLINICAL MEDICINE AND PHYSICAL DIAGNOSIS, 1897-1903. PROFESSOR OF THE THEORY AND PRACTICE OF MEDICINE, I9O3-9. PROFESSOR OF MEDICINE, CHIEF OF THE DEPARTMENT OF MEDICINE AND CHIEF OF MEDICAL CLINIC IN THE UNI- VERSITY HOSPITALS, 1909-15. AUTHOR OF THE MEDICAL EXAMINATION FOR LIFE INSURANCE AND ITS ASSOCIATED CLINICAL METHODS. ATTENDING PHYSICIAN, ST. LUKE'S HOSPITAL AND MILLER HOSPITAL; CONSULTING PHYSICIAN, STATE HOSPITAL FOR CRIPPLED AND DEFORMED CHILDREN; MEMBER OF THE ASSOCIATION OF AMERICAN PHYSICIANS, AMERICAN THERAPEUTIC SOCIETY, ETC., ETC. FIFTH EDITION REVISED AND ENLARGED WITH 14 COLORED PLATES AND 623 OTHER ILLUSTRATIONS PHILADELPHIA P. BLAKISTON'S SON & CO. 1012 WALNUT STREET \<\ v v Copyright December, 1922, by P. Blakiston's Son & Co. . ©GI.A(J92aiO PRINTED IN U. S. A. IY THE MAPLE PRESS YORK PA Dfi!ii22 PREFACE TO THE FIFTH EDITION The author regrets that the obligations of military service in the Great War and the concentration upon private affairs necessarily following it have delayed the issuance of this volume. He has made full use, however, of the opportunity afforded for a delib- erate, painstaking and thorough revision. Every section has been expanded by important additions and no effort spared to make the present volume a thoroughly practical and up to date treatise upon modern medical diagnosis. The rise of diseases of the heart and blood-vessels to first place on the list of causes of premature death makes imperatively necessary a better understanding of the now unrealized possi- bilities along the lines of their early recognition, prevention, and retardation. The author has endeavored, therefore, to further emphasize in this volume the means of early and accurate diagnosis now available to the physician. This has involved not only an amplification of those sections dealing specifically with etiology and clinical technic, but also a more extended reference to and discussion of the adoption of better standards and a more helpful view point. In the preceding edition considerable space was devoted to the clinical use of instruments of precision in the diagnosis of heart disease, but the great and growing interest in these newer aids to the detection and efficient manage- ment of heart lesions has led the author to expand greatly the sections dealing with polygraphic and electrocardiographic technic and interpretation. Among the many additions to the text, the author would call attention especially to the discussion of " influenza" and the interesting and unique radiograms of Dr. John Hunter Selby, illustrating the development and course of that "hemorrhagic pneumonitis" which gave to the epidemic of 1 918 its terrific mortality. The " Symptom Index" incorporated in this Edition must greatly increase the usefulness of the volume. The author would express his grateful appreciation of the assistance rendered by his valued associate Dr. Harold E. Richardson, by Dr. Frank S. Bissell, Dr. Wm. Hunter Selby and many others. He would acknowledge also the courtesy of his -publishers and the generous cooperation which has made possible the addition of 105 pages to the text and the introduction of 74 new illustrations at a time when publishing costs have risen to hitherto undreamed of heights. The author hopes sincerely that this new volume will merit a continuance of the kind reception accorded it through so many years by student and practitioner alike. Chas. Lyman Greene. 914 Lowry Building, St. Paul, Minnesota. CONTENTS Page CERTAIN FUNDAMENTAL PRINCIPLES AND SPECIAL PROBLEMS ... i CASE-TAKING n The value of the case-book; the subjective vs. the objective; "hearsay evidence," ii. The Outward Signs of Disease. n Facial expression, 12; syphilis; recent weight-loss or gain; edema, 13; voice and speech, 14; the color of the skin, 15; cyanosis; local vasomotor relaxation or paralysis, 16; other abnormal color variations, 17; jaundice, 18; dry and moist skin; edema, 20; lymphangitis and phlebitis; ascites, 23; subcutaneous emphy- sema; subcutaneous hemorrhages, 26; collateral venous circulation, 27; drug eruptions, desquamations, scars, 28; the head, 30; the eyelids; the eyes, 31; the nose; the ear, ^3', the lips; the buccal cavity, 34; stomatitis, 35; the tongue, 36; the gums; the teeth, 38; the jaws; the soft palate; the hands, 40; the finger- nails, 41; the arm and leg, 42; the back; the joints, 43; tremor, 45; spasms, cramps, and convulsive seizures, 46; infantile convulsions, 49; station, attitude, gait, 49; orthopnea, 50; gait, 51; weight and height, 54; the attitude of life insurance companies, 56. Age — Race — Sex — Habits — Social State and Residence 58 Age, 58; sex; race; habits and environment, 60; drug habit; marriage, 62; occu- pation, 63; mineral poisoning, 64; occupational stigmata, 65; residence, 66; family history, 67; the nervous system in heredity, 68; tuberculosis, 69; previous illnesses, 70. History and Analysis of the "Present Ailment" 71 Fever, 71; pathologic variations in temperature, 72; the phenomena of fever, 75; coma and its congeners, 79; pain, 83; paroxysmal pain, 85; colic, 86; acute intestinal obstruction, 87; headache, 90; sinus headaches, 91; neuralgia, 94; neuritis; muscular rheumatism,, 98; general comment, 99; tenderness, 100; perversions of sensation, 101; insomnia; vertigo, 103; dyspnea, 105; variations in respiratory rhythm, 107; shock and collapse, 109. DISEASES DEPENDENT UPON OR ASSOCIATED WITH CHANGES IN THE BLOOD OR BLOOD-MAKING ORGANS AND DUCTLESS GLANDS. . no Examination of the blood; Hematology, no; hemoglobin, 116; Erythrocytes and leucocytes, 122; Unusual or abnormal forms, 123; the red blood cell, 126; the blood cell count, 128; the red count, 129; the leucocyte count, 131; the hemato- crit, 136; leucocytosis and lymphocytosis, 137; cytodiagnosis, 143; inoscopy, 143. The anemias: types of anemia, 144; general considerations, 145; general etio- logic factors, 147; chlorosis, 148; the Addisonian pernicious anemia, 151; aplastic pernicious anemia, 154; splenic anemia, 154; splenomegaly with hepatic cirrhosis and anemia; splenomegaly of the Gaucher type, 155; congenital hemolytic jaundice, 155; leukemia, 156; myeloid leukemia; symptoms, 157; lymphatic leukemia; symptoms, 158; blood findings; acute lymphatic leukemia, 159; differential diagnosis of the anemias, 160; chloroma; Still's syndrome; myeloma; leukanemia, 161; prognosis in the anemias, 162. The polycythemias: polycythemia (erythrocytosis), 162; erythrocytosis megalosplenica, 163; Certain obscure diseases associated with anemia: Hodgkin's disease, 164; differential diagnosis, 167; purpura, 168; hemophilia, 169; scorbutus, 171; Barlow's disease, 171. vii Vlll CONTENTS Page DISEASES OF THE GLANDS OF INTERNAL SECRETION 173 Addison's disease, 173; symptoms, 174; status thymicolymphaticus, 175; myxedema and cretinism, 176; symptoms of sporadic cretinism, 177; endemic cretinism, 178; hyperthyroidism, 179; etiology; symptoms, 180; tests of impor- tance, 181; acromegaly, 184; symptoms, 185; gigantism; hypopituitarism; infan- tilism; pancreatic infantilism; exogenous obesity, 187; endogenous obesity, 188. CERTAIN DISEASES OF UNKNOWN CAUSATION 188 Osteitis deformans; leontiasis ossea; micromegaly, 188; plumonary hypertrophic osteoarthropathy, 189; achondroplasia, 189. URINALYSIS AND DISEASES OF THE KIDNEY.- 189 Polyuria, 190; oliguria; anuria, 191; the color; indican, 192; indol, 193; skatol; uroerythrin; melanin; urobilin; the oxyacids; alcaptone, 194; hydrochinon and pyrocatechin; urochrome and hematoporphyrin ; test of Weiss; Salkowski's test; creatinin, 195; milky urine; transparency; odor; reaction, 196; specific gravity, 197; urinary solids; total nitrogen, 198; estimation of total nitrogen, 199; urea; urea in Bright's disease, 201; uric acid, 210; urinary chlorides, 212; the phos- phates, 213; the sulphates; the oxalates; iron, ammonia, 214; albuminuria; nucleoalbumin; albumoses; 215; the Bence-Jones protein; the significance of albuminuria, 216; tests for. albumin, 217; quantitative tests for albumin, 220; pus; blood, 222; bile; tests for glucose in urine, 224; Allen's test; 225; the fer- mentation test; quantitative estimation with Whitney's reagent, 226; the polarimeter; levulose, 227; lactose; pentose; maltose; glycuronic acid; ace- tone, diacetic acid and oxybutyric acid, 228; diacetic acid — test; acetone — Legal's test, Lieben's test, 229. The examination of urinary sediments, 230; urates, 231; uric acid, 233; blood, 234; pus; varying significance of pus in the urine, 235; epithelium, 236; casts; true casts, 239; typical forms; cylindroid storms; the gonococcus, 244; Ehrlich's typhoid diazo reaction, 245; uremia, 246; cryoscopy, 249. The classification of renal diseases; renal inefficiency, 250: the phenolsul- phonephthalein test, 251; chronic passive congestion of the kidney, 253; general symptoms, 253; the kidney of pregnancy; acute severe congestion and acute nephritis, 254; general symptoms, 256; urinary findings, 257; acute focal glomeru- lonephritis; acute interstitial non-suppurative nephritis; chronic parenchymatous nephritis, 258; urinary findings, 259; the small white kidney, 260; focal arterio- sclerotic form, 261; chronic interstitial nephritis, 261; urinary findings, 264; trench nephritis, 266; amyloid kidney, 266; movable and floating kidney, 266; pyelitis and pyelonephritis, 268; renal tuberculosis, 269; renal infarct, 270; renal tumors; renal syphilis; renal cysts, 271; cystic degeneration of the kidney, 272; hydronephrosis, 272; acute cystitis; chronic cystitis, 273; Tuberculosis of the bladder, 273; tumors of the bladder; acute prostatitis; chronic prostatitis; urinary calculus, 274; chemic examination of urinary calculi, 275. METHODS AND MEANS EMPLOYED IN THE DIAGNOSIS OF THE DIS- EASE OF THE THORACIC VISCERA 762 The preparation of the patient; the topographic anatomy of the chest, 277; the thoracic viscera, 278; the liver; the pleurae, 279; the lobes of the lung, 281. Examination of the chest, with especial reference to the lungs and pleura, 282; inspection; essential points, 282; chest measurements; chest movements, 285; the diaphragm phenomenon; palpation, 286; percussion, 289; percussion sounds, 292; the normal percussion sounds, 293; spinal percussion zones, 296; special modifications of the percussion note, 298; auscultation, 301; vesicular breathing; puerile or harsh respiration, 305; bronchial breathing, 306; tubular breathing, 307; vocal resonance, 308; diminished vocal resonance, 308; bronchophony; pectoriloquy; egophony, 309; rales; dry rales; moist rales, 310; sounds apart; friction sounds, 312; bronchoscopy, 313. CONTENTS IX Page INTRATHORACIC RADIOGRAPHY AND FLUOROSCOPY: THE ROENT- GENOGRAPHS EXAMINATION OF T.HE LUNGS AND PLEURA, FRANK S. BISSELL, M. D 314 The hilus shadows; method of examination; tuberculosis, 314; advanced tuber- culosis, 317; cavities; resolution, 319; apical tuberculosis; differential diagnosis, 320; pneumonoconiosis, chalicosis, anthracosis, 320; characteristics of other pulmonary lesions; chronic bronchitis; bronchiectasis; tumors; foreign bodies in the bronchi; exudative pleuritis, 321; pleuritic adhesions, 323; pneumothorax, 323; artificial pneumothorax; pneumonia; broncho-pneumonia, 324; lung abscess; gangrene; empyema; emphysema, 326. Cough and sputum: cough; diverse causes; reflex cough, 326; hysteric, dyspep- tic, tobacco, dry and moist and paroxysmal cough, 327; pressure cough; various types, 328. The sputum, 328; reaction; color, 329; heart disease cells; air content; macroscopic appearance, 329; amount; odor; albumin content; Zenoni's differential color test, 330; microscopic findings, 331; the tubercle bacillus; concentrated sediment — the antiformin method, 332; Loeffler's modification of Uhlenhuth's antiformin procedure; Ziehl-Neelsen method, 332; Gabbett's method, 333. RHINOLOGY, PHARYNGOLOGY AND LARYNGOLOGY 334 Diagnosis at sight; technic; larynx; naso-pharynx, 334. Diseases of the nose: acute coryza; hypertrophic rhinitis; exostoses and ecchondroses; septal deviation; septal hematoma; septal abscess, 335; atrophic rhinitis; necrosing ethmoiditis; hay fever; nasal polypi; sarcoma and carcinoma; nasal syphilis, 336; epistaxis; the accessory sinuses, 337; the frontal sinuses; the ethmoidal sinuses; the sphenoidal sinuses, 338. Diseases of the pharynx: acute pharyngitis; chronic pharyngitis; atrophic pharyngitis, 339; post-nasal adenoids, 340; syphilitic pharyngitis; retro-pharyn- geal abscess; paralysis and tumors, 341. Diseases of the tonsils: acute tonsillitis, 341; suppurative tonsillitis; chronic tonsillitis, 342. Diseases of the larynx: simple, acute and subacute laryngitis, 342; edema of the glottis; croup, 343; laryngismus stridulus; membranous croup; syphilitic laryngitis; tuberculous laryngitis; tumors of the larynx, 344. DISEASES OF THE BRONCHI, LUNGS AND PLEURA 345 Bronchitis; acute tracheo-bronchitis, 345; rationale of acute bronchitis, 346; chronic bronchitis; eosinophilic bronchitis; obliterative bronchitis; putrid bronchitis; fibrinous bronchitis; syphilitic bronchitis, 347; trench gas poisoning (chlorine "gassing"), 348; bronchiectasis, 349; foreign bodies in the bronchi, 350; emphysema; vesicular emphysema, 351; localized, acute and compensatory, acute bilateral, interstitial, and subcutaneous emphysema, 351; vesicular hypertrophic emphysema, 352; rationale of emphysema, 353; atrophic or senile emphysema; spasmodic asthma, 355; sensitization tests, 357; spurious spasmodic asthma, renal asthma; aneurysmal asthma; cardiac asthma, 359; rationale of spasmodic asthma, 360; pleurisy, 361; etiology, 362; symptoms of acute fibrinous pleurisy; pleuris}' with effusion, 363; physical signs, 365; Grocco's triangle, 367; rhythmic lateral displacement of the heart, 368; rationale of pleurisy, 369; serous effusion, 370; diaphragmatic pleurisy, 373; empyema, 374; pleuritic adhesions, 375; interlobar pleurisy; chronic pleurisies; purulent exudate; encapsulated em- pyema; pneumothorax, 376; symptoms and rationale of pneumothorax, 378; physical signs, 378; displacement of sheltered viscera, 379; hippocratic succus- sion, 379; cardinal signs, 379; hydrothorax, 382. Lobar pneumonia, 383; pneumococcus types, 384; morbid anatomy, 384; vari- eties of pneumonia, 386; traumatic, migratory, and massive forms; afebrile and senile pneumonia; central pneumonias, 387; symptoms, 388; the blood; the urine;, gastrointestinal tract; headache and delirium, 389; physical signs of frank lobar pneumonia, 390; diagnosis, 391; rationale of lobar pneumonia; toxemia; X CONTENTS Page sputum; congestion; bronchial and tubular breathing; the crepitant rale; blocked bronchi, 392; cyanosis and dyspnea; complication; prognosis; septic pneumonia, 393; broncho-pneumonia; inhalation pneumonias; morbid anatomy of lobular pneumonia, 394; two chief divisions of broncho-pneumonia; subdivisions, 395; acute congestive broncho-pneumonia; acute disseminated broncho-pneumonia; common form of broncho-pneumonia, 396; physical signs of the chief types of broncho-pneumonia, 397; rationale of broncho-pneumonia; atelectasis, 398; massive collapse, 399; congestion of the lungs, 399; active congestion; passive congestion, hypostasis and edema; pulmonary edema, 400; important comment, 401. Tuberculosis of the lungs, 401; morbid anatomy, 402; etiology, 403; chronic congenital asthenia, 404; acute miliary tuberculosis, 405; physical signs; acute pneumonic tuberculosis, 406; chronic ulcerative tuberculosis, 407; hemorrhage; bronchiectases; phthisiophobia; symptoms, 409; hemoptysis; fluoroscopy; tuberculin, 411; preparation of tuberculin for subcutaneous use, 412; modifications of the tuberculin test; von Pirquet test, 413; physical signs, 416; pulmonary infarct, 418; pulmonary abscess, 419; pulmonary gangrene, 420; pulmonary tumors, 421; malignant growths of the pleura; diseases of the bron- chial glands, 422; mediastinal abscess; chronic interstitial pneumonia, 423; pulmonary syphilis, 424; pulmonary actinomycosis; aspergillomycosis; oidio- mycosis; nocardiosis; pulmonary distomatosis; pulmonary and pleural hydatids, 425; dermoid cysts of the lung; chylous pleurisy, 426. EXAMINATION OF HEART AND BLOOD VESSELS 427 The heart, 427; variations in size of the heart, 429; the aorta; mobility of the heart, 431; the heart valves; the clinical valvular areas; inspection; facies, 433; inspection of the neck and trunk, 435; the apex beat; various precordial retrac- tions, 436; precordial lifting; position and displacement of the apex beat, 437; precordial bulging; epigastric pulsation, 438; palpation; thrills; percussion, 439; superficial cardiac area; changes in percussion area, 440; area of relative dulness; sensation of resistance; threshold percussion, 441 ; orthopercussion, 442; the author's preference; auscultation, 443; heart sounds, 444; "the diastolic echo;" changes in timbre, 445; murmurish sounds; displaced heart, 446; re- duplication of heart sounds, 447; fetal rhythm; auscultation areas; heart mur- murs, 449; postural modifications, 450; the intensity of the' murmur; asthenic and "hemic" murmurs, 451; other forms of accidental murmurs, 453; pleuro- pericardial murmurs; curious crackles; splashing, 454; the rationale of organic heart murmurs, 455; practical synchronism, 456; systole; blended sounds; diastole, 457; presphygmic period, 458; important deductions; presystolic mur- murs in mitral or tricuspid stenosis; against the stream, 459; hypertrophy; secondary mitral leakage; consecutive involvement of the right heart, 460; differential points; rhythm, 461; hypertrophy and dilatation, 462. CERTAIN FACTORS BASIC IN THE CONSIDERATION OF THE DIS- ORDERS OF THE HEART AND BLOOD VESSELS 462 What the heart must do; arteries auxiliary hearts; arterial conservation of initial energy; the role of the vasomotor system, 462; speed of the blood stream; extreme vasodilatation; excessive vasoconstriction; the heart's capacity for work, 463; metabolism in insufficiency; what the normal heart must possess; myogenic theory, 464; rhythmicity; restoring the heart beat post-mortem; efficient con- traction; Gaskell's bridge, 465; auriculo-ventricular bundle; heart block; the pace maker of the heart, 466; extrasystoles; stimulus conduction; tonus; the neurogenic theory; independence of the heart; influence of the vagus and sympa- thetic cardiac nerves, 469; vagus overstimulation; remarkable anatomic structure of the heart; coordination of function; cardiac reserve, 470. Blood pressure: factors basic in its determination and interpretation; adap- tive cardiovascular automatism; systolic and diastolic pressure in the aorta, 471 ; pulse pressure; regulation of rate of flow; determination of blood pressure, 472; CONTEXTS XI Page the older technic of blood pressure determinations, 473; Koratknow's method, 474; normal readings, 475; age, 476; important statistical data, 477; abnormally high pressure, 478; intracranial pressure, 479; abnormally low pressure, 480; acute infections with persistent hypotension, 481 ; hypotension attending the sudden relief of abdominal pressure, 484; blood pressure determinations in pregnancy, 485; chief clinical significance of high diastolic pressure; blood pressure estimations in the arrhythmias; pulse deficit; venous pressure, 487. The radial pulse: "taking" the pulse; pulse palpation, points to be deter- mined, 488; the recurrent pulse; unilateral variations, 489; pulse frequency, 490; slow and rapid pulse; tachycardia; bradycardia, 491 ; sinus arrhythmias, 492; irregularity and intermittency, 493; pulsus irregularis perpetuus; "the paradoxic pulse;'' pulsus celer and pulsus tardus; pulsus magnus, vacuus, and parvus, pulsus durus; dicrotic pulse; capillary pulse; the bizarre in pulse terminology, 495; Mouse-tail pulse; water-hammer pulse, 495; venous pulsations; diastolic jugular venous collapse; venous pulse; visible respiratory venous phenomena; carotid vs. jugular pulsation, 496. Instrumental methods: the true value of instrumental methods, 496; the spygmograph and sphygmogram, 497; the polygraph, 498; interpretation of venous tracings, 500; the auricular venous pulse, 502; events of the venous pulse cycle, 503; registration of the venous waves; marking and interpretation of the polygram, 506; special conditions, 508; auricular flutter; paroxysmal tachycardia, 512; venous record, 513; radial record, 514; the electrocardiograph; basic prin- ciples, 517; sensitivity and responsiveness, 518; extracardial sources of deflection, 519; accidental vibrations; the electrocardiographic leads, 520; the auricular complex; the ventricular complex, 521; various interpretations of the electro- cardiogram, 522; summary; the phonocardiograph, 524; marking and interpreta- tion of electrocardiographic records, 525; extrasystoles, 527; fibrillation, 529; block, 531 ; arborization defect, 534; abnormalities in the P-wave; the P-R inter- val, 536; ventricular preponderance; auricular flutter; paroxysmal tachycardia, 539; alternation, 542; cardiac arrhythmias ; classification and analysis of arrhy- thmias; extrasystolic arrhythmia; frequency of extrasystolic contractions and their direct cause, 543; frustrated contraction, 544; intermittent pulse; ventri- cular extrasystoles, 545; clinical significance of extrasystoles; miniature murmurs; extrasystoles of ventricular origin, 546; electrocardiographic differentiation of extrasystoles, 547; the auricular extrasystoles; extrasystoles from bundle of His, 548; auricular and ventricular extrasystole, 549; auricular fibrillation, 551; auricular flutter, 555; physiologic heart block; paroxysmal tachycardia, 559; alternating pulse, 561; sinus irregularities, 563; simple bradycardia, 563; heart block; acute cerebral anemia, 565; acute infections, 566; recognition of heart block by simple means, 567; simultaneous auricular and ventricular systoles, 569; Adams-Stokes' syndrome; latent heart block; prognosis in heart block, 570. ROEXTGEX DIAGNOSIS OF CARDIAC LESIOXS, FRAXK S. BISSELL, M. D 571 Orthodiagraphy, 571; teleroentgenography; the "drop" or pendulum heart, 572; the normal heart, 574; mitral insufficiency, 575; mitral stenosis, 577; aortic insufficiency, 578; combined aortic and mitral regurgitation; aortic stenosis; pericarditis exudativa, 581; the normal aorta, 582; diffuse dilatation of the aortic arch, 584; aneurysm; aneurysm of the ascending aorta aneurysm of the descending aorta, 585; "Fatty heart; heart silhouette in nephritis, 586. THE DISEASES OF THE HEART AND BLOOD VESSELS 586 Importance of prophylaxis and early diagnosis; advance in knowledge; syphilis, 586;- rheumatism; foci of infection; the chief etiologic factor, 587; misleading delayed onset; physical debility and cardiac weakness; heart muscle vs. skeletal muscle, 588; percussion outlines; abnormal heart sounds and bruits; the vital point, 589; phasic changes in co-existent lesions; chronic myocarditis, 590; cardiovascular reserve; cardiovascular "sufficiency" and "insufficiencv;" obliga- Xll CONTENTS Page tory and morbid dilatation, 591; normal dimensions of the heart; the "drop" heart of the congenitally asthenic individual, 594; the heart of congenital asthenia, 598; effect of environment and sex, 601; misleading bruits, 602; thera- peutic test; 603; concurrence of "drop" heart and visceroptosis, 605; "neuras- thenia;" psychasthenia, 606; the rest cure; "soldier's heart,' 607; failures in pri- mary selection; vital points; adaptation and self-protection, 609; period of break- down, 610; leading characteristics, 611; obligatory exposure to adverse influences, 616; myocardial toxemia, 618; fundamentals in treatment, 620; minor insuffi- ciencies, 621; compensation and incompensation, 625; a cardiovascular paradox, 629; progressive diminution of cardiac reserve, 630; the laboring heart, 631; early diagnosis, 632; retardation and rehabilitation the primary need, 634; early recog- nition of failing reserve; tests of cardiac sufficiency, 635; skillful percussion, 638; cardinal factors in timely diagnosis; proper valuation of subjective symptoms; recognition of subjective symptoms; dyspnea, 639; pain or discomfort due to muscle fatigue and overstrain, 640; multiple factors; minor crises; extracardial factors; referred pain and discomfort, 641; epigastric, substernal, and precordial discomfort, 642; tenderness; major anginal pain; paroxysmal pain of sciatic type; obiective symptoms of decided cardiovascular insufficiency, 647; jaundice; edema, 648; cyanosis, 649; heart sounds; cardiac outline; truly effective therapy, 650; neither drugs nor rest adequate, 651 ; adaptation vs. "perfect compensation;" causative agents and portals of infection; the "abandoned" heart case, 652; after lifetime of the cardiopath; futile forecasts,. 653. Myocardial overstrain 653 Acute cardiac overstrain; fundamental factors, 653; physical fitness and habitu- ation, 654; minor heart strain, 655; the asthenic heart, 656; common cause of overstrain, 657; subjective weakness, 658; split second sound, 663; acute over- strain; preexistent lesions; overstrains of adolescence; the heart in laborious occupations, 664. Acute parenchymatous myocardial degeneration: acute myocarditis, 665; septic myocarditis; symptoms of acute simple myocarditis; weakness; dyspnea; facies; dilatation; heart sounds, 666; pulse; decompensation; pain; epigastric distress, vasomotor and urinary signs, 667. Chronic myocardial degenerations: chronic residual myocarditis; sclerotic changes; myomalacia cordis; fatty overgrowth; obesity and sedentary pursuits, 668; pathology; obesity and cardiac overstrain; insurability; associated patho- logic conditions, 669; symptoms and physical signs; cardiac outline; prognosis, 670; cardiac insufficiency of the glutton and the sot; brewery drivers and ice cart men; human vats; fatty degeneration, 671. Endocardial lesions: endocarditis, 672; verrucose, ulcerative, and sclerotic forms; symptoms of simple endocarditis, 675; subacute endocarditis, 676; recurrences of acute simple endocarditis; malignant endocarditis, 677; recurrent malignant septic endocarditis; mitral insufficiency; the typical case, 678; the murmur, 679; rationale, 681; etiology; secondary effects; pulmonary circuit, 682; compensation, 683; variation in lesions; variations in murmur, 684; murmurs of relative insufficiency; temporary absences of murmur, 685; transmission of murmur; cardiac area; associated signs; accentuation of pulmonary second sound; pulmonary stasis, 686; diminished pulmonary accentuation; subjective symptoms; prognosis, 687. Mitral stenosis, 687; anatomic types, 689; the typical case; murmurs, 690; characteristic first sound at apex; thrill, 691 ; pulmonary second sound, 692; effect of posture and exertion; changes in cardiac outline, 693; associated bruits, 694. Rationale. — The murmur of mitral stenosis, 694; blood pressure; thrill, 696; clinical division; cases lacking excessive pulse rapidity and extreme irregularity; cases characterized by fibrillation or flutter-arrhythmia, 697; distribution of overload, 698; changes in cardiac outline; effect upon heart sounds, 700; secon- dary systemic effects, 701. CONTENTS Xlll Page Tricuspid insufficiency (tricuspid regurgitation, tricuspid incompetence); etiology; endocarditic cases, 701; the typical case; the murmur, 702; rationale of tricuspid regurgitation; the murmur, 704; the second pulmonary tone; venous stasis, 705; a vicious circle, 706; slight or silent leakage; direct expansile hepatic pulsation; systolic jugular pulse; extreme examples, 707. Aortic insufficiency (aortic regurgitation, aortic incompetence) ; the murmur, 708; areas of maximal audibility, 709; area of maximal transmission; cardiac outline; associated signs; heart tones, 710; rationale — the mental picture. 711; five cardinal symptoms; murmur of aortic insufficiency, 715; transmission of the murmur, 716; increase of cardiac area, 717; aortic dilatation; hearts with small leaks; alternating high and low pressures; Corrigan pulse; arterial tones, 718; capillary pulse; sight diagnosis; modifications of heart sounds, 719; the Flint murmur; pallor; nutrition and temperament; pain, 720; dyspnea; sources of dan- ger, 721. Aortic stenosis, 721; the murmur; thrill, 723; aortic second sound; cardiac outline; the apex-beat; the pulse; rationale, 725; arrhythmia, 726. Tricuspid stenosis, 726; murmur; thrill; percussion area; subsidiary signs; rationale, 727; prognosis, 728. Pulmonary insufficiency (pulmonary regurgitation, pulmonary incompe- tence); etiology, 728; clinical signs and symptoms; murmur; pulmonary, pulse, and blood pressure, 729; rationale, 730; pain; differential diagnosis, 731. Pulmonary stenosis and atresia: etiology, 732; fetal endocarditis rare; extraordinary combinations, 733; murmur; thrill; pulmonary second sound; cardiac area, 734; cyanosis; clubbing of the fingers; secondary erythremia; differ- ential diagnosis; comment; prognosis, 736; patent foramen ovale, 738; patent ductus Botalli, 739; the murmur, 740. Stenosis or atresia of the aorta and coarctation of the arch: defec- tive ventricular septum, 741; congenital heart lesions in general, 742. The commoner combined valvular lesions, 742; multiple murmurs; differ- entiation, 743; common diastolic bruits; the Flint murmur; tricuspid and pul- monary stenosis; tricuspid regurgitation, 744; pulmonary insufficiency; thrills; the cardiac outline; paradoxic right heart pulsations, 745; rationale; mitral stenosis and regurgitation, 746; aortic stenosis and regurgitation, 747. Cardiovascular syphilis: enormous cardiovascular field; cerebrospinal syphilis; paresis, 748; luetic aortitis; astounding figures, 750; reduction of life expectancy; chronic productive mesaortitis, 751; Francis Welch aortitis, 752; early recogni- tion, 753; general symptoms, 754; pressure pain, 755; dyspnea; narrowing the cardiovascular field of response; physical signs, 756; many "Wassermann tests" valueless, 759; summary, 760. ARTERIOSCLEROSIS 761 Atherosclerosis; etiology; heredity; physical work; interstitial nephritis, 761; vicious complication; lesions; physical signs. — Inspection, 762; retinal arter- ies; palpation; auscultation; mesenteric arteriosclerosis, 763; limited ausculta- tory field, 764; general symptoms; cerebral symptoms; gastro-intestinal symp- toms, 765; cerebral seizures; pulmonary block; thoracic ailments commonly associated with arteriosclerosis; rationale, 766; arteries lesser hearts; storage power plant, 767. PAROXYSMAL SPASTICITY OF THE CORONARY ARTERIES AND ANGINA PECTORIS WITH OR WITHOUT CORONARY ARTERIO- SCLEROSIS 768 Claudication of the heart; morbid anatomy; symptoms, 768; the pulse; incon- stancy of pain; angina pectoris, major, 769; distribution and degree of pain, 771; rationale; minor anginas, 772; prognosis, 773. Aneurysm of the thoracic aorta: etiology; difficulties in diagnosis, 773; clini- cal divisions; statistics, 774; favorite sites; termination; symptoms, 775; physical signs; inspection, 776; palpation; the pulse; percussion; auscultation, 777; XIV CONTENTS Page aneurysm of the ascending aorta, 778; aneurysm of the transverse portion of the arch; aneurysm of the descending portion of the arch, 779; differential diagnosis, 780; final considerations and conclusions, 781. Pericarditis, 781; etiology, 782; dry vs. wet cases, 784; silent and unrecognized cases; idiopathic cases; symptoms common to both dry and wet cases; fever; pain, 786; the pulse; dyspnea and cyanosis, 787; the friction rub; pericardial mur- murs; pericardial friction; stethoscopic pressure effect, 788; failure of definite transmission; symptoms characteristic of effusion, 789; changes in the level of dulness; pressure symptoms; precordial and epigastric bulging, 790; hydroperi- cardium; pyopericardium; pneumopericardium; the rationale of pericarditis; pericardial relationships, 791; diaphragm and cervical fascia; pathology, 792; adhesions; genesis of friction sounds; modifying influences, 793; postural varia- tions in murmurs; absorption of exudate and return and recession of friction sounds; pleuro-pericardial friction, 794; resolution and repair; adhesions; poly- serositis; mediastino-pericarditis and indurative mediastinitis, 795; polyserositis proper; myocardial involvement, 796; calcification; serous exudates; cardiac out- line in effusion, 797; large vs. small effusions; pressure effects; compression of the lung and displacement of the liver, 798; diagnostic value of the quality of the percussion note; factor fundamental in diagnosis; dry pericarditis; obscure peri- carditis with effusion, 799; technic of aspiration; prognosis, 800; aneurysm of the heart; rupture of the heart; foreign bodies in the heart; new growths of the heart; situs viscerum inversus, 802. DISEASE OF THE ABDOMINAL ORGANS 803 The abdomen: abdominal examinations, 803; points to be determined, 805; topography and regional divisions, 807; the liver, 808; the gall-bladder, 809, 811; the spleen, 811; the kidneys, 813, 819; the pancreas; helpful data relating to abdominal tumors, 815; differential points relating to tumors, 818. The stomach, 820; physical examination — inspection, 822; direct inspection; the esophagoscope and gastroscope, 824; palpation of the gastric area, 831; percussion, 832; auscultation; Revidtzef's sign, 833. ROENTGENOGRAPHY AND ROENTGENOSCOPY IN THE DIAGNOSIS OF GASTRIC AND DUODENAL DISEASE— DR. FRANK S. BISSELL 834 Technic, 834; motility; peristalsis, 836; bulbus duodeni, 837; gastroptosis; dilatation; carcinoma ventriculi, 838; pyloric patency or obstruction, 840; gastric ulcer, 841; duodenal ulcer, 842; the colon; ileocecal tuberculosis, 847; chronic ulcerative colitis, 848; gall-bladder; the stomach tube and its uses, 849; the diges- tive ferments, 851 ; the examination of the duodenal contents, 852; examination of gastric contents, 856; gastric contents — chemical tests; qualitative tests, 860; quantitative test for hydrochloric acid; end reactions, 864; recapitulation, 866; normal acidity (Euchlorhydria); hyperchlorhydria, 867; chronic hypersecretion, 869; hypochlorhydria; anachlorhydria; certain prominent gastro-intestinal symptoms, 870; appetite, 871; nausea and vomiting, 872; examination of the vomitus, 873; hematemesis, 874; general microscopic findings, 877. DISORDERS CHARACTERIZED BY SENSORY, MOTOR AND SECRETORY DISTURBANCES , 878 Gastric spasm, 878; anorexia nervosa; achylia gastrica, 879; simple achylia, 880; heterochylia, 882; gastroptosis, 884; disordered motility; gastric atony and chronic dilatation, 885; gross atony, 888; asthenic dyspepsia, 893; chronic congenital asthenia, 895; acute atonic dilatation, 897; post-stenotic motor insufficiency; symptoms, 898; differentiation, 900; hour-glass contraction, 901. DISEASES OF THE ESOPHAGUS 901 The chief organic esophageal lesions; varices; acute esophagi tis; esophgeaal strictures, 901; esophageal dilatations, 902; diverticulum; acute esophagitis, 903; syphilis; esophageal neuroses; carcinoma of the esophagus; esophageal spasm, 904. CONTENTS XV Page ORGANIC DISEASES OF THE STOMACH 905 Acute gastritis; chronic gastric catarrh, Q05; hypertrophic chronic gastritis, 906. Gastric and duodenal (post-pyloric) ulcer: gastric ulcer; etiology, 907; pathology and morbid anatomy, 908; location; healing; perforation, 909; acute ulcer, 910; hemorrhage, 912; vomiting; acidity, 913; chronic gastric and post- pyloric (duodenal) ulcer; "hunger-pain;" hemorrhage, 914; hyperacidity; hypersecretion, 915; tenderness and defensive rigidity; radiography in gastric and duodenal ulcer, 916; secretion, 917; spasm of the pyloric antrum, 918; acute pyloric obstruction; post-pyloric (duodenal) ulcer; dyspeptic symptoms; fever; anemia, 919; differential diagnosis, 920; circumscribed pressure tenderness, 921; retention and hypersecretion, 922; ulcer with adhesions, 923; perforation, 925; differential diagnosis; gastric hyperesthesia, 926; hypersecretion. 927; operative cases of gastric ulcer, 929; gastric erosions, 930. Gastric carcinoma: etiology, 930; varieties and preferential sites; symptoms, 931; stomach contents; chemical and microscopic findings, 933; diagnosis, early and differential, 934; gastric crises, 935; spastic splanchnic abdominal crises; syphilis of the stomach, 936; tuberculosis of the stomach; congenital stenosis of the stomach. 937. THE FECES 937 Lines of investigation; character of the stools, 937; clinical significance of ab- normal findings; normal content; form; food remnants; blood, 938; mucus; pus; collecting the specimen; microscopic examination, 939; Schmidt's method; Steele's method; macroscopic findings, 940; chemical examination; inferences from the tests; value of results obtained, 941; concretions; hemorrhoids, 942; Meckel's diverticulum, 943. ENTERITIS . . 943 Clinical varieties; morbid anatomy, 943; acute intestinal indigestion; acute fermentative diarrhea; chronic enteritis; cholera infantum; membranous enter- itis, 944; dysentery; etiology; the cause of amebic dysentery; laboratory diagno- sis, 945; Walker's differential table, 947; acute specific dysentery; acute catarrhal dysentery; diphtheritic dysentery; symptomatology of dysentery; chronic dysentery, 948; differential diagnosis; mortality and general comment, 949. MISCELLANEOUS INTESTINAL NEUROSES 949 Rectal spasm; peristaltic unrest; meteorism, 949; enteralgia; hypogastric neu- ralgia; hyperesthesia, paresthesia, anesthesia; intestinal neurasthenia; paralysis of the intestines; chronic intestinal obstruction, 950; chronic intussusception; Lane's kink; constipation, 951; fecal accumulation, 952; thrombosis and embol- ism; tuberculosis of the intestines; syphilis of the intestines; enteroptosis (Glenard's disease), 953. APPENDICITIS 953 Mortality; etiology; symptoms, 954; physical signs; perforation and general peritonitis, 955; differential diagnosis of acute appendicitis, 956; prognosis; chronic appendicitis, 957; roentgenologic aids to diagnosis, 958; the exploratory operation; acute intestinal obstruction, 959. Acute peritonitis, 959; symptoms, 960; localized peritonitis; subphrenic abscess; differential diagnosis, 961; chronic peritonitis; proliferative peritonitis; tuberculous peritonitis, 962; -symptoms; differential diagnosis; cancer of the peritoneum, 963. DISEASES OF THE PANCREAS 964 Acute hemorrhagic pancreatitis; acute suppurative pancreatitis; gangrenous pancreatitis; chronic pancreatitis; pancreatic cysts; carcinoma of the pancreas, 964; pancreatic calculi; the Cammidge test and Loewi's test, 965. DISEASES OF THE LIVER AND THE BILIARY PASSAGES 965 Congenital anomalies; inflammation of the liver, 965; abscess of the liver; complications, 966; differential diagnosis; hepatic hyperemia, 967; tumors of the liver; parasitic involvement; echinococcus (hyatid) cysts, 968; cirrhosis of the XVI CONTENTS Page liver; basic pathology and varieties Laennec's cirrhosis; morbid anatomy, 969; symptoms of Laennec's cirrhosis, 970; diagnostic summary, 971; nutmeg liver; fatty cirrhotic liver; hypertrophic biliary cirrhosis (Hanot's disease), 972; syphilitic cirrhosis; syphilitic gummata of the liver; acute perihepatitis; capsular cirrhosis, 973; amyloid liver, 974. Acute yellow atrophy: differential diagnosis; Weil's disease, 974. Diseases of the gall-bladder: catarrhal jaundice; acute cholecystitis, 975; typical and atypical cases, 976; cholelithiasis, 977; biliary colic; obstruction of the common duct, 978; cystic duct; general comment, 979. INFECTION AND IMMUNITY— A BRIEF SUMMARY OF SOME OF THE IMPORTANT PRINCIPLES UNDERLYING THE "WASSERMANN" REACTION AND CERTAIN OTHER TESTS INVOLVING COMPLE- MENT-FIXATION, AGGLUTINATION, PRECIPITATION AND ALLERGY 980 Present status of the doctrine of immunity; nature of the Wassermann test; infection; bacterial toxins; exotoxins and endotoxins, 980; leucocytosis and chemotaxis; bacterial hemolysis; ptomains; immunity; 981; antibodies; opsonins; antigens, 982; bacteriolysis; substance sensibilatrice, 983; complement (alexin fixation); hemolysis; application to syphilis, 984; the Wassermann reaction — titration of hemolytic amboceptor or sensitizer, 985; fresh guinea-pig serum; scheme for Wassermann test after scheme of Noguchi, 986; Noguchi's method of complement fixation for the serum diagnosis of syphilis; controls, 988; addition of hemolytic system; results obtainable with the Wassermann test, 989; Schick's test of diphtheria immunity; true reaction; precipitin test for human blood, 990; meningococcus test; agglutination reaction, 991; anaphylaxis, 992; serum disease; symptoms, 993; opsonic theory, 994; technic, 996; measuring the dose of the vaccines, 999. THE INFECTIOUS DISEASES— TYPHOID FEVER (Enteric Fever, Typhus Abdominalis) 1000 Definition; etiology; distribution of the germs in the body, 1000; modes of entrance; incubation period; varieties, 1001; pathologic anatom)-, 1002; symp- toms and diagnosis; complications, 1003; the typical case, 1004; fever; the so-called abortive typhoid; rose spots, 1005; enlargement of the spleen; recovery of the bacillus from the stools, blood, or urine; nervous symptoms; important factors in accurate diagnosis, 1006; Ehrlich's diazo-reaction, 1007; agglutination test of Widal, 1008; the blood culture, 1009; differential diagnosis of typhoid fever, 1010; prognosis, 1013; colon bacillus infections, 1014. Influenza: epidemic variants, 1015; etiology, 1016; contagiosity; immunity; incubation types, 1017; symptomatology, 1018; the acute hemorrhagic pneu- monitis of the epidemic of 1918, 1021; symptoms of influenzal pneumonia; Roent- genographic findings, 1022; prognosis, 1030. Asiatic cholera: etiology; morbid anatomy; incubation, 1031; stages; the blood; prognosis; diagnosis; differential symptoms, 1032. Bubonic plague, 1032; etiology; morbid anatomy; pestis major, 1033; the blood; pestis minor; diagnosis; pathognomonic sign; mortality, 1034. Dengue: definition; etiology, 1034; symptoms; differential diagnosis, 1035. Yellow fever: etiology, 1035; morbid anatomy; symptoms; physiognomy, 1036; diagnosis; differential diagnosis; prognosis, 1037. Malaria: historic note, 1037; characteristics of the mosquito, 1038; classifi- cation of the organism, 1039; tertian organism; quartan, 1040; estivo-autumnal Plasmodium; evolution of the organism in the mosquito, 1042; cultivation of the parasites, 1043; examination of the blood for malarial organisms; immunity; symptoms, 1045; classification of pernicious forms; malaria in infants; chronic malaria, 1048. Relapsing fever: etiology; morbid anatomy; symptoms, 1049. Typhus fever: etiology; transmission, 1051; historic note; morbid anatomy CONTENTS XV11 Page incubation period; immunity; symptoms, 1052; variants; physiognomy and odor; Brill's disease, 1053. Malta fever: etiology, 1053; morbid anatomy; history; symptoms; differential diagnosis, prognosis, 1054. Rocky mountain spotted fever: causal agent; symptoms, 1055; differential diagnosis; prognosis, 1056. Tularemia: symptoms and course; prognosis, 1056. Milk fever; mountain fever; epidemic dropsy; epidemic gangrenous rectitis; miliary fever; foot-and-mouth disease, i os 7; flood fever; glandular fever; pappataci fever, io58; slx-day fever; seven-day fever; leishmaniasis, io59; infantile kala-azar; tropical sore; rat bite fever, 106 1 ; verruca peruana; oroya fever, 1062; hill diarrhea; sprue, 1063; trench fever, i065. Measles: etiology; contagiousness; symptoms; the rash, 1066; duration of stages; complications; the urine, 1067; diagnosis, 1068. Mumps: etiology; symptoms, 1068; complications, 1069. Scarlet fever: etiology; incubation period, 1069; mortality; symptoms; the blood; complications; suppurative otitis media; diagnosis, 1071; spurious rashes, 1072. Rubella, 1072; differential diagnosis, 1073. Fourth disease: incubtion; onset; fifth disease, 1073. Escherich's infectious erythema, 1073. Diphtheria: dissemination and distribution; morbid anatomy; symptoms, 1074; complications; differential diagnosis, 1076; Vincent's angina, 1077. Meningeal infections, 1077; morbid anatomy, 1078. Epidemic cerebro-spinal fever {Petechial fever, Spotted fever, Malignant Purpuric fever, Brain fever) : symptoms, 1079; intermittent form; abortive form; Kernig's sign; Brudzinski's phenomena, 1081; lumbar puncture; globulin content, 1082. Acute tuberculous meningitis; stages, duration, 1083; differential diagnosis; suppurative meningitis; syphilitic meningitis, 1084; alcoholic meningitis; sec- ondary meningitis; "circumscribed serous meningitis, 1085;" infantile meningitis; chronic remittent meningitis, 1086; Lethargic encephalitis, 1086; etiology; pathology; symptomology, 1087; diagnosis; prognosis, 1088; Acute infectious poliomyelitis (Acute Anterior Poliomyelitis, Infantile Paralysis): 1089; morbid anatomy, 1090; symptomatology; prognosis; chief clinical types of the disease, 1092; misleading factors in diagnosis, 1093. Smallpox (Variola): historic note, 1093; etiology, 1094; varieties of smallpox; characteristic symptoms, 1095; the typical eruption, 1096; confluent smallpox; hemorrhagic form; malignant smallpox; varioloid, 1097; diagnosis; vaccination; extent and duration of the protective influence, 1099; preparation of vaccine; sequence of events in vaccination, 1101. Varicella (Chickenpox): 1102; symptoms; differential points, n 03. Whooping cough (Pertussis): 1103; symptoms, 1104; diagnosis; comment, 1105. Syphilis if 1 Lues Venerea" "Pox"): smear preparations, 1105; mode of convey- ance, 1 106: the three stages; the initial lesion or chancre and the bullet bubo, 1 107; syphilitic exanthemata, 1108; indurative edema; the hair; the buccal cavity; tertiary syphilis, 1109; syphilis of the respiratory tract, 11 10; the lymph glands; hereditary syphilis; syphilis hereditaria tarda; prognosis, 11 n. Ulcerating venereal granuloma; yaws (frambcesia) : 1112; differential diagnosis, 11 15; gangosa (Muffled Voice): 11 16. Eryslpelas: symptoms; differential diagnosis, 1118; Pyemia and septicemia, 1119. Leprosy: the bacillus leprae; mode of conveyance, n 19; development of leprosy, 1120; anesthetic leprosy, 1121. XV111 CONTENTS Page Anthrax {Malignant Pustule, Charbon. Wool Sorter's Disease) , 1122; malignant anthrax edema; diagnosis, 11 23. Hydrophobia (Rabies, Lyssa): rabies virus and the Negri bodies, n 24; lys- sophobia (Pseudo-hydrophobia); tetanus (Lockjaw), n 25; symptoms; progno- sis. Glanders; acute glanders, n 26; acute farcy; the mycoses; aspergilloses; mucor-mycosis; systemic blastomycosis, 1127; coccidioidal granuloma; sporotrichosis; the nocardoses; madura foot, 1129; actinomycosis, 1 130; lupinosis; meat poisoning; lacquer poisoning, ii32. THE CHIEF ANIMAL PARASITES— RHIZOPOD A 1132 FLAGELLATA, II32; TREMATODA (Flukes), II33; CESTODES (Tapeworms) , II34 tenia echinococcus, 1136; ascaris LUMBRicoiDES; oxyuris vermicularis, 1 137; TRICHINIASIS, 1 138; UNCINARIASIS, H30; FILARIASIS, II40; DRACONTIASIS, II43; trichuris trichiura (Whipworm); dicotophyme gigas or eustrongylus gigas; strongyloides intestinalis, 1144. TRYPANOSOME FEVER AND THE SLEEPING SICKNESS; BRAZILIAN TRYPANOSO- MIASIS, 1145; sarcoptes scABiEi (Acarus Scabiei), 1147; vagabond's disease, 1148. The myiases and dermatophiliasis, cutaneous myiases: the screw-worm; timber fly disease; the creeping eruption, 1148. CERTAIN DISEASES OF THE JOINTS OF PROVEN OR PROBABLE INFECTIOUS ORIGIN 1149 Acute rheumatism: probable portals and agents of infection, 1149; symptoms, 1150; fever; heart complications, 1151; blood, 1152; skin; gastroin- testinal and respiratory tracts; nervous system, 1153; differential diagnosis, 1 1 54; prognosis, 1155. Arthritis deformans, 1155; general progressive arthritis deformans, 1156; chronic or recurrent infectious arthritis; still's disease; syphilitic arthritis; gonorrheal arthritis, 1 15 7; static ailments, i 158. ACUTE NON-SUPPURATIVE POLYMYOSITIS n 59 Etiology, symptoms, and duration, 1159; primary suppurative myositis; hemor- rhagic polymyositis; acute primary suppurative myositis, 1 160; syphilitic myositis; tuberculous myositis; myositis fibrosis, 1161; myositis ossificans; muscular cramp; myalgia (Muscular Rheumatism), 1162. CERTAIN IMPORTANT CONDITIONS OF UNKNOWN CAUSATION OR LACKING A PROPER DESIGNATION 1163 Diabetes mellitus, 11 63; clinical definition, n 64; symptoms; coma; precau- tionary measures, 1 1 66; the blood, 11 67; the urine; prognosis, 1168. Diabetes insipidus, 1168; symptoms; prognosis, 1169. Gout: etiology; inheritance, 1169; age, 1170; essential factors, 1171; clinical characteristics; symptoms, 11 72; onset; glycosuria; retrocedent gout, n 73; chronic gout; irregular gout, n 74. Rickets: symptoms, 1175. Neurasthenia ("Nervous Prostration," "Nervous Exhaustion"), 1176; symp- toms, 1 1 81; diverse localization of symptoms, 1182; diagnosis, n 83. Sea-sickness and car-sickness: 1184. DISEASES OF THE NERVOUS SYSTEM 1185 The neuron theory, 1185; conduction in motor and sensory areas; the motor tracts, 1 1 86; direct sensory tract, 11 87; the indirect sensory tract; functions of the tracts of the spinal cord, n 88; causes of disease of the cerebro-spinal sys- tem, 1189; degeneration, 1190; regeneration; sequence of degenerative changes; general relation of pathologic changes to symptomatology, 1191; sensory areas; motor lesions; unilateral spinal cord lesions; complete transverse spinal cord lesions, 1192. Reflexes, 1193; the more important special reflexes; the patellar reflex (knee- jerk), 1 1 94; ankle clonus, 1195; Babinski's toe reflex; Oppenheim's reflex; organic CONTENTS XIX Page reflexes, 1196; synkenesias of diagnostic value, 1197; examination of the muscles; significance of electrical reactions, 1200. Certain psychic derangements : disorders of memory; illusions, hallucinations, delusions, 1201; delirium; disturbances of sleep and of speech, 1202; the lesions affecting speech, 1203; mind blindness and mind deafness; investigation of sensory functions, 1204; tactile sense; muscle sense, 1206; ataxia, 1207; signi- ficance of sensory disturbance, 1208; hyperesthesia and hyperalgesia; anesthesia dolorosa, 1209. Topical diagnosis: certain cerebral centers; motor centers; cortical center for sight, 1209; cortex; silent areas, 1210; centrum semiovale; optic thalamus, 1211 ; the crura, 121 2; lesions of the medulla oblongata; lesions of the cerebellum summary of segmental paralyses, 12 13; the tongue, 1214; the uvula and velum palati; the pharynx and larynx; the sternocleidomastoid; flexion and rotation of the head; deficient upper spine flexion, 121 5; inability to raise arm; impaired lateral trunk movement; deficient supination; atrophy of forearm, 1216; failure of abduction and adduction of fingers; atrophy of ball of thumb; spinal lordosis; thigh adduction and flexion; leg extension and rotation, 121 7; drop foot; toe adduction and flexion; brachial plexus paralysis; summary of lesions of certain spinal nerves, 121 8; the cranial nerves, 12 19. The eye, its reflexes, and the optic nerve, 1220; eye reflexes; the optic nerve, 1221; amblyopia, amaurosis; the visual field, 1225; color fields; optic neuritis; ophthalmoscopy, 1227; conjunctivitis; retinoscopy, 1228; the fundus oculi; methods of ophthalmoscopy, 1229. Motor nerves of the eye, 1230; tests for lesions of the third, fourth, and sixth nerves; paralytic symptoms; strabismus; diplopia, 1231; conjugate deviation; trifacial; taste; motor action, 1232; the seventh nerve; facial spasm and paralysis, 1233; auditory nerve; deafness, 1234; Meniere's disease; glosso-pharyngeal nerve; the vagus, 1235; the laryngeal nerves;, cardiac plexus; spinal accessory, 1236; the sympathetic nervous system 1237. DISEASES OF THE BRAIN AND SPINAL CORD 1237 Hemorrhagic pachymeningitis, 1237; external pachymeningitis; intrameningeal hemorrhage, 1238; hematomyelia; caisson disease; "miliary," "diffuse,'' and "tuberculous" sclerosis; multiple sclerosis, 1239; sinus thrombosis, 1240; cerebral congestion; cerebral anemia; cerebral edema; congenital hydrocephalus, 1241; hydrocephalus in adults; tumors of the brain, 1242; tumor identification, 1243; summary of focal symptoms, 1244. Cerebral hemorrhage, embolism and thrombosis, 1245; premonitory symp- toms, 1246; symptoms of attack; second stage, 1247; residual and localizing symptoms, 1248; differential diagnosis; intracranial aneurysm; embolism, 1249; thrombosis; cerebral abscess, 1250. Dementia paralytica ("General paralysis of the insane"), ("General Paresis"), 1251; symptoms, 1252; variation in type; differential diagnosis, 1252; anemia of the cord; thrombosis, embolism, endarteritis of the cord, 1253. Locomotor ataxia (Tabes Dorsalis), (Syphilitic Posterior S phial Sclerosis); symptoms, 1254; ataxic paraplegia ("Gower's disease," Posterolateral sclerosis"); primary combined sclerosis; hereditary ataxia (Friedreich's ataxia), 1256; cere- bellar hereditary ataxia (Marie); primary lateral sclerosis (Erb-Charcot disease), ("Spastic Paralysis of the Adult"), 1257; hereditary spastic spinal paralysis (Hereditary spastic paraplegia), (Family form of spastic spinal paralysis); the spastic paralysis of infants (Birth palsy, Spastic cerebral paraplegia, Little's dis- ease, Spastic diplegia); 1258; hysterical spastic paraplegia; amaurotic family idiocy; syringomyelia, 1259; myelitis; compression myelitis, 1260; acute myelitis, 1261; differential diagnosis, 1262; course; Landry's paralysis, 1263. Progressive muscular atrophy, 1263; Aran-Duchenne type; amyotrophic lateral sclerosis; the bulbar type, 1264; the peroneal type; muscular dystrophies; XX CONTENTS Page pseudo-muscular hypertrophy, 1265; myotonia (Thomsen's disease), 1266; myasthenia gravis, 1267. Neuritis, 1267; acute febrile polyneuritis; pressure paralysis, 1268; Von Reck- linghausen's disease; neuralgia; herpes zoster (Zona), {Shingles) ; periodic trans- ient paralysis; facial hemiatrophy, 1269; paralytic vertigo (Gerlier's disease); Raynaud's disease {Symmetrical gangrene, Local asphyxia); erythromelalgia; acroparesthesia; angio-neurotic edema, 1270; intermittent joint effusions; epilepsy; grand mal, 1271; petit mal; Jacksonian epilepsy; epileptic equivalents, psychoses, 1272. Chorea (St. Vitus' s Dance, Sydenham's Chorea), 1273; symptoms, 1274; differ- ential diagnosis; convulsive tic (Habit spasm); generalized impulsive tic (Gilles de la Tourette disease), 1275; pandemic chorea; saltatory spasm; paralysis agitans (Shaking palsy, Parkinson's disease); hysteria, 1276; symptoms, 1279; diagno- sis and prognosis; traumatic hysteria, 1280; symptoms commonly presented, 1 281; mountain sickness; aviator's syndrome, 1282. THE INTOXICATIONS 1283 Sunstroke (Thermic Fever, Insolation, Siriasis); etiology; symptoms, 1283; warning signals; sun traumatism; heat exhaustion, 1284. Alcoholism: acute and chronic alcoholism, 1284; Korsakoff's psychosis; delirium tremens (Mania a potu), 1285; morphine and cocaine habits, 1286. Chronic lead poisoning, 1286; chronic arsenical poisoning, 1287; ptomain poisoning and pood poisoning; botulism, 1 288; ergotism; pellagra, 1 289; beri-beri; the vitamine doctrine, 1291. MALINGERING 1291 Simulated injury, 1292; some of the commoner feigned states; angina pectoris; blindness, 1293; contractures, 1295; fictitious wounds, 1297; insanity, 1298: pain and tenderness; paralysis, 1299. CONDITIONS SIMULATING DEATH 1301 Asphyxia; catalepsy; syncope, 1301; signs of life in persons apparently dead, 1302. A BRIEF SUMMARY OF THE SYMPTOMS AND TREATMENT OF ACUTE POISONING 1302 Acids, mineral; treatment, 1302; aconite; arsenic; atropin; cantharides, 1303; carbolic acid; caustic alkalies; chloral hydrate; cocaine; colchicum; croton oil; castor oil; corrosive sublimate, 1304; formaldehyde; gelsemium; hydrocyanic acid; lead acetate; lobelia; mushroom poisoning, 1305; oxalic acid; opium; phosphorus; potassium nitrate, 1306; potassium chlorate; stramonium and hyoscyamus; strychnine; tartar emetic; tartaric acid, 1307. TABLE OF (APPROXIMATE) METRIC EQUIVALENTS 1308 CENTIGRADE AND FAHRENHEIT SCALES 1308 INDEX OF SYMPTOMS 1309 GENERAL INDEX 1317 MEDICAL DIAGNOSIS CERTAIN FUNDAMENTAL PRINCIPLES AND SPECIAL PROBLEMS Scope of the Term Diagnosis. — Diagnosis means more than merely nam- ing a disease. It demands such accurate subclassincation and intelligent, painstaking individualization, as necessitates a knowledge of etiologic factors, the nature and sequence of pathologic changes, the effect of age, occupation, residence, habits, heredity, past ailments, and even of the constitutional peculiarities and personal characteristics of the individual. Text-book vs. Bedside. — Accurate diagnosis is prerequisite to accurate prognosis and effective treatment. From text-books and lectures the student learns the known types; at the bedside he studies variation from the type and the "personal equation." Pedagogic Spoon-feeding. — The older teaching of medicine represented, of necessity, an extreme and remarkably effective application of the dogmatic method combined with a sort of pedagogic forced feeding of the student with enormous conglomerates of predigested pap. This resulted in a tremendous overload for the memory, slight opportunity for thoughtful consideration and an exaggerated respect for ex cathedra statement. Modern Methods. — The necessity for this system has passed in large measure and, with the lengthening of the courses in medicine, these have taken on the seminar form, and the objective type, to whatever degree the amount of available clinical material of the individual school permits. With respect to the student, this change has resulted in the replacement of mere feats of memory and unquestioning acceptance of authority, by intelligent individualized study, personal observation and a well-developed critical faculty. Even during his college years or his period of internship he may commence the sifting, sorting, and necessary forgetting, which was formerly postponed until the graduate dealt with his own patients in actual practice, a form of post-graduate study too often fraught with initial damage and discomforture to both parties. Honesty and an Open Mind. — In medicine, even more than in surgery, diagnosis demands a sufficiency of facts, truthfully recorded, intelligently sifted, and viewed without bias or prejudgment. Self-deception, a narrowed mental vision which disregards new facts of later development in the individual case and resists blindly the introduction of new methods in practice, no less than cowardly adherence to an erroneous preconception, are deplorable. Subclassifica- tion and indi- vidualization. Types and variants. Mental indigestion. A boon to the student. The critical faculty. Bias and cowardice. MEDICAL DIAGNOSIS Proper balance important. Many tests proposed. Few are chosen. Dangers of hasty accept- ance. Sanguine promises. Over-confi- dence and over-reaction. Scientific Optimism and Scientific Skepticism. — We of the medical pro- fession have not attained, as yet, that proper balance of scientific optimism and corrective scientific skepticism, no less necessary to the best interest of patient and physician than to medical progress itself. The civilized world is thronged with eager altruists seeking new medical truths; the result being a vast continuous outflow of honest, but more or less imperfectly established and unproven assertions, together with a small but persistent trickle of valuable facts, which tends constantly to raise the level of scientific fitness and practical achievement. To separate the wholesome grain of truth from the great volume of chaff is a never ending task of no small magnitude. Bricks without Straw. — Within the past few years, for example, many tests have been advocated as of more or less specific value in the differential diagnosis of gastric carcinoma; yet up to the present time not one of these has demonstrated its right to any place higher than that of a member of the symptom group and some have fallen short of that. To have accepted any of these tests as specific would have worked untold evil through errors of commission and omission alike; to have tried them out without bias would be most creditable to any student or practising physician possessing the necessary facilities and requisite technic* The Magic of a Name. — The glamor of a great name is well illustrated by the history of the rise and decline of tuberculin. Tuberculin. — It required years of disastrous experience to demonstrate the decided limitations with respect both to the diagnostic and therapeutic use of tuberculin, originally announced as a cure for tuberculosis, even in its advanced stages, under a most excessive dosage. J The use of huge test doses for diagnostic purposes excited violent local and constitutional reactions even in the slumbering and innocuous foci carried by a large proportion of humanity and in many instances lesions, apparently obsolete, awoke to renewed activity. No one who lived and practised medicine during that period can forget the furor which followed the first announcement of Koch; the wild rush of patients and physicians alike, to Berlin; the astounding self-deception of public and profession; the absurd statistics of incredibly rapid cures; and finally, the inevitable over-reaction, embodied in the dictum of Nicholas Senn, "away with tuberculin!" Every medical man knows now that harm resulted from a wholly natural overconfidence in the honest, but mistaken, oversanguine and premature, announcement of a genuine discovery by one of the greatest and most sincere * Sneyer: Absence of digestive leucocytosis. Watson: Increased alkalinity of the blood. Lang: Increased resistance of the red blood cells to hypo-isotonic salt solution. Brieger and Triebing: Heightened antitryptic index. Xeubauer and Fisher: Glycyl- tryptophan test. Salkowski and Kojo: Estimation of colloidal urinary nitrogen. Grafe andRohmer: Specific hemolysis. Salomon and Saxl: Urinary test, etc., etc., etc. t The initial therapeutic dose, one thousand times that employed by users of tuberculin today, was carried rapidly upward, despite the stormy local and general reactions excited. FUNDAMENTAL PRINCIPLES of medical investigators, who, despite this one error has placed the entire civilized world under a debt of gratitude. " The magic of a great name" is too often only magic in the end and there is no quality more valuable to or in the student, than a decent and respectful attitude of interrogation, inquiry, and independent reasoning. Conflicting Evidence. — Extraordinary differences between the results of laboratory experiment and those attending their clinical application are of relatively frequent occurrence. What is true in relation to the guinea pig, dog or rabbit is not true always and necessarily for mankind and, furthermore, the reaction of the diseased human body may be wholly different from that of the sound one. It follows that, despite the fact that through the laboratory and the experi- mental work there done, we have obtained the truths fundamental in the greater part of that new knowledge which is the glory of modern medicine, we cannot achieve results always by mere hasty translation of laboratory experiment into clinical usage. The best of the many modern illustrations of this fact is found in the relationship of acidosis to periods of starvation. In the case of the normal body, starvation means inexorably an increase of ketone bodies in the blood and urine. Resting upon this proven fact, the clinician has carefully avoided starving his diabetic patients. Now we learn through the brilliant work of Allen that what is true of the normal body may be wholly untrue of the patient suffering from severe true diabetes mellitus and that oftentimes the best way to remove diabetic acidosis is to starve the patient for a limited period. Similarly until within the past few years the diabetic diet was made rigidly one of proteins and hydrocarbons because of the well established laboratory proof of the inability of the diabetic to burn and store carbo- hydrates in a normal manner. By this method of feeding the output of sugar was reduced, but we actu- ally invited the far greater threat of acidosis. Now, one seeks to combine rationally all of the known facts with relation to protein, fat and carbohydrate metabolism in health and in diabetes alike and patients have a mixed dietary fitted to their caloric necessities and toler- ance for a minimal carbohydrate intake. Limitations Imposed by Extreme Delicacy. — Many genuine discoveries are unpractical or demand such delicacy of technic as renders them of limited use and sources of real danger in unskilled hands. The determination of the u opsonic index" affords an example of a pro- cedure so complex and delicate as to place it quite beyond the realm of the practical, yet its introduction was accompanied by an assumption of practical utility which the lapse of time and the test of experience have almost wholly destroyed. The Wassermann test is now undergoing its trial by ordeal and we are al- ready learning its limitations and better estimating its very genuine value in its proper field; yet so many and so subtle are the sources of technical error, Valuable qualities. A source of error. Acidosis. The opsonic index. The Wasser- mann test. MEDICAL DIAGNOSIS Fragmentary complexes. as to make the test unsafe in the hands of anyone who is not a trained and up-to-date serologist. The Desirable Attitude. — It behooves the student, physician and teacher alike to be alert and open in mind, prompt to try out new methods, yet slow to accept that which is merely new or to replace by it the older methods of known value and potency, until it shall have been thoroughly tested and proven. The name of tlie originator may stand for capacity, past achievement, and honesty of purpose, but is not to be considered the hallmark of impeccability. The Reactionary. — On the other hand lies that most abominable of all abominations, the stubborn mind-blindness represented by an extreme skepticism which denies even a hearing to anything representing a radical departure from established theory and practice. The extent to which this was carried in an age which tolerated the most fantastic theories and lacked even the fundamentals of rational medicine is well illustrated by the antagonism which Harvey encountered, despite his beautiful demonstrations proving the circulation of the blood. A Modern Instance. — Even the epoch-making discovery of Lister failed to secure general acceptance and application for years after that great investi- gator himself and many followers had practically eliminated both " damn- able" and "laudable" pus from their surgical wards. To achieve a proper balance between these two extremes is the duty of every student and practitioner of medicine and to the greatest possible extent he should seek to add his mite to the great and ever increasing treasure of scientific truth. A Common Source of Diagnostic Error.; — To any one who has taught and practised medicine for many years it becomes clearly apparent that a certain incompleteness of conception with relation to pathologic sequence and its resultant symptomatic expressions is accountable for many of our diagnostic shortcomings. We forget that the usual descriptions of chronic disease apply chiefly to its classical symptomatic expression as an established and far-advanced pathologic process, which has been steadily extending and progressing for years prior to its detection. Early Diagnosis the Desideratum. — The true end and aim of modern of scientific diagnosis must be the earliest possible recognition of any disease, acute or chronic, and the promptest feasible institution of an effective therapy, whether this consists merely in wise instruction, in a conservative and retard- ant regimen, adequate supervision and control, or, the immediate and direct use of drugs. Complete Clinical Picture Often Lacking. — The text-book description of a disease embodies necessarily an enumeration of all of the many symptoms which may be encountered in a large group of such diseases. The ailment as encountered in individuals may only in small part fulfill these apparent requirements. In chronic interstitial nephritis or chronic myocardial degeneration the frank symptoms presented by the far-advanced lesion in a state of gross and FUNDAMENTAL PRINCIPLES often terminal functional insufficiency are those that chiefly strike the eye and im- press the mind of the reader, yet it is not at that stage but in the earlier and lesser decompensatory periods, such as may precede by years the fatal issiie or -the obvious breakdown, that the physician must find ultimately his greatest usefulness. Though we cannot detect often their actual beginnings, we can measur- ably succeed in the diagnosis of relatively early stages of many chronic dis- eases, if we avail ourselves of the many direct tests now applicable under modern methods of examination and realize the value of imperfect diagnostic mosaics composed of fragmentary but sufficiently significant symptom complexes, subjective and objective, combined with an accurate and detailed case history, a thorough knowledge of etiologic factors and a proper under- standing and appreciation of the known variants of disease. The Distinctive Value of a Knowledge of Etiologic Factors. — A study of the causes of disease is valuable in relation to chronic, no less than acute ail- ments and certain constitutional peculiarities of structure and temperament, no less than actual antecedent illness are oftentimes of the utmost signifi- cance in relation to symptoms otherwise obscure. "Chronic congenital asthenia" is of the utmost value, as a constitutional defect known to underlie many conditions of great importance. The history of certain past acute ailments is of extraordinary suggestiveness in many instances. Example. — Knowing that at least 50 per cent, of even single attacks of acute rheumatism in childhood result in permanent damage to the heart, a history of such an attack becomes peculiarly suggestive in the presence of any suspicious but indeterminate cardiac symptoms or signs, and, in little children, may represent in such instances nothing more than a mother's account of "sore throats" and "growing pains," the peculiar significance of which must be known and appreciated.* A knowledge of past luetic infection, the most protean and potent of common etiologic factors, at once throws special emphasis upon certain lines of investigation or offers a probable explanation of the presence of obscure and ill-coordinated nervous symptoms, a mysterious recurrent headache, or vague and indeterminate indications of pressure at the base of the brain. Poll Parrotry. — The student should not memorize symptoms without proper consideration of their relation to the known specific and peculiar pathologic changes of the individual disease: rather let him learn primarily the general symptom groups, common to the many forms of u fever" "anemia," and the like, and then associate with the individual disease that which is "peculiar^ and specific in its symptomatology and, above everything, the distinctive pathologic changes which underlie it. A multitude of diseases are u febrile" and there are hosts of u anemic" patients of various types, but all fevers and anemias have a basic general symptomatology. This last he should learn thoroughly as of broad appli- * The younger children are peculiarly likely to show nothing save a little tenderness about one or more joints, following, after several days, "a sore throat." A vast number of such cases are wholly overlooked. Clinical mosaics. Affect diag- nosis, progno- sis, and treatment. Masked rheumatism. Syphilis. Useless overload. Learn basic symptoms. MEDICAL DIAGNOSIS Value of picture. Diagnosis by exclusion. Usual method. Of great value. Sources of humiliation. Differentiating cation, but stamp especially upon his memory the peculiarities or definite symptoms. . . . ._.."., symptomatic variations that any specinc ailment of that group presents. Mental Photography. — Furthermore, every student should try to get a clear mental photograph of any ailment he is studying, and of the pathologic changes that underlie and explain its symptoms. In his mind's eye as he reads he should see the man with typhoid, the fever chart, his physiognomy, decubitus, rose spots, and more than that, the intes- tinal ulcers that underlie them. Such a method makes for quickness of per- ception and thoroughness alike. Direct vs. Indirect Methods.— Diagnosis by exclusion is a useful and val- uable though roundabout method of arriving at conclusions by a process of negation; the object being to find in the signs or symptoms presented by a given case, one or more inconsistent with the diagnostic symptom group of all diseases save one. [Modern advance has greatly reduced the necessity for the method and added enormously to its difficulty and laboriousness. Diagnosis by deduction based upon our knowledge of the pathologic processes and sequences of disease together with the fullest obtainable symp- tomatic and contributory data, is the method in common use, and exclusion becomes merely a factor, not a formal procedure. Therapeutic Diagnosis. — A therapeutic diagnosis is sometimes necessary and valuable, as, for example, in obscure syphilitic infection when the effect of mercury, the iodides, or salvarsan may go far to banish doubt. In the recognition of the damaging, earlier, and lesser, cardiovascular insuf- ficiencies, digitalis is invaluable. "Snap" Diagnoses. — Certain single symptoms may name a disease and such are termed pathognomonic, but woe to the man who is betrayed into the habit of making "snap" diagnoses based upon some obvious or striking signs of apparent conclusive significance. His opportunity passed when pathology came to her estate and subjected brilliant but superficial opinions to the acid test of the autopsy. Precipitate Decisions. — Many complex cases are encountered in which several ailments are concurrent and the obvious diagnosis may not represent the lesion of chief importance in the given case. Hasty conclusions are damaging in most instances and their frequency lends emphasis to the rule that all examinations must be thorough and complete and that the discovery of one important condition must not close the mind to other possibilities.* * Finding the malarial organism had led to a hasty conclusive diagnosis of malaria in a case seen recently and, as an antecedent diagnosis, tuberculosis had been affirmed quite properly because of positive sputum findings. A blood culture revealed streptococcus viridans and the domina?it and progressively fatal ailment proved to be chronic recurrent bacterial endocarditis. Like instances are by no means infrequent and failures in diagnosis are extremely com- mon in decompensated heart lesions of the silent murmurless type, because of the assump- tion that some obvious secondary morbid change is primary. Dyspepsia, albuminuria, hepatic enlargement, congestion of the lungs, chronic bron- chitis and paroxysmal dyspnea are some of the common secondary conditions leading to hasty and erroneous conclusions and midway diagnoses. FUNDAMENTAL PRINCIPLES The Fundamental Source of Diagnostic Error in Chronic Ailments. — This may be briefly expressed by the statement that we do not take or are not granted the time indispensable to good work. There is evident still, that same tendency to seize upon that which is obvious and guess at that which is obscure, which, in times past, found its sole justifica- tion in lack of available knowledge and instruments of diagnostic precision. If one is to do good work he must be thorough, painstaking, and delib- erate, and the patient must be taught that a look, or even a "look-over," a few questions, and a prescription, do not constitute a modern examination. On the contrary an intelligent opinion, the unravelling of the tangled skein of symptoms in an obscure case, means more than the work of any one day and may demand a more or less prolonged period of direct observation and complete control. Exactly the same statement holds good with respect to failures in treatment. A tendency to patch rather than to repair is the cardinal sin in therapy today, as it was a hundred years ago. We cannot cure inveterate " nervous dyspepsia" with digestants or intestinal antiseptics, nor greatly prolong the life expectancy of a decom- pensating cardiopath with occasional doses of digitalis and a half-hearted attempt to restrict activity. We can do both in surprising measure, if opportunity, cooperation and time are given us to make possible genuine repair and relative rehabilitation. With respect to tuberculosis the lesson has been learned. With respect to cardiovascular disease and other ailments quite as important and responsive, we have yet to realize the possibilities both of diagnosis and treatment. Taking the Long Odds. — Many students and some practitioners habitu- ally diagnose medical curiosities, failing to thresh out the variations of the prosaic and simple before assuming the long odds. On the other hand, it falls to the lot of every physician to encounter rarities, and their recognition means added credit and reputation. The physician often encounters some unusual case, only to have it dupli- cated within a short time, and one hears often of the triplication of such cases. Such occurrences are less mysterious than they seem for the detection of the primary case intensities our interest and alertness. Diagnosis is easy, usually, if the given disease of great rarity occurs to us as a possibility, and we at once proceed to analyze and clarify the hitherto obscure history. We also magnify the fact of accidental concurrence of like ailments, for- getting the many individual instances which lack the apparently mystic duplication. Prognosis. — Accurate diagnosis is indispensable to an intelligent prog- nosis and, unless the patient is actually in articulo mortis, the uncertainty of mere time forecasts makes them veritable traps for the unwary. W T e often see patients at the point of death rally and live for months or years even when suffering from chronic disease, and to an even greater degree Two basic factors. Futile methods. Important field. Consider the prosaic first. Duplication of rare cases. A fallacy. Traps for the unwary. s MEDICAL DIAGNOSIS Rash prophecies. The man, not the disease alone. Common variants. the statement applies to those apparently overwhelmed by the toxemia of acute infections. The physician who rashly sets exact time limits to chronic diseases in response to the natural and inevitable interrogation of the relatives of a patient seldom gains much credit from his few successful guesses. Indeed prognosis has little to do with specific forecasts as to life expectancy, which must usually prove futile, but in its broader sense it is the field in medicine which best exercises the knowledge, judgment and ripened experi- ence of its master minds. Prognosis embraces almos: :!or that can enter into an accurate, broad and highly individualized diagnosis and peculiarly exalts and emphasizes the value of a study of the "personal equation" the setting apart of the particular man, woman or child afflicted with this or that disease* from the mc We must neither treat, nor forecast the result of, pneumonia of itself, but study the individual who is suffering from it. We know that the flabby fat man is quite inferior to his lean wiry brother in resisting power, and that the total abstainer is a better "risk" in disease, as in health, than the tippler. The vigorous young adult with sound heart and blood vessels stands quite apart from the man whose heart muscle and arteries alike have surfered from the storms and stress of four score years of life. The man of unimpeachable family history, sound physique, good habits and moral courage offers a far better prognosis than his fellow who comes from tainted or short-lived stock, is defectively constructed, the victim of bad habits or possessed of little or no courage and determination to fight for his life. Previous illnesses and their erfects, the particular virulence of the indi- vidual infection, the condition of the heart, the extent of pulmonary involve- ment, and the degree to which the circumstances and environment of the patient permit the use of the full resources of modern medicine to be exercised in his behalf, are some of the factors which would enter into the prognosis. In other diseases, acute and chronic, the last consideration is extremely important. Optimism vs. Pessimism. — The confirmed optimist in prognosis, when an extremist, does far less damage to any. save himself, than does the pessimist, for the latter not only frightens many a patient into an untimely : .::-.-. but. by his willingness to stop lighting the apparently victorious d:: loses a host of golden opportunities to wrest victory from seemingly irreparable disaster. Pessimistic forecasts in relation to chronic disease, especially when bluntly and tactlessly communicated to the patient himself, are oftentimes fraught with disastrous results, and in acute disease the physician is seldom justified in exercising a brutal frankness which may serve no good purpose, but remove one of the strongest of the fighting reserves of the sick man. In certain ir. U is wholly proper and necessary to convey to the patient the advice that he take precautionary steps with relation to his afairs; but this may be so delicately imparted, and so guarded by hopeful and comforting assur- ances, as to cause little shock in most cases. Vital factors. Lost opportu- nities. Damaging revelations. FUND AMK MAT. PRINCIPLES A Difficult Problem. — On many occasions the doctor is urged by family members to tell the failing but hopeful or unsuspecting patient flatly that he must die or is actually dying. Instances occur which make it necessary for the physician to assume this delegated function and of its legitimacy in the individual instance he must be the judge. The only deathbeds the author has attended in which peace was lacking at the end, have been those in which weak, high-strong patients were told that death was inevitable. On the other hand, he has witnessed the most beautiful resignation in the face of such knowledge. The wonderful euthanasic calm which so generally precedes dissolution robs death of much of its pang and is not lightly to be broken, but, if it must be, the same mysterious, kindly influence of ttimes softens the blow. Never- theless, the demands of religious belief, the known character and tempera- ment or expressed wish of the patient, certain legal formalities, such as the "dying declaration," which demands that the statement be made under the firm conviction that death is impending, justify such a disclosure, but only in rare instances need it be absolute, luiqualified and unattended by some expression of hope. In any event, bald disclosure is but seldom the duty of the physi- cian and its damaging effect, as long as any atom of fighting hope remains, must be remembered. Truthfulness Desirable. — All this does not mean that a patient cannot be told the nature of his ailment even though the full and detailed knowledge of its gravity or severity be withheld. This statement applies with peculiar force to cases of tuberculosis in that not only is the patient's cooperation absolutely essential to arrest or cure, but uuiispensable to the protection of others. The questions of frankness, evasion or actual temporary deception, are deter- mined by ordinary common sense which takes into consideration primarily, the fundamental fact that the physician's function is that of securing for the patient the maximum of benefit. If the patient may know the truth without added danger to himself, that truth should be told and, in chronic cases especially, it is rarely wise to keep the patient in ignorance of his condition. Tactful Disclosure. — Heart disease, Bright's disease, pernicious anemia and many other conditions can be dealt with effectively only when the full cooperation of the patient is secured, for absolute control, full opportunity for supervision and abundance of time, are absolutely necessary to his welfare. In the minds of the laity the terms "heart disease" and "Bright's disease" have a meaning but little less dreadful than cancer and this is the inevitable result and reflection of the traditional general attitude of hopelessness and neglect held by the medical profession toward these conditions. Knowing as we do the wide differences existing in the subdivisions of these ailments, the extraordinary frequency of over accentuation and over estimation of the gravity of the individual case, the astonishingly long duration and slow prog- ress often manifested, the curious and conservative transformations in type which are possible and the wholly insuperable obstacles to diagnostic and prog- nostic impeccancy, we serve our patients best, usually, by avoiding the sinister Euthanasia. Obligatory revelations. Securing intelligent cooperation. The funda- mental factor. Dread terms Fallibility of forecasts. IO MEDICAL DIAGNOSIS Tactful honesty. Revelation with reassurance. Usual response. Firmness and decision. concrete terms and telling them roughly and sketchily the pathologic causes or the general underlying basis of their symptoms. The patient who would translate into the terms of a rapidly fatal disease the words "Bright's disease," may be disturbed relatively little by the knowledge that his kidneys "are inadequate" to their daily task whether as to excretion, filtration or secretion, by reason of some changes in the filtra- tion apparatus and the secreting cells. Thence, he is told, comes the tend- ency to retain at times body poisons, raise blood pressure and overtax the circulation and the necessity for his faithful and conscientious cooperation is manifest. The revelation of the fact that "the circulation is deficient," that the Jieart muscle "is deteriorated," "is a bit short on horsepower" or "lacking in tone," or even that one of the valves is not wholly competent," oddly enough, may be told a patient with far less in the way of resulting shock than might be supposed. Furthermore, even though a fuller knowledge of a genuinely serious condition must be imparted, there is a world of comfort to the patient in the citation of actual instances of the same sort where the happiest results were obtained. The intelligent patient at once sees that a logical reason underlies the demand for his cooperation and is the more likely to prove genuinely help- ful and responsive, while retaining that hopefulness and undamaged morale which may bring added years of useful life. In general, the physician whose only thought is the welfare of his patient and who is possessed of humanity, tact, and sound common sense will not go far astray. The fool oftentimes must be frightened into obedience and some fools must be abandoned to their folly. Practitioner and Consultant. — The physician must work methodically, deliberately, and with open mind, but once his opinion is formed it should find tactful, clear and emphatic expression and every subsequent order and act must be characterized by firmness and decision. If to these qualities he adds that modest self-confidence, born of fulness of knowledge and re- source, he will go far. Consultation. — Such a man can deal with intelligent patients frankly and freely, will not be afraid to call counsel nor feel always that his after-confer- ence with his consultant must be held in private, according to a custom more honored in the breach than in the observance. Few physicians will use a visit of courtesy as a means of self-advantage or the humiliation of a fellow-practitioner, and one who cannot deal fairly with all parties concerned is out of place in this day and generation. Lay Co-workers. — There are few intelligent families, moreover, in which the attending physician cannot find a confidant with whom he can talk freely and honestly, thereby increasing his usefulness and gaining cooperation and support. Attitude in Sickroom. — Doubts, fears, and arguments, however, are not for the sickroom, where a confident, cheery bearing and helpful suggestion may mean far more than drugs. CASE-TAKING II Unworked mines. Essentials of case-taking. Quack vs. Physician. — Ihe quack never hesitates to make a diagnosis, Honesty vs. . . . . , , , , r i ignorance and but the physician ot parts, knowledge, and honesty must often make none or dishonesty. at best a provisional one, and wait for more light. The charlatan never acknowledges an error; the honest man, whatever his ability, must occasionally confess one. The more superficial, ignorant or dishonest the man, the more dogmatic and hasty are his diagnoses, for with breadth and depth of knowledge comes its highest gift, a conception of its limitations. CASE-TAKING Significance and Importance of the Components of the Case History The Value of the Case Book. — 77 should be stated most emphatically that case-taking, recording, and reporting should be carried into every man's practice. Old case books well kept are mines of knowledge, and the science of medi- cine would be greatly enriched were the workers in city and hamlet alike to give to it reports of the unusual cases now for the most part allowed to pass without record. Tyro vs. Expert. — Ability to make a case history full, accurate, yet con- cise; to elicit the salient facts, and to each assign its proper value and per- spective, demands that the observer be full of usable knowledge, quick of perception, and capable of avoiding both omission and verbosity. Certain routine inquiries are indispensable and the student should be consistently painstaking and systematic in the days of his apprenticeship, though later, when a skilled clinician, he can elicit the cardinal points of a case and arrive at correct conclusions with less ink and fewer words. The Subjective vs. the Objective. — Our knowledge of clinical symptoms in a given case depends upon either (a) what we are told or (b) what we see or determine for ourselves; i.e., they are either (a) subjective or (b) objective, the latter group including bacteriologic and chemic tests as well as physical signs. "Hearsay Evidence.' ' — In the patient we may encounter garrulity, stu- pidity, concealment, deceit or hypochrondriacal exaggeration. If he is coma- tose or possesses no common language, we are left dependent upon the testi- mony of outsiders. In any event we must exercise sound judgment, keen discrimination and facility in cross-examination or we cannot weigh properly the fallible, yet extremely valuable subjective data. THE OUTWARD SIGNS OF DISEASE The First Impression. — The first glance or even the handshake may influence diagnosis and prognosis, and, while shunning the habit of making V ak hasty physiognomonic diagnoses, the physician should train his observation fnspectfon. and emulate the example of his predecessors of a darker medical era, who became adepts by force of necessity. Diagnosis in disease of the nose, throat, eye, ear, and skin is essentially that of inspection, which throughout the whole range of medicine and surgery plays an important part. Obstacles to case-taking. 12 MEDICAL DIAGNOSIS Malingerers. Melancholia. Facies, pupils, and speech, _ Luetic bahes. Character and temperament, bad habits, disease past or present, may stand revealed at a glance. Diathesis.* — "Temperament/ 1 which relates to the physical type and mental cast of the individual and was born of the old humoral pathology, is closely related to " diathesis," which applies to the group, but the latter implies a tendency to some special type of disease or diseases and the former has lost the prominent place it held in earlier times. One need give little thought to the elaborate older classification, though the " nervous," "bilious," " phlegmatic, " "lymphatic," and " melancholic " temperaments are often clearly defined and aid in diagnosis and prognosis alike. Who, for example, has not encountered the "lymphatic" (congenitally asthenic) individual with a ''prairie-fire tuberculosis" before which the physician stands helpless? FACIAL EXPRESSION.— The expression helps us with those forgers of symptoms who seek ease, food and shelter under the hospital roof or wish to saddle damages for some spurious hurt upon the rich individual or corporation. If melancholy has marked the patient for her own, "he carries on his face the impress of her signet," and incipient or established insanity of other types may manifest itself in a peculiar expression of the eyes, an ''intensifi- cation of emotional expression" and oftentimes a deceptively merry one. The stolid or even morose appearance of the immobile "mask-like" face of paralysis agitans or the fixed expression of surprise or fright which it may bear, and even the slighter facial palsies are often overlooked by the unobservant. General paresis even in its early stages often yields outward evidence. Lips, tongue, fingers and facial muscles may be tremulous; the pupils unequal and reacting to accommodation, but not to light, or wholly rigid. The speech may be slow, hesitant or explosive, consonantal words being difficult for the victim. In the "expansive" type excessive irritability, outbursts of causeless anger or delusions of grandeur accompanied by rapid- changes of facial expression may be evident; everything of his being superlatively beautiful, his schemes grandiose yet obviously fallible, and he incomparable. The " depressive" form is characterized by a marked but somewhat unstable mental depression often associated with delusions of the hypochondriacal or even persecutory type. Carcinoma of the stomach in its advanced stages is frequently associated with a curiously morose or saturnine expression well shown in a famous statue of Napoleon in his last days.f This, when associated with marked emaciation and a peculiar muddy pallor, is most suggestive. Syphilis. — The syndrome formed by a peculiar eruption, coryza ("snuf- fles"), a hoarse cry, a weazened monkeyish face, fissured lips and raw nostrils and buttocks, if seen in a babe, is pathognomonic of congenital syphilis. * Modern research has robbed the term of much of its meaning and ancient importance through the discovery of specific etiologic factors in relation to its manifestations. It would be absurd, for example, to refer to the "furuncular" or "aneurysmal" diathesis in the light of our present knowledge of the infections underlying these conditions. t In the Corcoran Gallery, Washington. THE OUTWARD SIGNS OF DISEASE 13 Fig. 1. — Classical fades of untreated or inveterate lues. Areas of gray hair representing past alopecia. "Saddle nose." Patient and his father both showed perforated palate. The permanent upper central incisors of the older children are often peg-shaped, notched at their cutting edges, irregular and separated. Fine linear scars may radiate from the angles of the mouth, keratitis and chronic otitis media often co-exist, and at any age a frog-face may result from syphilitic necrosis of the nasal arch. Syphilitic alopecia may be present also, or may have left its mark in a patchy grayness of the hair. Many cases of past syphilitic infection give no evidence, the examiner being forced to put the direct or indirect question. The former may often- times be definitely and clearly put in the case of men, but it is usually wiser to ask casually first as to antecedent "venereal" or "private" disease, or, in certain instances of especial delicacy, to quietly submit a blood specimen to the pathologist and await the report on a Wassermann test.* The therapeutic test is often invaluable though fallible and no mere negation on the part of the patient should outweigh a significant symptom group so far as the physician's attitude is concerned. Outward acceptance, inward doubt, and appropriate action make a good tripod. One of the most easily recognized and pathogno- monic {but in our day rare) syphilitic types combines alopecia or scattered areas of gray hair with saddle-nose and perforated palate. A deeply fissured tongue suggests this disease, and many cases present themselves with significant body scars, an active and unmistakable eruption, or the "primary lesion itself." Dress. — The quality of the clothing and its condition may suggest social station and occupation.. Carelessly worn and disarranged garments, stained by food droppings, if noted in a person formerly neat, suggest mental deterioration. An ammoniac al odor suggests advanced prostatic disease with urinary incontinence or cystitis, and in such cases white stains upon the shoes might sometimes give a hint of coexisting saccharine diabetes. Recent Weight-Loss or Gain. — In public services especially, needy patients, formerly obese or dropsical, who have recently lost greatly in weight, may wear their old clothes, which may be suggestively loose and, on the other hand, a recently developed anasarca may make the patient appear to be bursting through his trousers. Edema of the ankles is frequently suggested by loose lacing of the shoes, which may be cut and slashed for the same reason or the better to accommo- date corns, bunions, or gouty toes. Paralysis. — In the various forms of pathologic gait, and especially in spastic conditions, the wearing away of the shoe in a particular part may be suggestive. * The student must realize that no individual, whatever his or her rank or calling can safely be held exempt from suspicion, yet tact and delicacy are essential. The therapeutic test and the Wassermann show how often a negative response must be discounted. Hutchinsonian teeth. Keratitis and frog-face. Putting the question. A pathogno- monic syn- drome. Social station and occupation. Ill-fitting clothing. Loose lacings. 14 MEDICAL DIAGONSIS Phthisis. Prostitutes. Larynx. Essentials of .speech. True aphasia vs. anarthria. Aphemia, agraphia, amimia. VOICE AND SPEECH.— One should carefully note departures from the normal tone and enunciation. Even the layman recognizes the soft, high- pitched tones of the phthisical patient, and one notes oftentimes the peculiar harshness in the voice of the prostitute and the thick muffled speech of the victim of tonsillitis or adenoid disease. Hoarseness and aphonia are at times symptoms of great importance, as pointing to acute or chronic laryngeal diseases, and the " whispering voice" may arise from tuberculosis or malignant laryngitis, extreme exhaustion, hysteric aphonia or a paralysis of the abductors, the last being due oftentimes to the pressure of an aneurysm or mediastinal growth upon a recurrent laryngeal nerve. Slow, scanning, syllabic speech, combined with an intention tremor, suggests disseminated sclerosis or, very rarely, Friedreich's ataxia. In advanced paralysis agitans the crescendo speech may sometimes be encountered, the sentence being begun slowly and with hesitation, but increasing in rapidity and ending in a storm of words. Monotony of tone is the commoner vocal characteristic of this disease. In glosso-labio-pharyngeal paralysis, pseudo-bulbar paralysis, one encounters amyotrophic lateral sclerosis and a mumbling speech, associated with tremor and atrophy of the tongue and a curious immobility of the lips. Aphasia and Anarthria. — Normal speech demands that the centers and mechanism for the perception and recollection of spoken and written or printed w T ords, of articulation, and of association, should be normal and harmoniously interacting. It is evident that various disturbances may exist according to the charac- ter and location of the lesion; furthermore, that we must discriminate between " aphasia" and the cases of paralysis of the muscles of articulation ("anarth- ria"). True aphasia is usually of central origin, the peripheral mechanism being unaffected. Motor Aphasia. — This must be recognized as distinct from sensory aphasia. It is characterized by inability to voluntarily express by speech ("aphemia"), by writing ("agraphia") or by gestures ("amimia") what may be a perfectly clear mental image. Sensory aphasia, on the other hand, indicates a failure to understand or recognize spoken words (auditory aphasia, word deafness) or written words (visual aphasia, word blindness). A large number of subdivisions occur under both types, such as the loss of power to carry a tune or write music, or a failure to interpret or recognize musical sounds. Still another variety ("paraphasia") occurs in w T hich wrong words or characters are spoken or written, or the same word repeated. Apraxia. — By this is meant a loss of the faculty of recognizing or appre- ciating the identity, nature, and uses of objects or sensations, and here again one has various subdivisions, such as mind blindness (visual amnesia), mind deafness (auditory amnesia), as well as terms indicating an inability to recognize and interpret odors, tastes, etc. THE OUTWARD SIGNS OF DISEASE is THE COLOR OF THE SKIN.— The two conditions chiefly to be noted are pallor and cyanosis. The pale face may or may not mean true anemia, for a high color may co-exist with a low hemoglobin percentage. The color of the mucous membranes is more reliable and even u rosy chlorotics" usually show a pale conjunctiva. Ordinarily, pallor of the cheeks, lips, tongue, throat, ears, conjunctivae and finger-nails indicate a reduced hemoglobin percentage with or without a reduction in cells, though it may only mean a reduced amount of normal blood at the surface due to contracted vessels or a weak circulation. Anemic Types. — The color varies markedly in different types of severe anemia, being greenish yellow in typical cases of chlorosis, almost waxy white in many simple anemias, a peculiar lemon yellow in most cases of Addisonian anemia, and a curious earthy tint in the profound secondary anemia of advanced malignant disease of the stomach. Mode of Onset. — Sudden pallor, as in minor shock, syncope, nausea or certain neuroses, is usually unimportant and fleeting, but, in tubal pregnancy, cardiac disease, concealed hemorrhage, perforation of the stomach or bowel, and similar conditions, sudden pallor is a valuable and important sign. The pallor of the anemias, aside from those due to rapid blood loss, is slowly progressive and persistent. Nephritis. — In acute Bright' 's disease the skin is white and associated edema may produce a peculiar and characteristic pasty pallor. In parenchy- matous nephritis we meet with pallor, or in its late stages a sallow or brownish hue. Many authors speak of the peculiar "fawn-colored" skin as related to interstitial nephritis, but the author has found it oftenest in the "mixed'' type of chronic kidney disease or in very late stages of the interstitial form Fig. 2. — Bright's Disease. Fades occasionally encountered in chronic nephritis. Morning fulness of eyelids. Fig. 3. — Appearance of lids in afternoon or evening. the earlier period being often associated with the ruddy or high-colored ("clubman") countenance, and many of its victims appearing exuberantly healthy. In most instances interstitial nephritis exists for long periods without the slightest physio gnomonic sign. Baggy Eyelids. — A tendency to edema of the eyelids, especially of the lower, is often evident, and the pale, puffy and almost translucent lid of early morning may have become shrunken and wrinkled later in the day. The condition cannot be considered as pathognomonic, but should be regarded as suggestive. In chronic parenchymatous and "mixed" nephritis alike, the face may appear more or less puffy, sallow or even fawn colored. A misleading symptom. Chlorosis, pernicious anemia, and cancer. Sudden pallor. Acute vs. chronic nephritis. Mixed and interstitial nephritis. Diurnal variations. i6 MEDICAL DIAGNOSIS False pallor. False color. Selective points for cyanosis. Venous obstruction and impaired oxidation. Acute diseases. Extreme cyanosis in ambulants. "Red cyanosis." Drug cyanosis. Cold skin. Heart Disease. — The color in certain forms of advanced heart disease is both interesting and important. Aortic regurgitation is usually associated with a pallor of the indoor- worker type, without true anemia, but in endocarditic regurgitant and obstruct- ive disease of the mitral valve, even if compensation is present, the color is often deceptively high, producing, in girls especially, what the laity may consider an exquisite complexion, though in older women the pink is duskier and more patchy.* The skilled eye detects the underlying cyanosis which shows still more plainly in the mucous membrane of the lips, the skin of the ears, nose and pa- tella, or in the nails whose pink is replaced by a darker hue or, in extreme cases, by a purplish or blackish gray. Cyanosis. — This, whether general or local, with or without true dyspnea, ordinarily indicates obstructed venous return, deficient oxidation, or com- monly both factors, such as may result from any of the following conditions: ordinary suffocation, congenital heart disease, asthma, emphysema, pul- monary fibrosis, obstructed glottis, trachea or bronchi, as from foreign bodies, croup, laryngeal diphtheria, capillary bronchitis or broncho-pneu- monia proper, mediastinal tumors, or other heart and lung lesions. It occurs also in acute diseases, such as pneumonia, pleurisy with either liquid or gaseous effusion, and, to a slight degree, in severe acute bronchitis. Paralysis and spasm, particularly of the diaphragm, may produce marked cyanosis, as may the inhibition of efficient respiration by severe pain. The chief and most important physical factor in both local and general cyanosis is the slowing -of the circulation, whether central, localized or due to increased viscosity and blood volume, as in erythremia, but the reduction of hemoglobin may result from the action of chemical poisons alone without any material slowing of the blood current. In lobar pneumonia, profound cyanosis of the finger-nails is usually the forerunner of death. No outward sign of disease exceeds cyanosis in importance, and in its extreme form it exists in but three classes of walking patients, viz., severe em- physema or erythremia in the adidt and congenital lie art disease in the child. It is often associated with mere chilling of the body surface, hysteria, neuritis, etc. Erythremia is associated with a peculiar red cyanosis and in all cases of erythrocytosis cyanosis is a prominent feature. Local vasomotor relaxation or paralysis is readily distinguished by the lack of turgidity of the venous trunks, and it should be remembered that cer- tain forms of drug poisoning, especially that of acetanilid and its congeners, nitro-benzol, etc., may account for an otherwise inexplicable and extreme cyanosis. Through excessive heat loss cyanotic areas are cold save in acutely in- flamed parts. The slighter degrees are often unnoticed by the student, but pronounced cyanosis cannot be overlooked. *Such deceptive color is frequently present in splenic leukemia, even when quite advanced. THE OUTWARD SIGNS OF DISEASE 17 Other Abnormal Color Variations. — Of the many other departures from the normal tint one may mention the yellowish brown, dark brown, or brown- ish black of Addison s disease, the peculiar bluish or blackish gray of argyria (chronic silver poisoning), the sallow tint of chronic malaria and the varying yellows produced by jaundice. Arsenical melanosis is quite common and may exactly simulate Addison's disease, but usually diminishes under drug discontinuance. Marked pig- mentation is occasionally encountered in exophthalmic goiter. The yellow- ish-brown patches of pregnancy (chloasma gravidarum) and pelvic disorders are common and easily recognized. Certain abdominal tumors and peri- toneal tuberculosis may cause extensive and misleading color changes. Streaky pigmentation usually indicates scratching as the result of skin parasites or pruritic lesions and is often seen in public clinics. One occasion- ally encounters a pigmentation of like causation so diffuse as to closely simu- late that of Addison's disease. Melano -sarcoma is associated with a grayish or blackish skin and the urine shows melanin. A brownish or dirty gray, spotted or patchy discolora- tion may occur in hepatic cirrhosis with or without jaundice, and bronzing may be associated with combined cirrhosis and diabetes (bronze diabetes) or, in rare instances, with extreme long-standing jaundice alone. Aside from its secondary color manifestation, syphilis in its tertiary and congenital form sometimes produces a peculiar sallow pallor not easily described, but readily observed. The author has encountered it chiefly in old cases of imperfectly treated syphilis, and it is likely to be associated with other luetic " reminders." Drug Habitues. — Peculiar but indefinable forms of pallor and sallowness may mark the cocain and opium habitue, and occasionally the author has ob- served in such cases a physiognomy remarkably like that of chronic nephritis; but more often the habit may exist for years without distinctive outward signs. Certain cases of deep pigmentation occur lacking demonstrable etiology and without impairment of the general health. As regards both marked color loss or its decided modification in chronic dis- eases, it should be borne in mind that the symptom is, as a rule, one indicative of the advanced stage of the disease. High Color. — A florid face is often present in gouty subjects or in many of those suffering from early interstitial nephritis or hepatic cirrhosis, but may be due to idiosyncrasy, acne rosacea or daily exposure to harsh weather con- ditions. It often indicates an overluxurious and self-indulgent life or the abuse of alcoholics. Unilateral flushing is frequently observed as a neurosis, in lobar pneu- monia, or as the result of mere pillow pressure, migraine, and, less commonly, of irritation of the fibers of the cervical sympathetic as in aneurysm of the aortic arch or mediastinal growths. "Morbid blushing" is a troublesome and not uncommon vasomotor idiosyncrasy. The flushed face of fever patients is too common to merit extended dis- cussion. Yellow, browD, and black skins. Chloasma gravidarum. Vagabond's pigmentation. Obscure pigmentation. Not always high living. i8 MEDICAL DIAGNOSIS Hemolysis. Toxic jaundice. Blocked bile current. Icterus nervosa. General cutaneous hyperemia is seen in poisoning by belladonna, hyo- scyamus, or coal-tar products, is common in the trivial fevers of infancy and early childhood, and may precede the specific exanthem in fevers of the eruptive type. JAUNDICE. — {Icterus) Hepatogenous vs. Hematogenous. — Clinically, jaundice is either u obstructive ," as in inflammation of, or direct or indirect obstruction of, the common duct, or, "toxemic" the latter form often being wrongly termed hematogenous. Although hemolysis is the primary change,, both types are essentially hepatic as regards the direct source of bile pigment, and ''obstruction" and "diffusion" jaundice cover nearly every type. . There are toxins which act directly upon the blood itself (within the hepatic tissues) or affect the hepatic cells. Poisoning by phosphorus, potas- sium chlorate, ether, chloroform, toluylendiamin, snake venom and arsenic are examples of one form; yellow fever, pyemia and malaria of another; while certain infectious diseases are characterized by marked associated jaundice. Such are "WeiVs disease" and " acute yellow atrophy" It occasionally complicates pneumonia, ulcerative endocarditis, syphilis, relapsing fever, and even influenza. The typical mild jaundice is seen in simple obstructive catarrh of the bile ducts. In hepatic cirrhosis it is late and seldom extreme. Obstructive Jaundice. — The term "obstructive" as usually applied, covers a blocking of the passage of the bile from the liver to the intestines with resultant absorption into the general circulation. The causes are severe gastro-duodenitis, catarrhal conditions, gall-stone, or parasites, involving the common duct, pressure closure by tumor, or, very rarely, by fecal accumulation, the pregnant uterus, or abdominal aneurysm. Strictly speaking, all cases of jaundice are obstructive, as even in the toxic form there is a high viscidity which favors absorption.* Emotional Jaundice. — The remarkable jaundice associated with mental shock or profound emotion is probably obstructive and due to spasm and reversed peristalsis. In one such case coming under the author's notice pro- found jaundice followed a mere fleeting fit of anger. f Dardanelles Jaundice. — This curious form, very prevalent amongst the British soldiers of the Dardanelles expedition, was non-obstructive, and proved to be due to a paratyphoid bacillus. Hereditary Jaundice, of the Minkowski Type.— This interesting condition may affect succeeding generations and appears in several forms. First, hereditary icterus neonatorum, in which an angiocholitis and com- mon duct stenosis is commonly present and an extreme mortality ratio observed. Second, a peculiar form associated with hepatic and splenic enlargement, anemia and infantilism. f Carcinoma of the liver is accompanied by jaundice in more than one half the cases, but the cause is found to be pressure from the adjacent involved glands. In abscess of the liver, single or multiple, it may be absent or only slight. * Jaundice is observed occasionally in cases of brain concussion. THE OUTWARD SIGNS OF DISEASE 19 "Diabete bronze." Clay-colored stools. Third, a congenital acholuric form with splenic enlargement, no bile in the urine, and little disturbance of the general health. Symptoms of Jaundice. — The skin, ocular conjunctiva, and the oral and pharyngeal mucous membrane yield the best evidence, especially if the latter importance oi are blanched by the pressure of the ringer or better by a microscope slide, but even a marked discoloration is invisible by artificial light. By daylight the color of the skin varies from a faint or brilliant yellow to a deep greenish brown or bronze (melas-icterus), sometimes simulating Addi- son's disease, and not infrequently present in the last stages of ordinary cirrhosis of the liver as well as in that extremely rare form of combined inter- stitial hepatitis and pancreatitis known as bronzed diabetes. Obstructive Type. — The sweat and urine are discolored* in clinically obstructive jaundice, the latter often yielding the first evidence of the condition: the pulse and respiration are usually slow; the stools are pale gray, pasty and fetid; either constipation or diarrhea may be present; trouble- some pruritus is common and urticaria or purpura occur in occasional instances. A marked hemorrhagic tendency is shown in severe cases and is of special interest with relation to surgical procedure. There may be marked mental depression or extreme irritability and, in certain grave cases, muscle cramps, convulsions, active delirium or a typhoid state may end in coma. The urine often contains albumin and hyaline casts. Acute Yellow Atrophy. — True malignant jaundice is a rare disease of unknown causationf chiefly affecting women, often related to pregnancy, sometimes to violent emotion or shock, but is probably invariably associated with some antecedent or concurrent infection. Icterus Neonatorum. — There is a mild type, benign and trivial, extremely common in new-born children, occurring during the first twenty-four or forty-eight hours and lasting for a week or two. The grave form of icterus of the new-born , when not hereditary, may be due to sepsis, usually of umbilical origin, to syphilitic disease of the liver, or to congenital absence of the ducts. It is frequently associated with hemorrhage from the navel and is a fatal disease. Toxemic Jaundice. — In this condition jaundice is usually less intense, the stools are colored, the urine contains little or no bile, and the disease termi- nates promptly in recovery or death. It is associated with severe acute infec- tions of varying character, certain forms of mineral or snake-venom poisoning, or the pernicious forms of anemia and malaria, and the constitutional symp- toms may be profound. In certain fatal cases observed by the writer actual obstructive jaundice of the Jaundice may / y J J be extreme. ordinary clinical type has been closely or even exactly simulated but disproven by operation or autopsy. Urobilin Icterus. — Urobilin cannot cause icterus, but may be associated * The milk of nursing women and even the sputum may be discolored. t But 250 cases are on record since the first observation by Ballonius in 1616 (Osier). "Icterus gravis." The mild form , A fatal ailment. 20 MEDICAL DIAGNOSIS Malnutrition and fluid loss. General terms. Obstruction and hydremia. Salt retention. with bilirubin in a jaundice due to partial biliary obstruction, and in slight degrees of obstruction may appear alone in the urine.* DRY AND MOIST SKIN.— Hyperidrosis.— Sweating of the hands or feet may indicate idiosyncrasy, debility, congenital asthenia, or sexual neuroses. Unilateral sweating, especially of the head or face, like pallor or cyanosis, occurs in pressure involvement of the sympathetic and in certain migraines and neuralgias. Sweating of the head is especially common in rickets and, of half the body, in rare instances of hemiplegia. General sweating occurs as a critical phenomenon in certain acute dis- eases, as an associated symptom in malarial fever or phthisis and persistently in acute rheumatism, collapse, and severe pain. Anidrosis. — A dry skin is associated with profound malnutrition and with most diseases causing extreme loss of fluid by the bowels or kidneys. It is a pronounced symptom in certain ailments such as myxedema, in which the skin may be both dry and harsh, and diabetes, chronic interstitial nephritis and carcinoma also furnish good examples. Sudden checking of perspiration in those working under conditions of extreme high temperature is a well-known warning of impending heat stroke. Qualitative Changes in the Perspiration. — The yellow sweat of jaundice, the extraordinary and rare, blue, brown, yellow, red, or even hemorrhagic per- spiration of hysteria, the sour-smelling sweat of acute rheumatism, the dis- gusting odors of bromidrosis or the urinous taint of the sweat in diseases associated with impaired renal function may be encountered. EDEMA. — Three terms are used in this connection: (i) edema proper, i. e., fluid confined to the actual connective tissues and usually localized; (2) dropsy, the accumulation of fluid in the serous cavities combined with edema; (3) 'anasarca (general edema). The last term, however, is often used synonymously with the one preceding. Obstructive vs. Hydremic Edema. — Edema represents a capillary transu- dation exceeding the absorptive capacity of the lymphatics and may be ob- structive (passive congestions), or hydremic (toxemias, infections, cachexias) and in many if not most instances represents a combination of both. Re- tained toxic substances and increased permeability of the systemic capillary walls are doubtless prominent factors in the latter, if not in both groups, and experiment fails to prove the older theory of pure hydremic plethora, i. e., increased blood volume and water retention, while nevertheless indicating that the latter may play some part. In both the so-called static and hydremic forms, and especially in that asso- ciated with chronic parenchymatous nephritis, sodium chloride retention has been shown to assist in maintaining the edema. Milroy's Edema. — This is a curious hereditary, permanent edema of the legs usually asymmetrical in its early stages. Inflammatory Edema. — The clinical distinction between inflammatory edema and ordinary edema is largely dependent upon the physical constituents * Such is the case in the two latter forms of congenital jaundice mentioned on the preceding page. THE OUTWARD SIGNS OF DISEASE 21 of the inflammatory exudate as compared with the simpler transudate, but, inasmuch as pronounced evidences of local inflammation and usually of acute infection accompany the former, no difficulty can often arise in differentiation. Vagaries of Edema. — A thorough knowledge of the favorite locations and the vagaries of this condition is essential, inasmuch as it may shift its seat, obey or disobey the law of gravitation, and vary from swelling of the lids, slight purfiness of the ankles, or a localized angioneurotic edema, to general dropsy, in which the patient is drowning in his own transudate. Angioneurotic edema is a localized* but transient, firm swelling, closely allied to urticaria and erythema nodosum, not ordinarily pitting readily on pressure, found in various regions of the body in certain ill-defined conditions and serious only when, as rarely happens, it involves the glottis. Slight and Transient Edema of the Lower Extremities. — Aside from the lesser degrees and earlier stages of many of the recognized causes of edema this is found in cases of simple anemia, or after prolonged and exhausting tramps in those unaccustomed to physical exercise. In the earlier stages of gradually induced cardiac decompensation edema may appear late in the day, only to vanish during the night's rest, and its absence during the greater part of the waking hours causes many errors of observation. Of certain cases of Bright' s disease the reverse is true, slight ptiffiness of the eyelids being present in the early morning, but vanishing during the forenoon. Cardinal Signs of Edema. — The characteristic feature of all simple edemas is the appearance of a non-inflammatory swelling, often very slight, but usually tending to obscure the normal outline of the affected portion, readily receiving, and for a variable period retaining, indentations produced by the pressure of the examiner's finger or by the constriction due to clothing. Cavity Exudates and General Dropsy. — In its extreme grades the same process tends to produce liquid transudates in such serous cavities (lymph spaces) as the pleura, pericardium, and peritoneum, producing what are known respectively as u hydrothorax," u hydro pericardium" and "ascites." Such conditions accompanying general edema constitute u general dropsy," which in practice is limited to Bright' s disease, a failing heart, from whatever cause, or, both combined. In Bright' s disease, especially, an hydrothorax or hydro pericardium may occur suddenly and unexpectedly and escape observation until serious pres- sure symptoms are manifested even though no localized or general edema exists elsewhere in the body. Cardiac Edema. — As between renal and cardiac conditions the attendant edema at times presents some distinguishing features. In heart disease, edema (predominantly obstructive), even without general anasarca, is associated usually with cyanosis, often very slight, and in its original seat and progress usually follows the law of gravity, commencing in the feet (or over the sacrum in recumbent patients) and extending upward. In all forms of non-inflammatory edema the slighter primary manifestations occur in loosely bound connective-tissue areas of maximum distensibility. * Very rarely the condition is universal in distribution. Usually transient and trivial. An important and elusive sign. Lymph-space transudates. Unheralded complications. Seeks the dependent part. Primarily in looser tissues 22 MEDICAL DIAGNOSIS Primarily dis- regards law of gravity. Marble edema. Cardiac type of edema. Diurnal vs. nocturnal edema. Misleading or elusive edemas. Urticaria and angioneurotic edemas. Unilateral vs. bilateral edemas. Renal Edema. — In acute and chronic parenchymatous nephritis any marked edema (hydremic) usually appears first in the face and eyelids and extends downward, being associated with marked pallor, unmixed with any considerable degree of cyanosis, unless there be obstructive effusion in the peri- toneal cavity or thorax, or, as frequently happens in the established cases, there exists a complicating decompensation on the cardiac side. Furthermore, the edema of acute Blight's disease as it appears on the body generally, or the extremities, is distinctly firmer than a recent cardiac edema, and in persons with a delicate skin and more especially in children, the blue super- ficial venules contrast sharply with the dead white of the tense overstretched skin (marble edema). Interstitial Nephritis. — In typical cases edema of any severity is absent until the terminal stages are reached and then appears as a result of cardiac insufficiency and is of the cardiac type. Effect of Posture. — Edema of the cardiac or renal type, when established, is markedly affected by changes in the position of the patient; that of heart disease or parenchymatous nephritis, especially so, the attitude assumed by such a case during any night being often indicated in the morning by an in- creased swelling of the side upon which he has lain. As before stated, cardiac edema usually appears first in the most dependent portion of the body, as in the feet and ankles after a day's activity, or over the sacrum in the bedfast. * Leathery Edema. — In those curious, partially compensated heart cases with chronic gravity edema, in which the ambulant patient mistakenly or from necessity keeps on his feet for weeks, months, or years, one may see a peculiarly hard edema of the legs and lower thighs. The shin becomes leathery and pigmented in such instances and in conse- quence can be indented only by sustained firm pressure. One should not be misled by certain edemas of the lower extremities due to varicose veins, usually, but not always, unilateral, though seldom equal in degree if bilateral. Edema of the calves without edema of the ankle or other regions has been observed by the author in several victims of heart disease possessed of un- usually tight, trim ankles. Such an edema might easily be overlooked if, as is usually the case, only the ankles or lower tibial shaft are tested. Collateral Localized Edema. — Over purulent exudates, areas of suppurative inflammation and severe neuritis, such edema may, but does not always, occur; as, for example, in empyema, mastoiditis, parotitis, pericarditis, hepatic abscess, perinephritic abscess, superficial lymphangitis and multiple neuritis. Non-inflammatory circumscribed edemas are either angioneurotic, pur- puric, giant urticarial, or, of the ordinary obstructive type due to the mechan- ical blocking of veins or lymphatics. Edemas are almost invariably bilateral, if of the cardiac or renal type; uni- lateral, if due to the blocking of the local circulation; but bilateral edema may also result from blocking of a main venous trunk. * Tenderness' over the tibia, if bilateral, should always suggest persistently recurring edema even if none is detected at the time of examination. THE OUTWARD SIGNS OF DISEASE 23 Edema of the arm may be due to the pressure of tumors or enlarged glands upon the venous drainage channel, to thrombosis, and even to massive pleuritic effusion or mediastinal tumors, including aneurysm. Obstructed flow in the femoral veins causes edema of one leg or unequal involvement of both.* The whole lower half of the body may be affected if the inferior vena cava be blocked. The head, neck, arms and thorax are edematous if the superior vena cava is obstructed below the azygos veins; the head and neck alone, if the obstruction be above these veins. Other specific causes of edema are trichinosis, beri-beri, and ordinary multiple neuritis. The blue edema of hysteria is a rare condition allied to or identical with the angioneurotic form. The cachectic edemas, as seen in leukemia, scurvy and pernicious anemia, are usually of the mild cardiac type and, as previously stated, in terminal chronic Bright's disease of the interstitial type the edema is distinctly or predominatingly cardiac. LYMPHANGITIS AND PHLEBITIS.— Acute Septic Forms.— Both acute lymphangitis and acute phlebitis, if severe, may be associated with edema and occasionally great difficulty arises in the differentiation of the two conditions. For that matter the two ailments may, and often do, co-exist and both depend upon the same etiologic factors in the form of pyogenic organisms. Acute Septic Lymphangitis. — This is extremely common as compared with phlebitis and especially so in relation to infected wounds of the upper extremities. Its cardinal features are : first, red streaks running proximally in the direc- tion of the tributary glands, associated with tenderness on pressure over these lines and tenderness and swelling of the glands draining the infected area. In severe cases the edema is progressive, the swollen lymphatics may be felt as thin raised cords and irregular areas of redness occur at intervals over the lymphatic lines. Acute Phlebitis. — In acute phlebitis the glandular tenderness and swelling are usually absent or much less marked. The redness is less decided or altogether lacking, the vein if palpable is much larger than the lymphatic cords and the superficial venules are markedly dilated. If the resulting thrombus undergoes purulent transformation, embolic phenomena initiate a pyemic state. The red areas of a lymphangitis may suggest erysipelas but lack the well- defined, sharply circumscribed, advancing, raised margin of that disease. A migratory form of septic phlebitis is occasionally encountered which may be most baffling. ASCITES. — Fluid in the peritoneal cavity may be part of a general dropsy as in heart disease, Bright's disease, or obstructive pulmonary conditions such * Such edema may coexist with that of the cardiac or renal type and persist after the heart or kidneys cease to be factors in its production. In walking patients especially the unequal involvement of the two sides always suggest it. Venous block. Secondary cardiac edema. Confusion possible. The red lines. Palpable lymphatics. Migratory phlebitis. Common causes. 24 MEDICAL DIAGNOSIS Massive effusions. Shifting dulness and tympany. Ascitic wave. False wave. Effect of adhesions. Technic important. Small exudates. as emphysema and fibroid lung, which have produced right heart insufficiency, or it may result from any form of chronic peritonitis, whether simple, tuber- culous, or malignant. Furthermore, it may be caused by portal obstruction, whether due to disease of the liver itself, to thrombosis of, or to pressure upon, the vein. Small and Large Effusions. — In tuberculosis, malignant disease and most of the cases associated with new growths, the effusion though always con- siderable is relatively small. Occurring as a part of general cardiac or renal dropsy, or of portal obstruc- tion, the exudate is ultimately large and produces a tense and markedly pro- tuberant abdomen. This tends to broaden in the flanks if the patient assumes a dorsal recumbent position. The umbilicus is prominent and percussion reveals a dulness obeying the law of gravity, and hence, in the absence of limiting adhesions, shifting its seat as the position of the patient is changed. Whenever and from whatever cause the peritoneal cavity contains any con- siderable free exudate, the fluid seeks the most dependent portion, the intestines float upward, and yield a tympanitic note which shifts posturally exactly as does the dulness, but to diametrically opposite locations. The patient being in a sitting or standing posture, a fluctuation wave may usually be felt as a shock to the receiving finger if the abdomen is sharply tapped upon one side just below the line of percussion dulness, while the finger-tips of the other hand are placed opposite. The ulnar surface of the hand of an assistant should be lightly applied in the median line between the percussing and receiving fingers to interrupt a false vibration in the wall otherwise indistinguishable from the true ascitic wave. Sources of Error. — Shifting dulness may be interfered with by adhesions which prevent the flow of exudate or hold intestinal coils in a fixed relation to the wall; moreover, some time may be required in certain cases for the fluid to change its site, and several moments should be allowed to elapse before negative findings are reported. Dipping. — Such effusion makes palpation of the spleen, liver or underlying tumors difficult and often demands that the palpating finger shall be suddenly and sharply depressed, preferably both during forced inspiration and at the end of forced expiration, the temporary displacement of the fluid often mak- ing the underlying structure palpable. The knee-elbow position is necessary for the detection of small exudates, the dulness then appearing in the very region most resonant in the recumbent patient. In massive effusions with excessive tension the ascitic thrill or wave may be, but rarely is, absent. It may be difficult to obtain in small effusions, in the presence of adhesions or through an excessively fat or edematous abdominal wall. Differentiation. — Elaborate tables of differential diagnosis in relation to ascites seem to the author almost futile. Movable percussion dulness in the flanks and bilateral dulness with central resonance at once rules out pregnancy and cysts, whether pancreatic, massive THE OUTWARD SIGNS OF DISEASE 25 ovarian or hydatid, the signs being diametrically opposite. Encysted ascites may give rise to insuperable pre-exploratory diagnostic difficulties. Meteor- ism, i.e., excessive tympanites yields a universally tympanitic note. Hepatic Cirrhosis. — The ascites of portal obstruction, usually due to hepatic cirrhosis, lacks the associated edema of the face usually encountered in acute and chronic parenchymatous nephritis, though a variable degree of edema of the cardiac type may be present in the lower extremities in long- standing cases. Ascites without general edema often co-exists with emacia- tion, giving rise to the " poached-egg belly" which in the adult is usually asso- ciated with cirrhosis of the liver, portal thrombosis or a tuberculous or malig- nant peritonitis. A big belly in a thin man invariably indicates a pathologic condition. Character of Ascitic Fluid. — In hepatic cirrhosis, cardiac or renal disease, it is usually clear, straw colored, and of low specific gravity (1010 to 1015). It is but moderately albuminous (2 per cent, or less) and may spontaneously coagulate on standing. The color is slightly darker in cirrhosis than in the ordinary secondary forms. In tuberculosis and malignant disease it is of higher specific gravity, contains 4 per cent, or more of albumin, may be hemorrhagic and, rarely, is milky or turbid from fat or true chyle. Chylous vs. Fatty Ascites. — The two latter conditions may oftentimes be readily distinguished by the size of the fat globules which in chyle resemble a closely packed field of cocci as shown on microscopic examination. Mere blocking of the thoracic duct may or may not cause chylous ascites. Rup- ture of the duct or of a chyle-bearing lymphatic may occur, or filaria sanguinis hominis, or malignant or tuberculous ulceration be present. Chyliform Ascites. — In malignant or tuberculous disease especially, a milky ascitic fluid may be present which is not a true chylous ascites but rather an exudate attending a chronic inflammatory process and containing fat as a product of cell degeneration and disintegration. In such cases the exudate contains large numbers of such degenerating cells. Lactescent Ascites. — A curious milky, but not fatty, ascites is occasionally met with, under the same conditions as accompany chyliform ascites. In such cases there is no separation into layers and the peculiar appear- ance is due supposedly to lecithin or some protein. Occasionally an exudate occurs which cannot be distinguished from that of a true chylous ascites save by its relatively very slow reaccumulation after tapping and emptying the peritoneal cavity. LYMPHEDEMA, — The chronic forms of edema due primarily or chiefly to lymph stasis involve also a persistent and more or less progressive prolifera- tion of the skin and subcutaneous connective tissue of the affected members. Its best known form is that known as "elephantiasis." This ailment is endemic and due to the presence of the filaria sanguinis hominis, and indeed is frequently encountered in countries infested with this organism (filaria Bancrofti). On the other hand, sporadic cases are not infrequently encountered which present the same clinical appearance but lack any specific etiologic factors. Edema slight. "Poached-egg belly." Characteristic of transudate Exudate. Milky fluid. The false and commoner form. Endemic form. Sporadic type. 26 MEDICAL DIAGNOSIS Prominent symptoms. Onset and ex- acerbations. Palpatory crackling. In each variety the persistent and slowly progressive enlargement of the leg, the leathery, furrowed, uneven, varicose surface and the slowly increasing difficulty in locomotion are unattended by the cardinal sign of cardiac or renal edema, viz. — pitting on pressure. Fig. 4. — Sporadic lymphedema. {Courtesy of the late Dr. Burnside Foster.) Fig. 5. — Sporadic lymphedema. {Courtesy of the late Dr. Burnside Foster.) One or both legs may be affected and in the endemic form a similar enlarge- ment of the scrotum, penis, labia, or clitoris may occur or the same process may attack the arm, lip, or ear. (See under c: Elephantiasis"). Only slight pain or discomfort is experienced in the non-filarial cases, but in those of the endemic type a considerable amount of suffering may arise. The endemic (filarial) form may come on suddenly with fever, redness, and swelling and such patients may be subject to recurrent attacks of the same type, each resulting in greater residual permanent enlargement of the affected part. SUBCUTANEOUS EMPHYSEMA.— Save in malignant edema and glanders, this condition indicates the entrance of air into the subcutaneous tissue through a wound or rupture of an air-containing viscus, as in trach- eotomy, cough, rupture of pulmonary alveoli, malignant ulceration of the esophagus, etc. It offers no difficulty in diagnosis because of the pathogno- monic tissue-paper-like crepitation of the distended tissue under finger pressure. SUBCUTANEOUS HEMORRHAGES.— These will be fully considered under purpura, and it need only be said that the discoloration of the effused THE OUTWARD SIGNS OF DISEASE 2 7 blood is persistent under pressure, that the spots undergo the same changes in color as an ordinary bruise, are not elevated usually, and vary greatly in size. Petechiae and Ecchymoses. — The term ecchymosis is applied to the subcutaneous hemorrhage one-half inch or more in size as in the ordinary bruise and, like the petechia, it may be regular or irregular in outline. The petechia is less than one-half inch in area and often is pin-point or pin-head sized. This term is often incorrectly used to describe a point of incorrect redness which blanches under pressure such as the "rose spots" of typhoid term, fever. When complicating an exanthem, as in measles or smallpox, true petechiae invariably indicate a severe type of disease. In chronic diseases they are ordinarily associated with a definite cachexia or a hemorrhagic tendency (see "purpura"), and in certain obscure infections they indicate sepsis and, especially, malignant or "chronic infective endocarditis, should not be confused with the nodular swelling of erythema nodosum In ulcerative endocarditis the occurrence of petechiae may be of great diag- nostic value and in the u recurrent infective endocarditis" the presence of cutaneous ephemeral, red, raised, tender cutaneous nodules appearing upon the extremities is of interest and of almost pathognomonic value. They In acute and chronic disease. Fig. 6. — Collateral veins in a typical case of portal obstruction {After Krause.) Fig. 7. — Collateral veins in a typical case of obstruction of the inferior vena cava. (After Krause.) COLLATERAL VENOUS CIRCULATION.— Portal vs. Caval Obstruc- tion. — Hepatic cirrhosis or thrombosis of the portal veins may produce a marked and evident enlargement of the superficial abdominal veins, and a similar condition occurs in thrombosis of the inferior vena cava. The former chiefly affects the median region of the abdomen; the relation of its veins to the navel suggesting the term " caput medusce," and though the lower thoracic veins are involved, the group lies chiefly within lines dropped from the middle of the clavicle to the groin. "Caput medusae.' 28 MEDICAL DIAGNOSIS Visible dilatation. Visible arterial pulsation. Clinical rela- tionships. Simulate many diseases. Idiosyncrasy. Important inferences. Wet cupping and the electric belt. In the latter (obstruction of the inferior vena cava) the enlargement is predominantly lateral and usually less complicated in pattern. Unfor- tunately, admixture of the two may occur as in the case of a massive ascites of cirrhosis producing caval obstruction leading to enlargement of both groups of superficial veins, and furthermore the distinctions laid down above do not always hold true in other instances. Visible Internal Mammary and Intercostal Veins. — In any form of intrathoracic tumor, especially of the mediastinum, visible enlargement of the internal mammary and intercostal veins may be evident when the main venous trunks are blocked. If the superior vena cava is obstructed the blood flows downward to reach the ascending current in the inferior vena cava through the azygos veins. Congenital Obliteration of the Aorta. — Obliteration of the descending thoracic aorta below the ductus arteriosus Botalli is a clinical curiosity, the patient usually, but not always showing a visible, pulsating, arterial, collateral circulation between the subclavian above and the vessels of the lower extremity below. The pulse in the lower extremities is small and delayed, the aorta dilated proximally to the point of obstruction, and a diastolic aortic bruit and left ventricular enlargement, are usually manifest. Lower Thoracic Veining. — The arborescent branchings, indicating more or less closely the peripheral diaphragmatic attachment and frequently ob- served on the walls of the chest, seem to be without definite clinical signifi- cance. The author has seen them most often in cases showing pleural adhesions, right ventricular dilatation or overstrain, cirrhosis of the liver, obstructed pulmonary circulation of the chronic type, chronic cough, and, not infrequently general arterial or myocardial degeneration. DRUG ERUPTIONS.— The iodides may produce acne-like or even varioliform or erythematous rashes; the bromides, an acne-like eruption; whereas phenacetin and its congeners, the balsams (such as copaiba), sodium salicylate, diphtheria antitoxin and various other sera, are capable of pro- ducing urticaria, or, other rashes, the more misleadingly simulating scarlatina or measles, in that a febrile ailment may be coincident. Many drugs produce rashes in certain individuals only, and these efflorescences are so varied as to preclude description. DESQUAMATIONS.— The chief diseases followed by desquamation are: scarlet fever (lamella), measles (bran-like scales), smallpox (crusts), erysipelas (flakes), dermatitis (exfoliation). SCARS. — Study the history of scars. The pits of previous smallpox may exclude that disease in some doubtful exanthem in a comatose patient. The scar of a carbuncle at the back of the neck may suggest glycosuria, . and multiple linear scars at the angles of the mouth often follow congenital syphilis. Linear knife-cut scars on the left hand usually indicate right- handedness and vice versa. Small, bright, shining, slightly depressed scars on the chest may indicate the past use of croton oil, and grouped, finely linear, parallel scars over the lungs, heart, liver, or spleen, suggest wet cupping for THE OUTWARD SIGNS OF DISEASE 20 the relief of some pain or acute inflammation in the past, the nature of which may prove an important link in the case history. Scars at the waist line are common in those who have worn electric belts, and in the supraorbital region or intercostal zones may suggest respectively supraorbital or pectoral zoster. The tiny depressed scars of acne affect the chest, shoulders or face, and similar ones when generally distributed suggest syphilis, whereas cicatrices over the heel, sacrum and scapula suggest bed sores and hence past severe ailments such as typhoid. In elderly men an old time "seton" may have left its double scar at the back of the neck. Scars of Suicidal Attempts and Past Operations. — Bullet and stab wounds especially, may be suggestive in relation to past suicidal attempts, character, past associations, occupation and present disease.* Cervical scars, if anterior, long and linear, particularly if left-sided in origin and transverse in direction, suggest abortive suicidal attempts. Such are usually made by a razor and run obliquely downward from the angle of the jaw across the median line, or almost transversely across the throat, seldom following the line of operative incision of the anterior cervical gland chain or observing the limitations in extent and direction of the thyroidectomy in- cision, as would be the case with the somewhat similar scar of a past operation. Puckered, depressed irregular scars in the cervical triangles, especially the anterior, suggest the slow healing of once broken down, discharging, tuber- culous glands; while fine, long, linear cicatrices suggest radical operation for their removal, when they follow the known direction of the glandular chain. Irregular depressed scars in the groin do not suggest past syphilis but rather chancroid. The scars of operations for appendicitis, ovariotomy, gall-stones, gastric ulcer, and the like are but too common nowadays and too characteristic to merit special description. All abdominal scars, however, demand an exami- nation of that part of the abdominal wall incised in order that any hernial tendency may be detected. Luetic Scars. — There is not much of positive differential or diagnostic value in syphilitic scars save in certain situations or in certain forms of eruption, but when present and sufficiently characteristic they are of great assistance. In general, one may say that syphilitic scars may be round, reniform, oval or horseshoe-shaped, and are smooth and seldom traversed by fibrous bands except at joints. Lupus scarring may closely simulate syphilis, but is not multiform. Fre- quently there are multiple punctate depressions, and some old luetic scars are pliable and have a brownish-red areola (see also " Syphilis"). Of special * In a person of a misleadingly clerical appearance and pretensions, such a wound proved to have been the result of a drunken brawl in a bawdy house of which he was the proprietor, and led to an investigation of past and present habits that proved illuminating with relation to his obscure ailment. Zoster, acne, and syphilis. Bed sores. Neck scars. Glandular tuberculosis. Groin scars. Common operative sites. Valuable when distinctive. 3Q MEDICAL DIAGNOSIS Drug habit. Tumors and nodes. Caput quadratum. The rickety rosary. Cranio-tabes. significance are the scars indicating a primary lesion (usually, of course, upon the genitals), and those of a destructive ulceration of the soft palate. Epithelioma and Hypodermic Marks. — The scar of operation for epi- thelioma of the lips or nose is especially suggestive, and bluish marks from an old needle coated with oxide of iron, or similar marks together with evidences of repeated superficial infection, may suggest confirmed morphinism or cocainism. Many victims of drug addiction use a dirty needle and in its introduction disregard clothing when circumstances render its removal inconvenient. In right-handed persons of this type the opposite arm and the right thigh are often characteristically scarred. THE HEAD. — Sutures and Fontanelles. — Open sutures persisting after the ninth month suggest hydrocephalus, cretinism or rickets. The posterior fontanelle should be closed at the end of the second month; the anterior at the end of the second year. Delayed closure with a gap of unusual size suggests hereditary syphilis, rickets or cretinism. Bulging fontanelles occur in chronic hydrocephalus and in meningeal hemorrhage or inflammation, but slight prominence and pulsation may occur in any child suffering from febrile ailments and is negligible. A sunken fontanelle is present in wasting diseases and spurious hydrocephalus. Cranio-tabes, indicated by a soft "egg-shell" crackle on pressure over circumscribed occipital areas or over the posterior portion of the parietal bones may occur in rickets, congenital syphilis or hydrocephalus.* The pulsating congenital tumors of variable size bulging from the sutures are classified as hydrencephalocele, meningocele or encephalocele. Wens or cysts are common in the scalp and should not be confused with the deeper seated immovable syphilitic nodes representing a gummatous periostitis. In the latter case any co-existing brain symptoms suggest similar growths on the inner surface, their consistence being soft and doughy and nocturnal exacerbations of any attendant pain a prominent feature. Rickets. — A square or oblong head with flattened elongated vertex; a high, square forehead, often with frontal and parietal protuberances, when it surmounts a small face, indicates severe, classical rickets. It is usually associated with delayed closure but no bulging of the fontanelles, together with a sweating forehead, muscular weakness, mental retardation, delayed growth and beading of the costo-chondral articulations especially the fifth and sixth ('rickety rosary"). Epiphyseal swelling and thinning and palpable crackling of the postero-inferior aspect of the parietal and occipital bones {cranio-tabes) are often demonstrable. Deformities of the chest, legs and spine are common and the restless little sleeper may have rubbed away the hair at the occiput. Hydrocephalus. — If the child's head be large but globular or pyramidal rather than square, the face relatively small, the space between the eyebrows prominent, the fontanelle large and bulging, the sutures separated and the external veins visibly distended, a history of excessive cranial growth or congenital deformity will be obtained and hydrocephalus is evident. * The same "egg-shell" crackling is encountered in osteosarcoma of the long bones. THE OUTWARD SIGNS OF DISEASE 31 Typical syndrome. Deformity of long bones. A curious contrast. Oxycephaly. (Tower Head). — The head of excessive height above the ears and running to a narrow or pointed vertex is occasionally encountered. The supra-orbital ridges are poorly developed and exophthalmos and optic neuritis may result from increased intracerebral pressure. The ailment is due to premature closure of certain of the sutures. Congenital Syphilis. — Cranial asymmetry, exaggerated frontal emi- nences, keratitis, a saddle-nose, or a perforated palate may co-exist with "sore bottom" in the luetic child, and, with the exception of the last, even as isolated symptoms are of great diagnostic significance. Osteitis Deformans (Paget' s Disease). — A marked increase of the head circumference without facial involvement may be associated wdth the curvature of the enlarged shafts of the long bones characterizing the disease. Leontiasis Ossea. — This frequently produces marked deformity of the Leonine brow, skull by osteophytic deposit particularly in the frontal regions and is asso- ciated with massive orbital rims and exaggerated malar prominences. Facial Hemiatrophy. — Slight unilateral differences may be merely degenerative stigmata, but in true hemiatrophy the face is mesially divided into distinctly different halves, the extreme and apparent emaciation of the one side contrasting sharply w T ith its better-nourished fellow. In microcephalic idiocy the skull is extremely small and narrow. THE EYELIDS. — Dark circles or duskiness under the eyes most marked in brunettes are commonly but often mistakenly construed as indicating pelvic disease. Though frequently an indication of such conditions, and often present as a transient condition in young women during or at the onset of a menstrual period, they may be constantly present in certain normal women and especially in olive-skinned brunettes. In both sexes and at any age they may accompany extreme prolonged pain, insomnia, overexertion, weak heart, or exhausting diseases. Puflaness or edema of the lids may indicate mere recent weeping, trichino- sis, disease of the accessory nasal sinuses, Bright's disease, arsenical overdose or chronic poisoning, anemia, or pertussis. Unilateral swelling may be due to angioneurotic edema or to actual inflammations, such as boils, insect bites, erysipelas or glanders. Associated with exophthalmos, it may indicate cavernous sinus thrombosis or tumor pressure upon the ophthalmic veins. Inflammation of the lids may be due to conjunctivitis, simple or specific, and is a common manifestation in measles, coryza, iodism, hay fever and eye strain. Styes, chalazion, warts, epitheliomatous or syphilitic ulcers, gouty tophi, lachrymal cyst, or obstruction with tear overflow, and blepharitis marginalis need no extended description. The injected conjunctiva of measles is an early and suggestive symptom. THE EYES. — Many valuable inferences may be drawm from careful inspection of the eyes, and the expression may indicate bad habits con- cealed, or give a valuable clue to the temperament and mental status of the patient. Study of the background is of course a matter for special investigation. Trivial or important. Seek simple causes first. Red eyes of measles. 32 MEDICAL DIAGNOSIS Sign of slight value. Bilateral vs. Unilateral. Wasting diseases or atrophy. Important associations. —Exophthalmic Typical facies. Ocular Palsies. — Paralysis of the ocular muscles alone as indicated by ptosis or strabismus at once suggests syphilis, brain tumor, locomotor ataxia, meningitis or profound toxemia. Nystagmus is an involuntary lateral, rotary or vertical movement of the eyeball, and in the absence of hysteria, extreme refractive errors, albinism, cataract or corneal opaci- ties, suggests disseminated sclerosis, Friedreich's ataxia, tumors of the cerebellum or pons, terminal locomotor ataxia, basal meningitis, chronic hydro- cephalus, or epilepsy. The Arcus Senilis. — This is indicated by a white line surrounding wholly or in part the corneal margin and is a symptom of slight specific signifi- cance when seen in persons beyond middle age, as it is merely a local indication of a general senile degen- erative process. In younger persons it is of much more significance and may be associated with definite cardiovascular symptoms. Exophthalmos. — In most cases this is bilateral and associated with exophthalmic goiter, both eyes being unduly prominent and producing a peculiar staring expression, striking and easily recognized. Unilateral exophthalmos usually indicates a new growth, abscess, or tumor of some kind in close relation to the affected eye, thrombosis of the cavernous sinus or hemorrhage into the orbital tissue. Enophthalmos. — This is the oppo- site of exophthalmos and ordinarily accompanies collapse, wasting diseases, severe hemorrhage or persistent pro- fuse diarrheas. Unilaterally it is found in hemiatrophy or lesions of the sym- pathetic nerve. Corneal Opacities. — These indicate, as a rule, syphilis or tuberculosis, but they may result from direct corneal injuries of any nature. Cataract. — In many cases this dis- ease of the crystalline lens is associated with diabetic manifestations or seems to reflect a general degenerative process and should suggest a painstaking in- vestigation of the heart, blood vessels, and urine. Juvenile cataract is fre- quently associated with struma or congenital syphilis. The Dry and the Moist Eye. — If the eye be permanently or for long periods uncovered by the lids, as in profound collapse, it becomes glazed and dry, or even seriously inflamed as in rare cases of exophthalmic goiter with Fig. 9. — Thrombosis of right cavernous sinus. Edema of right side of face and right unilateral exophthalmos. {Gordon.) THE OUTWARD SIGNS OF DISEASE 33 Epiphora. Misleading redness extreme protrusion of the eyeballs. On the other hand, profuse lachryma- tion may accompany irritation of the conjunctiva or result from a mere photophobia. Actual persisting overflow (epiphora) may be present if the lachrymal duct is blocked or markedly displaced from any cause. THE NOSE. — Saddle-nose is discussed elsewhere. A coarse, broad organ is seen in certain strumous types and in pituitary disorders, myxedema and cretinism, or may be purely racial or familial. Its base may be broad and shapeless in adenoid disease and nasal polypi, and it may be the seat of dis- tressing and humiliating vascularity even in the temperate individual. Such innocent redness is most frequently due to exposure to the elements, gastric and pelvic derangements, cardiovascular disturbances, or chronic obstructive nasal catarrh. The alas may carry a tuberculous or epitheliomatous ulcer and are frequently involved in the herpetic manifestations of certain acute diseases. False Saddle-nose. — In achondroplasic dwarfs (see under " hands") the broad-based pug nose often suggests the true saddle-nose of syphilis. No confusion should arise and the condition as seen in achondroplasia is due to precocious calcification. Offensive nasal discharge suggests atrophic rhinitis, syphilis, necrosis or impacted foreign bodies. Sneezing needs no special discussion though occasionally a troublesome phenomenon.* Working Alae. — In neurotic individuals this is commonly observed and it also constitutes one of the signs of marked dyspnea. THE EAR. — Earache. — Iri infants the condition may be indicated only by crying, restless movement of the head or rubbing of the ear, and in them, as in the case of the profoundly toxemic adult, who may give no evidence of pain, an acute suppurative otitis media may be entirely overlooked until the discharge appears. The condition is a common one in acute infections, such as in tonsillitis, pharyngitis, scarlet fever, 'influenza, typhoid, diphtheria and measles, and its complications are so serious (mastoiditis, meningitis, brain abscess, etc.) as to demand careful watching in such cases. Earache and deafness may also be due to impacted cerumen, abscess or ordinary furuncle of the meatus externus, simple catarrhal inflammation and blocking of the Eustachian tube, decayed teeth and alveolar abscess, foreign bodies, neuralgia, and rarely cancer of the tongue. Hematoma Auris. — Bruising and swelling of the pinna is frequently encountered in the insane. Cyanosis and anemia may be reflected in the color of the external ear. It is the most frequent situation for frost-bite and may be the seat of ochronosis (blue-black cartilages), persistent localized gangrenef and gouty ochronosis, tophi (gritty sodium urate nodules near the margin of the pinna). • tophi. * In one instance known to the author violent and persistent sneezing was excited by normal sexual stimuli. t In a case of drug habituation a recurrent superficial gangrene of years' duration affected the ear alone and ceased permanently only when the victim, who refused all treatment directed to a cure, stopped the use of the hypodermic and took his morphin by the mouth. Otitis often overlooked. 34 MEDICAL DIAGNOSIS Significance of discharge. Herpes and mucous patches. Sordes. The "fruity* breath. Cadaveric emanation. Discharges of various kinds may be noted, slight and serous if due to meatal eczema; purulent if from suppurative otitis media or meatal abscess; clear and serous or primarily bloody in fractures at the base of the skull. Hemorrhage from the lobe is not uncommon in hemophilia even without wound or demonstrable abrasion. Edema over the mastoid process and pressure tenderness are important signs of mastoid disease though occasionally due to local periostitis. THE LIPS. — The grouped vesicles of herpes common in coryza, pneu- monia and malarial fever, the mucous patches or even the initial lesion of syphilis, epithelioma, fissures, and, in badly nursed profoundly prostrated patients, crusts and sordes, are some of the important conditions to be noted. The color of the lips is a valuable sign of cyanosis and a less constant and specific one of anemia. Epithelioma usually occurs at or beyond middle age, ordinarily affects the lower Up, grows indolently and exists for a long time without marked involvement of the neighboring glands. Syphilis. — A labial lesion of syphilis is promptly followed by glandular swelling. Mucous patches and syphilitic fissures tend to involve the angles of the mouth and leave linear radiating scars, but ordinary "cold cracks "or fissures are of no significance. Acute swelling of the lips commonly indicates trauma, insect bite, angio- neurotic edema, simple abscess, or, more rarely, corrosive poison, cancrum oris, erysipelas or phlegmon. The Open Mouth. — Aside from paralysis or primary mental defects, the dry lips and open mouth are seen in coma, chronic hypertrophy of the tonsils, or nasal obstruction (usually due to adenoids), inflammation of the buccal cavity, the profound exhaustion of certain acute adynamic febrile conditions and the terminal stages of chronic disease. The Odor of the Breath. — In acute poisoning this may yield information of the first importance and the odor of carbolic acid, the aromatic, bitter- almond aroma of hydrocyanic acid and the peculiar smell of ether, chloro- form, laudanum and alcohol are readily detected. In the terminal stages of diabetes mellitus the fragrant fruity breath is most suggestive of an excess of acetone and diacetic and oxybutyric acids in the blood and hence of im- pending coma. Phosphorus yields an unmistakable odor. Foul breath in itself most often indicates improper care of the teeth, consti- pation, chronic naso-pharyngeal catarrh or local disease of the buccal cavity and pharynx, or, more often, the naso-pharynx. The bad breath of chronic drinkers is usually associated with a furred tongue and chronic gastritis. Uremia. — A peculiar heavy, aromatic odor is noticeable in the so-called "uremia" of acute and chronic nephritis or in the terminal stages of failing heart, and a peculiar cadaveric emanation is sometimes noticeable at the time of death from exhausting disease. THE BUCCAL CAVITY.— Pigmentation.— The pigmented areas of Addison's disease appear here and upon the lips and tongue, as do the tints of jaundice and cyanosis. THE OUTWARD SIGNS OF DISEASE 35 Exanthems. — In acute exanthematous diseases the buccal cavity may be the site of the earliest eruption, as in measles where small red spots with a tiny bluish-white center appear before the development of the cutaneous rash (Koplik's spots). The papules and vesicles of varicella and variola may often be seen and the vivid redness of scarlet fever is somewhat characteristic. Petechiae. — In scurvy (scorbutus), purpura, terminal leukemia, hemo- philia and other ailments associated with hemorrhage, both submucous and superficial bleeding may occur and the latter may assume a most intractable and even fatal form. Moisture and Dryness. — As regards secretion, there may be either dry- ness, such as occurs in the administration of atropin, in mumps, or as the result of mouth-breathing from whatever cause, or, the opposite condition, salivation, such as accompanies certain of the acute inflammations of the buccal cavity or results from the overuse of mercury. Either secretory abnormality may be associated with hysteria. "Drooling," such as occurs in bulbar palsy, facial paralysis, diphtheritic paralysis, and idiocy, is not necessarily attended by actual increase of secretion. STOMATITIS. — Inflammation of the buccal mucous membrane may be encountered in any one of six chief forms: i . Simple catarrh, as seen in teething children, acute infections, gastro- intestinal disturbances or direct irritation. This condition is characterized by redness, dryness and heat of the mucous surface with subsequent increase of mucous secretion, local discomfort upon taking food, and moderate fever. True salivary flow is diminished. 2. Follicular or Aphthous Stomatitis. — This indicates impaired general health and digestion, is common in children and not infrequent in adults, and is characterized by small vesicles soon transformed into superficial small ulcers with an inflamed areola, often appearing in crops and involving chiefly the edges and the tip of the tongue, the deeper folds, or the inner aspect of the cheeks. Constitutional symptoms are identical with those of the catarrhal form but the process may be persistent or spreading and painful. 3. Parasitic Stomatitis ("thrush," "muguet," "soor," "mycotic stoma- titis") is due to the didium albicans seen readily under the microscope and indicates usually poor nutrition and uncleanly artificial feeding in infants. It is characterized by small curd-like deposits appearing first upon the tongue, but tending to coalesce, spread, and, in extreme cases, cover the whole aural and pharyngeal surface. The patches are readily removed and leave no ulcerated or excoriated stir face. 4. Mercurial Stomatitis (Salivation). — Either through occupational poisoning, idiosyncrasy or overdosing, mercury may cause profuse salivation associated with spongy swelling and even ulceration of the gums, loosening or loss of the teeth, or even necrosis of the jaw. A metallic taste and fetid breath with tenderness of the teeth are usually the first symptoms, and patients under mercurial treatment should be care- Salivation and drooling. A useful procedure. 36 MEDICAL DIAGNOSIS A deadly disease. fully watched for increased flow of saliva and made to bring the teeth sharply together at each visit in order that tenderness may be detected. 5. Gangrenous Stomatitis {Noma). — This fatal ailment is rare, being seldom encountered save in the badly nourished and environed children of the slums, in whom it follows convalescence from acute fevers, chiefly measles. It is characterized by the appearance of a sloughing, spreading ulcer usually on the cheeky rarely on the gum. The breath is fetid, there is high fever, pro- found prostration, delirium and diarrhea. Gangrene rapidly develops in the cheek and may involve adjacent structures to a frightful degree or appear in other portions of the body. 6. Ulcerative or Fetid Stomatitis. — This condition stands midway between the aphthous form and cancrum oris, occurring chiefly in children during dentition, rarely in adults, and at times seeming to be epidemic. The gums are swollen and spongy, bleed readily and show linear sloughing ulceration. The process occasionally involves the tongue and inner surface of the cheeks and lips; the submaxillary glands enlarge and the constitutional symptoms are often severe and associated with extreme prostration and marked febrile reaction. . A recurrent form and a membranous form occur. Rarely, and chiefly in marasmic or scorbutic children; the process assumes a type suggesting noma, but ordinarily recovery occurs in a week or ten days. The interesting stomatitis of "sprue" and "Trench Mouth" is fully described under the proper headings. THE TONGUE.— The Coated and the Clean Tongue.— In many diseases, acute or chronic, whether affecting proximate or remote structures, the condition of the tongue may assist, slightly, diagnosis, prognosis and treatment. A lightly coated tongue may be found in health or may indicate fever, disease of the naso-pharynx, gastrointestinal disturbances, mere smoking, drinking, or the possession of bad teeth. A heavy, pasty, yellow coating is usually indicative of naso-pharyngea] catarrh, catarrhal gastritis, or other disturbances of the digestive tract and is encountered in rheumatism, influenza, and certain other acute infections. Abnormally clean tongue may be, and often is, associated with gastric hyper- acidity or even ulcer. In chronic dyspepsias of the asthenic type the tongue is flabby, often enlarged and laterally indented by the teeth. In the typhoid state the heavily coated tongue is sometimes bright red along its margin and at its tip, which oftentimes shows a triangular red area. The Brown Tongue and the Beefy Tongue. — In all conditions of profound The tongue of toxemia and exhaustion such as septic conditions, severe typhoid fever and the typhoid state in general, the tongue tends to become brown, dry and fissured, is tremulous and is protruded or retracted slowly or only on command. Such a tongue or its congener, the red, shiny, dry, "beefy" tongue indicates a bad prognosis. Helpful but not dependable. The indented tongue. THE OUTWARD SIGNS OF DISEASE 37 The "Strawberry Tongue" with its bright red swollen papillae empha- sized by a white pasty background is often an early sign of scarlet fever. A unilateral coating is sometimes present in hemiplegia, but may be due to bad teeth on the affected side. Ulceration and Fissures. — These may be a part of the buccal inflammations elsewhere described and always suggests a careful examination for syphilis, gastrointestinal disturbances and disease of the teeth and gums. Tuberculous ulcers are surrounded usually by a zone of pallor and are | themselves relatively pale, shallow and sharply defined. Like syphilitic ulcers they are rarely primary. The luetic ulcers are usually like serpiginous fissures if secondary, but in the gummatous tertiary form may be deep and rapidly progressive. Sus- pected malignant ulceration always demands the preliminary therapeutic test for the exclusion of syphilis as, otherwise, differentiation may be extremely difficult. Deep fissures along the edge or deep scarring of the surface suggest past syphilis as does a smooth atrophy of the posterior surface. The tongue reflects more or less definitely the general pallor of anemia and the cyanosis of cardiac or pulmonary disease, and one may detect sometimes scars suggestive of the tongue-biting accompanying multiple past epileptic seizures. Such scars may also result from an existing glosso-labio-laryngeal paralysis. In general, tongue scars are especially suggestive-of syphilis. Unilateral atrophy, the tremor and jerky protrusion of marked alcoholism or actual delirium tremens, and the intermittent fibrillary muscle spasm associated with paresis, must not be forgotten. Marked enlargement may be due to acute glossitis or to acromegaly and myxedema. Tumors must be thought of as well as the various acute condi- tions affecting the mucous membrane of the mouth. Various pigment deposits may occur here as in other portions of the oral mucous membrane, the most marked being the deep brown, purple, or black deposits of Addison's disease, and the yellow tint of the inferior lingual surface in jaundice. Miscellaneous Discolorations. — A black tongue usually indicates the use of iron, bismuth, or charcoal, and brown discolorations axe most commonly due to the use of tobacco, licorice or chocolate, less often to laudanum and rhubarb. The term Nigrities linguce is applied to a peculiar form of black tongue due to the development of a yeast-like fungus Cryptococcus- lingua pilosce upon its dorsum. The pigmentation of the prominent elongated, filiform papillae has given it also the name "hairy tongue." The corrosive acids either whiten the surface (oxalic, carbolic, sulphuric acids as well as ammonia and corrosive sublimate) or yellow it (chromic, hydrochloric and nitric acids). Caustic soda or potash and the nitrate of mercury redden it. The tongue may be the source of persistent hemorrhage in purpura or hemophilia. Scarlatina tongue. Tuberculosis and syphilis. Important indications. "Black" or "hairy" tongue. Mineral acids and caustic alkalies. 3& MEDICAL DIAGNOSIS Geographic tongue. Etiologic importance great. Lead poisoning. Sordes. Mucous patches. Early vs. Late dentition. Wot negligible. The term "geographic tongue" is derived from the annular red patches on the dorsum and edges, due to a painless desquamative process. These spread peripherally and, by coalescence, form eccentric areas with prominent margins. Leukoplakia buccalis ("buccal psoriasis," "leucoma," "ichthyosis") is characterized by non-ulcerative, smooth, white, firm, raised patches. The smoker's patch occupies the dorsal surface of the tip as a pearly yellow, or perhaps reddish plaque. Movements. — : Slow, hesitant protrusion and withdrawal are observed in the typhoid state. Tremor may be marked in the same condition as well as in paralysis agitans and, combined with fibrillary twitchings, in bulbar palsy, general paralysis of the insane and disseminated sclerosis. THE GUMS. — Relation of Diseases of the Teeth and Gums to General Ailments. — The relation of diseases of the teeth, jaws, gums, and of mouth infections in general, to other ailments both local and constitutional, is of late receiving deserved attention and it would appear that these tissues are second only to the tonsils and accessory nasal sinuses in etiologic importance. Certain cases of heart infection, chronic arthritis, nephritis, dyspepsia, general malnutrition and the like have been repeatedly traced back to mouth and jaw infections in the author's clinic and private practice. Marginal redness is usually of little significance, being attributable to uncleanliness in most instances, or to dental caries. It is of some impor- tance in young persons as an indication of tuberculosis and is present in some cachectic states. A grayish or bluish-gray line, composed actually of a series of dots and lines, about i mm. from the actual margin may indicate lead poisoning. Rarely a similar greenish-blue line is present in copper poisoning. Swollen, spongy or bleeding gums commonly indicate mercurial stoma- titis or conditions of great debility and exhaustion as in scurvy and various cachexias. In neglected cases of the typhoid type accumulation of oral debris form the so-called sordes. Dental abscesses, pyorrhea, and various growths such as the malignant epulis also occur. Around the base of the gums as well as in the more readily visible portions of the buccal mucous membrane may be seen the sharply defined, flattened, moist, grayish, "mucous patches" in cases of syphilis. THE TEETH. — As regards the period of eruption of the first and second sets of teeth, a wide margin must be allowed in both directions, an unusually early or distinctly delayed appearance being of no significance. A greatly delayed dentition is usually indicative ofmalnutrition and often associated with distinct developmental defects. The disturbances of "teething," while doubtless greatly exaggerated and usually negligible in well-nourished, breast-fed children, are nevertheless important and are accountable, directly or indirectly, for many "upsets" of infancy. Any doubting physician would be convinced of this fact if he him- self should for a time suffer from similar inflammations from whatever cause. THE OUTWARD SIGNS OF DISEASE 39 .Ttffliffinr »*II»»«i* Fig. io. — First dentition. Illus- trating the sequence of eruption of the temporary teeth. A, sixth to ninth month; B, eighth to twelfth month; C, twelfth to fifteenth month; D, sixteenth to twenty- fourth month; E, twenty-fourth month to end of third year. On the other hand, we should not adopt dentition as a blanket term to cover obscure ailments lest we overlook more concrete and A serious conditions.*! As in the case of the finger-nails, transverse grooves or furrows on the teeth indicate past severe illness; dentated cutting margins are common in malnutrition; and pitted teeth may be due to past stomatitis. B Early decay is common in pregnancy, phosphorus poisoning, rickets, diabetes and other forms of severe malnutrition and the importance of good teeth and especially, sound roots, in connection with chronic dyspepsia and many other conditions is too little ap- C predated. Many obstinate and persistent gastric ailments are promptly cured by proper attention to the remaining teeth. In " status lymphaticus" the two central upper incisors may unduly exceed their lateral neighbors which are actually sub- normal in size. Pyorrhea alveolaris, associated with the presence of entameba buccalis, and such blind abscesses and peridental infections as are re- vealed only by the X-ray, are extremely im- portant as hidden sources of chronic infection. Hutchinsonian Teeth. — If the upper central incisors of the second dentition are peg-like, short, narrow, separated, with a single notch at the cutting edge and rounded corners, they constitute an almost pathog- nomonic sign of congenital syphilis. Mere serration of the cutting edge, or even notching, is in itself insufficient for diagnosis, being encountered frequently in badly nour- ished, non-syphilitic children. D * The normal periods are, in months: First dentition: two lower central incisors 6 to 9. Four upper incisors 8 to 12. Four anterior molars and lower lateral incisors 12 to 15. Canines 1 6 to 24. Posterior molars 24 to 36. Permanent set {in year s) -.Molars, first set 6; second set 12 to 15; third set 17 to 25; Incisors 7 to 8. Bicuspids 9 to 10. Canines 12 to 14. It follows that at the end of the first year there are 6 teeth; at the end of the second 16, and that the first dentition should be completed in two ancl one- half years. t The late Frederic Forchheimer taught that "teething produces teeth and nothing more," and such statements, though exaggerated, have gone far to correct the tendency to ascribe specific, serious ailments to this common and usually trivial condition. Often important. Foci of infection. True type. 4° MEDICAL DIAGNOSIS Caution Commonly misinterpreted. Arched palate. Pain inhibition. Lack of vigor. Fig. ii. — Hutchinsonian teeth. Congenital syphilis. A false diagnosis of syphilis is a very serious matter and every case should be fully proven before any opinion is expressed to family members. One may base tentative treatment upon his own assumption and the therapeutic test is still invaluable but extreme reticence is wise and necessary. Progressive Separation of the Teeth. — This is encountered in cases of acromegaly associated with enlargement of the upper or lower jaw and constitutes an important sign of this disease. Teeth grinding is a common symptom of adenoids, reflex irritation or gastric disturbance in children and is rarely due to the commonly accepted cause, worms. THE JAWS.— The high-arched palate, due usually to neglected chronic naso-pharyngeal obstruction, and so often associated, with the neurotic temperament in the adult, is readily noted, as is the massive lower, or less often, upper, jaw of an acromegaly. The prominent square jaw and the receding chin are universally associated in the lay mind with firmness or the lack of it respectively, but such assumptions are subject to many exceptions. Jaw spasm suggests tetanus, spasmophilia, hysteria, strychnin poisoning or irritation of cerebral origin. . Paralysis may be noted in pontine hemor- rhage, neuritis, brain tumor, or meningitis, and the jaw movement may be more or less mechanicallyimpeded or pain-inhibited in such diseases as quinsy mumps, and trichiniasis. THE SOFT PALATE. — Perforations have been referred to previously as essentially pathognomonic of syphilis. Paralysis is usually due to diphtheria, less commonly to cerebral tumor, meningitis, caries and bulbar palsy. The condition of the fauces and tonsillar areas is of great importance in relation to the exanthemata, but will be considered under diphtheria, ton- sillitis and other headings. Anesthesia of the soft palate and its uvula is a common and valuable indication of hysteria. THE HANDS.— The Handshake.— Aside from the stigmata of occupa- tion, the hands afford much suggestive information. The flabby handshake itself often indicates a congenital lack of vigor or acquired weakness. Tremor may often be felt as well as seen, and thus what seems like a mere formality may contribute to diagnosis and prognosis. Persons of the asthenic or tubercular type often have hands of a peculiarly delicate texture, easily compressed and weak in grasp and the flexible slender hand of many such individuals sharply contrasts with the clumsier resistant one of the person of phlegmatic type and lacking such congenital stigmata. The broad spade-like hand of myxedema, the bulbous terminal phalanges and incurved nails of chronic pulmonary disease (pulmonary osteoarthro- pathy), the clumsy hand of acromegaly with its bony hypertrophy, great THE OUTWARD SIGNS OF DISEASE 41 size and myxedema-like outline, as well as hands showing Heberden's nodes, gouty tophi, the deformities of arthritis deformans, or those of so-called chronic rheumatism may be readily recognized. The atrophy of neuritis and deforming arthritis is associated with a peculiar glossiness of the skin especially marked in the fingers. In Raynaud's disease the so- called "cold" or "dead" fingers are encountered and actual gangrene of the skin may result from that ail- ment, or from direct injury, severe frost-bite, neuritis, leprosy or senile endarteritis. In achondroplasic dwarfs one may encounter excellent examples of the " trident hand" (see "Achon- droplasia"). Wasting of the Hand. — Aside from neuritis, arthritis deformans, and mere disuse, a most significant and im- portant wasting occurs in progressive muscular atrophy, syringomyelia, poliomyelitis, amyotrophic lateral sclero- sis, and the cervical forms of chronic pachymeningitis. Tender, Superficial, Transient Nodules. — As stated previously superficial, small, tender nodules constitute one of the most important signs of "chronic recurrent infective endocarditis" and appear both upon the hands and feet, affecting especially the dorsal, but occasionally both surfaces. These transient tender nodules should not be confused with the relatively or absolutely insensitive ones so com- monly seen after an attack of acute rheumatism, especially in children. These persist for weeks or months. Wrist-drop. — This common symptom is due to paralysis of the musculospiral nerve as the result of direct injury or poisoning by lead or alcohol. THE FINGER-NAILS. — Chronic indolent ulceration (onychia) surround- ing the nail suggests syphilis or marked malnutrition but occurs also in tuberculosis, leprosy, syringomyelia, neuritis and chloral habit. Brittle, striated, or split nails, with or without marked deformity, most fre- quently occur in connection with gout, peripheral neuritis, syringomyelia, and prolonged repeated exposures to the X-ray. Most important to the case-taker at times are the transverse ridges indicating a past severe illness. These are easily noted, last for a period of six or eight months, and by the proximity to the matrix indicate approximately the date of the causative ailment. Fig. 12. — 1. Heber- den's nodes. 2. Syph- ilitic dactylitis. 3. Clubbed fingers. 4. Arthritis deformans. 5. Spade hand of myxedema. Fig. 13. — Clubbed ringers. Chronic pulmonary disease. Myxedema and acromegaly. "Dead fingers." " Trident hand." Rheumatic nodules. Register past illnesses. 42 MEDICAL DIAGNOSIS Color indicators Rachitis and scorbutus. Barlow's dis ease. The nails are also color indicators for cyanosis and anemia and will show the ebb and flow of the capillary pulse in aortic regurgitation. Nail-shedding occurs after injury to the matrix or may be the result of neuritis, locomotor ataxia, or syphilis. THE ARM AND LEG. — Many of the conditions affecting these extremi- ties, such as edema, pain and tenderness, are discussed under their appro- priate headings. Hard, circumscribed, immovable, bilateral, non-mflammatory swellings, Luetic nodes, upon either the ulna or tibia, are usually syphilitic nodes, and the more diffuse, bilateral, painful enlargements of the tibia often associated with nocturnal increase of pain usually prove to be luetic when the modern tests are applied or antisyphilitic treatment is instituted. The smaller rheumatic nodules are described fully elsewhere. Localized edema, heat, redness, and severe deep-seated pain over long bones and especially the tibia, suggests acute periostitis or osteomyelitis which, if neglected, may lead to death from acute sepsis or to chronic fistulous openings indicating secondary necrosis. Enlargement of the lower end of the radius suggests rachitis, and an exquisitely tender, non-inflammatory, branny induration over the shaft of the femur or leg bones in infants or young children is an almost pathognomonic sign of infantile scurvy, an ailment often obscure in its other manifestations (see '•Scorbutus 5 '). Varicose veins are common in the lower extremities and may be bilateral or unilateral. They are often associated in middle-aged or elderly persons with chronic indolent ulcers and may produce a misleading edema like that of cardiac weakness. Such swelling, however, is, as stated previously, usually either wholly or predominantly unilateral. Unilateral edema with congestion or pallor, pain and localized tenderness, suggests phlebitis. .4 perforating ulcer, usually under the ball of the great toe. may be present in advanced locomotor ataxia or, more rarely, in diabetes. Deep cyanosis or cold whiteness of the foot or toes suggests Raynaud's disease, frost-bite or the early stage of an actual gangrene which may be associated with injury, arteriosclerosis, massive embolism, diabetes, frost- bite, ergotism, Raynaud's disease and rarely, it is claimed, with exoph- thalmic goiter. Mottled, dusky redness and pain over the sole of the foot may indicate erythromelalgia. The presence or absence of normal pulsation in the accessible peripheral arteries, such as the dorsalis pedis and posterior tibial, should be carefully noted, in connection with painful diseases of the lower extremities especially, as indicating the dysbasia arteriosclerotica of Erb [inter mittier end e Hinken ,* obliterative endarteritis or incipient gangrene. This condition, much more common than is generally believed, is fre- * This interesting ailment is also known as "intermittent claudication" and "crural angina" and is associated with an arteriosclerotic process localized or predominant in the affected extremities. Intermittent lameness. THE OUTWARD SIGNS OF DISEASE 43 quently overlooked in its earlier stages and the patient is treated for chronic sciatica or rheumatism without avail and to the neglect of the cardio- vascular system. It may never lead to gangrene but always suggests the presence of degeneration of the myocardium and thus demands that special attention be paid to the heart itself. Enlarged glands in the groin or femoral triangle suggestive of syphilis, chancroid, Hodgkin's disease, leukemia, malignant disease, etc., should be noted, as well as the enlarged epitrochlear gland above the inner condyle of the humerus which may indicate a past or present syphilis.* Transient nodular swellings usually painless and subsiding with bruise- like color changes are common in erythema nodosum and as stated previously, small, painful, tender areas occur in chronic recurrent septic endocarditis. The BACK. — The chief deformities of the spine are essentially four in number: i. Lateral Curvature ("Scoliosis"). — This is most frequent in young girls of asthenic structure and habitus who suffer from faulty position in standing and sitting, and from general muscular weakness. It also results from rickets, chronic diseases of the lung and pleura, paralyses affecting posture, and mollities ossium. In its ordinary form this deformity is seldom extreme and is usually remediable. 2. Lordosis or exaggerated normal curve is ' exemplified by the later stages of pregnancy and suggests that condition, abdominal tumors, ascites and pseudo-muscular hypertrophy. 3. Kyphosis. — If the sharply angled posterior projection of the spine is present, Pott's disease (spinal caries) or mollities ossium are suggested, though a simple dorsal curve occurs in rickets, debility and chronic emphysema. 4. Immobility of the Spine. — Temporary stiffness may be due to muscular strain or rheumatism, and chronic rigidity indicates arthritis deformans, paralysis agitans or Pott's disease. The curious spondylitis deformans is a rare ailment chiefly affecting middle-aged men and is a peculiarly localized rheumatoid arthritis. One form affects the spine alone; another commences in the hip-joints and ex- tends upward to the spine and shoulder, the result being a rigid kyphotic spine alone or with ankylosis of other affected joints. Certain cases are associated with marked muscular atrophy and nerve root pains. Tumors and Swellings. — A great variety are discussed in surgical and orthopedic works, and congenital spina bifida, abscesses due to caries, fatty tumors, bed sores and sacral edema are more or less frequently encountered. THE JOINTS.— The following points should be determined: (a) Presence, extent and character of any redness, swelling and deformity, (b) The position assumed, (c) Heat, (d) Tenderness, (e) Fluctuation or edema. (J) Degree of mobility in relation to pain excitation, (g) Presence of crepitus, (h) Outline of bony structures, (i) Ankylosis, (j) Atrophy, (k) Contractures. (I) Associated or antecedent injury, (m) Acute or chronic *A most inconstant sign in old syphilitic cases. Often overlooked. Asthenic girls. "Poker spine." 44 MEDICAL DIAGNOSIS Sign of effusion. Exudate is purulent. infection, local or remote (tonsils, accessory sinuses, teeth., etc.). (n) Excessive exhaustion, exposure, fatigue or other recognized causative or pre- disposing factors. General Comment. — It should be remembered that in acute rheumatism the larger joints are chiefly and primarily affected, usually bilaterally, suc- cessively, and in a definite order, and that the skin is moist, the sweat acid, and fever and anemia marked. In acute gout a single joint, usually the great toe, is primarily affected, a preference is shown for the small joints, the actual pain and throbbing are greater and more definitely paroxysmal than in rheumatism in which they are chiefly excited by movement even of the slightest degree. In chronic rheumatism deformity is, as a rule, not extreme, fever absent, changes of the weather markedly affect it and exacerbation and subsidence are the rule. In arthritis deformans an acute primary attack cannot at first be dis- tinguished from acute rheumatism, but it is more persistent, yields less readily to specific treatment (salicylates, etc.) and tends ultimately to become chronic, the joints grating on movement, deforming and finally becoming fixed. Both large and small joints are involved and the disease may be- come almost universal.* Many cases of arthritis deformans develop in- sidiously and exhibit no acute or subacute stage. The Floating Patella. — In the knee-joint, fluid is most readily detected by fully extending and supporting the extremity and making downward pressure upon the patella which may be felt to tap against the articular surfaces. Ordinarily the outline of the distended synovial membrane in such a case is characteristic. Septic Arthritis. — This occurs chiefly in the course of, or immediately following, acute infectious diseases, especially scarlet fever and dengue, and is common in pyemia and gonorrhea. The infantile form of septic arthritis may occur without an assignable cause and progress rapidly to suppuration. This term is specifically applied to such cases as show a purulent joint exudate. The various tuberculous lesions are too numerous to permit of discussion in this volume. Common Errors.— One of the most regrettable of diagnostic errors is involved in the failure to recognize osteomyelitis which all too frequently is treated primarily as rheumatism. Radical surgery is urgently needed in Fatal mistakes, these cases and one should remember that the epiphyses are chiefly involved rather than the joint itself and that the disease is distinctly septic in type, I the pain extreme, deep-seated and boring, and, further, that in osteomyelitis as in acute rheumatism several points may be involved, and furthermore, that a secondary pyemic arthritis may occur. * In all cases of chronic affections of the joints, of a rheumatic or rheumatoid nature, one must consider the probability of their etiologic unity as now clearly indicated by recent investigations relative to the causative effect of chronic infections of the tonsils, accessory nasal sinuses, the teeth and gums and the prostate. Acute rheumatism itself is really a streptococcic arthritis, though the joint exudate is usually sterile, the peculiar strepto- cocci being found in the subserous connective tissue, as first shown by Poynton of London. THE OUTWARD SIGNS OF DISEASE 45 //; hemophilia, scurvy or purpura, both hemorrhagic and pseudo-rheumatic joint affections may occur. In locomotor ataxia and in syringomyelia, one of the large joints, most frequently the knee, ankle, or hip, may become suddenly swollen, with or without pain, and go on to rapid disintegration (Charcot joints). In any chronic joint affection, and as a result of prolonged disuse, there may be marked muscular atrophy simulating that of certain diseases of the spinal cord, but the electrical reactions are preserved. Hysterical joints may create much confusion, being excessively tender and frequently contractured. Chorea is often associated with what is probably a true rheumatic arthritis. Pain Referred to Joints. — Examples of misleading pain of this character are found in the reference of the pain of hip-joint disease to the corresponding knee; the shoulder- joint pain of angina pectoris or a circumflex neuritis; the misleading radiating pains of spinal caries, of aneurysms and of locomotor ataxia. Diaphysitis, caries of the ends of the long bones and especially osteomyelitis are most misleading. TREMOR. — Modes of Testing Tremor. — To distinguish between passive tremor and intention tremor the patient is asked to make some movement such as is involved in taking up and fastening a collar button, buttoning the vest, or lifting a glass of water to the lips. In the latter variety a tremor is in- creased, or indeed initiated, by the coordinate movements, and may be wholly absent when the patient is at rest. All tremors of the extremities are increased by extension; therefore the patient should stretch the arm or leg in front of him, keeping the fingers or toes separated as widely as possible in hyperextension. Again if the tips of the fingers are allowed to rest upon the physician's palm a vibration other- wise imperceptible may be readily detected. Facial Tremor. — Any latent or existent tremors of the muscles of the face may be emphasized by the firm closure of the eyes, elevation of the eyebrows, or by drawing the corners of the mouth down or outward, and tremor of the tongue is markedly increased by full protrusion. In the case of individual muscles or muscle groups in various portions of the body, putting these in action or under continued strain usually increases the tremor. One should note whether the tremor in question is localized or general, passive or intention, coarse or fine, jerky, rapid or slow, regular or irregular, temporary or persistent. Conditions with Which Tremor is Associated. — The tremor of advancing age and the extremely rare condition of congenital or inherited tremor are unimportant, as are those due to temporary nervousness, muscular or mental overstrain and the excessive use of tea, coffee or tobacco. Tremor in acute disease usually indicates a profound toxemia, being one of the unfavorable symptoms, for example, in typhoid-fever, and it is often encountered in the typhoid state whatever be the underlying original disease. Hemorrhagic diathesis. Charcot joints. Atrophy of disuse. A confusing type. Misleading localization. Effect of coordinated movement. Extension increases tremor. Action vs. Repose. Trivial tremor. 4 6 MEDICAL DIAGNOSIS Rapid, fine tremor. "Pill-rolling' and "bread- crumbling." Disseminated sclerosis. Tongue and lip tremor. Scrivener's palsy. In alcoholism it is not only a prominent feature of delirium tremens, but may often enable the physician to detect a recent debauch or persistent excessive potations, and, if marke'd, it suggests the possible imminence of an acute attack. Such a tremor is ordinarily fine, regular and persistent, and very similar to that of drug habituation. Exophthalmic Goiter. — In this disease the tremor is fine and rapid, and if associated with a large thyroid and rapid pulse with or without exoph- thalmos, the diagnosis is made. Every suspected case should be tested for tremor. Coarse jerky tremor may be associated with cerebral lesions or dis- seminated sclerosis. Paralysis Agitans. — This is ordinarily a relatively slow tremor, first affecting the thumb and forefinger and causing a rolling movement of the thumb over the forefinger known as the " pill-rolling " or "bread-crumbling" tremor. It disappears during sleep and unlike intention tremor is checked by volitional movement. In its more advanced form it may involve the arms, legs, and head. Mineral Poisoning. — Any case of otherwise unexplained tremor should sug- gest the possibility of chronic poisoning by some metal or drug, such as cocain, opium, arsenic, lead or mercury. Intention Tremor. — This condition suggests always disseminated sclerosis, but may be met with in a marked form as a senile tremor, occasionally in hysteria, and rarely in cerebral lesions, or even lead poisoning. Tremor of Muscles of the Face. — Fibrillary twitching or flickering of the facial muscles strongly suggests profound asthenia, general paresis or chronic alcoholism. In progressive muscular atrophy, juvenile or spinal, it may be observed in other regions as well. Tremor limited to the tongue and lips occurs in some cases of profoundly asthenic fevers and in general paresis. SPASMS, CRAMPS, AND CONVULSIVE SEIZURES.— The term cramp should be reserved for a painful, spasmodic, muscular contraction, temporary or intermittent and localized. In the skeletal muscles it may be associated with alcoholism, gout, diabetes, Bright's disease, pyelitis, pyelo- nephritis, hysteria, or excessive muscular fatigue and most commonly involves the calf of the leg. Occupational Cramps. — The constant overuse of one set of muscles such as is met with chiefly in the occupational neurosis, is typified by the "scrivener's palsy" and may take the form of cramp, though more frequently it is a simple spasm, mere weakness or an actual paralysis. Cramp Colic. — The term is quite correctly applied to painful muscular spasm of the viscera such as is involved in renal, intestinal, or biliary colic. Wry Neck. — This may be congenital, traumatic or purely spasmodic and save for cases associated with actual traumatism at or subsequent to birth, represents a disturbance affecting the spinal accessory nerve. In true congenital wry neck there is atrophy of the sterno-mastoid (usually the right) and facial asymmetry, as opposed to mere muscle callus due to THE OUTWARD SIGNS OF DISEASE 47 rupture at the time of delivery. Spasmodic wry neck may be tonic, clonic, or more rarely combined, and may follow injury or exposure or be a true neurosis. In any event the muscle group of spinal accessory innervation is chiefly involved and the spasm of the rotators elevates the chin and swings it toward the unaffected side. The shoulder may be raised and the head drawn decidedly backward if the trapezius be much involved. Bilateral spasm drawing the head back and the face upward is rare. The clonic spasms are particularly distressing, and unfortunately the disease usually tends to be- come fixed. One must remember the possibility that wry neck of the acquired type may be the result of an associated cervical caries, or a part of the phenomena of "spasmophilia." Nodding Spasm. — {Spasmus nutans). — This condition is usually a neu- rosis, particularly, as seen in the adult. In children it may be mimetic, reflex (teething), or associated with rickets and, probably, with spasmophilia. Ocular spasm, especially nystagmus and, less often, strabismus, may be associated with this condition. The oscillations cease during sleep, are in- creased by excitement or when under observation and associated mental defects or an epilepsy are occasionally noted. The reflex cases may be purely transient. Tetany. — This condition is probably one expression of the spasmophilic diathesis and is entirely distinct from tetanus * It is merely a painful bilateral and symmetrical tonic spasm of the extremities, of variable duration, tending to exhibit periods of exacerbation and occasionally intermit. It usually involves the feet and hands, less often the face, neck and jaw (trismus) and rarely affects the muscles of the trunk. The disease is most frequent in infancy and the tendency diminishes with added years save for a disposition to intensification occurring at puberty. Excessive muscular irritability is evidenced by the active contraction not only of the one, but sometimes of all, the extremities following pressure upon the main nerve trunks (Trousseau's sign), and even the lightest tap over the facial nerve causes contraction of the facial muscles (Chvostek's sign). The spasms may be intermittent, rhythmically recurrent, or persist- ent over considerable periods. The attacks vary greatly in severity and duration and in infants and young children may last but a few hours or even minutes. Paresthesia may follow the lightest pressure upon a sensory nerve and the response to the galvanic current is greatly intensified, both cathodal and anodal closure contractions being induced by 5 milliamperes of current. Fever is some- times present, and the disease is usually paroxysmal in type and associated with poor nutrition, deficient calcium salts, rickets, and marked gastro- intestinal disturbances. Among the rare exciting causes of tetany are gastric lavage (in cases of * A deficiency of calcium has been noted in this condition and oral administration is said to relieve it. Varieties. Trapezius involvement. Important warning. Nocturnal intermissions. "Trousseau's" sign. Chvostek's sign. Duration of attacks. Electric reactions of spasmophilia. Calcium deficit. 48 MEDICAL DIAGNOSIS Epidemic tetany. Transitory cramp. Often familial. Vermicular muscular contraction. Of slight importance. Journalistic standbys. dilated stomach), pregnancy and lactation, and removal of the thyroid gland, or, more probably, as the result of coincident parathyroid resection. An epidemic, non-fatal, form of tetany in adults has been quite prevalent at times on the continent of Europe, but is extremely rare in America. Paramyoclonus Multiplex. — This syndrome covers those peculiar cases occurring almost always in males and of unknown causation, in which lightning-like clonic, with occasional tonic, spasms of the larger muscles recur either persistently or paroxysmally, unaccompanied by sensory disturbances. These are usually symmetrical and rhythmical and cease during sleep. It is often distinctly familial and in the type described by Unverricht either succeeds or accompanies epilepsy. Myokymia. — This condition is characterized by continuous fibrillary contractions chiefly affecting the extremities. The affected muscles show a diminished response to both faradic and galvanic currents. Myotonia (Thomsen's Disease). — This markedly but not exclusively familial disease is characterized by tonic muscle cramp induced by voluntary movement but passing off as these are repeated. The myotonic reaction observed in these cases is a characteristically slow contraction and relaxation upon stimulation by either the faradic or galvanic current; a deliberate vermicular muscle-contraction wave passing from cathode to anode. Athetoid Movements. — These curiously deliberate, writhing, twisting movements of the fingers and hands, more rarely of the feet and toes, may result from infantile palsy or follow hemiplegia in adults. They are slower and less jerky than the movements of chorea, with which they are sometimes confounded. Myoidema. — One frequently notes a marked fleeting, localized contrac- tion if a muscle be sharply tapped with the finger. This phenomenon is especially common in the muscles of the chest in connection with tubercu- losis but is not a sign of diagnostic importance. Catalepsy (Auto-hypnotism). — This extraordinary symptom usually indicates hysteria, but may be encountered, in melancholia, dementia, brain tumor, meningitis and tetanus, or be produced by hypnosis of which it con- stitutes the second stage. The patient appears asleep and the limbs show a peculiar plastic rigidity and will remain for minutes or hours in the position in which they are placed. It is often auto-hypnotism, the eyes are closed, rolled upward, the pupils contracted and sensibility to pain and special general sensation is abolished. The duration of such attacks varies from a few minutes to several hours, but may endure for months in dementia precox or melancholia. In such cases the patients are kept alive by gavage. Hysterical Seizures. — The actual study of cases is necessary to an under- standing of the physiognomy and external manifestations of this extraordinary condition, but once a large number have been carefully observed the difficulties, in great degree, are removed. The topic is dealt with entire in its proper section. THE OUTWARD SIGNS OF DISEASE 49 disease. Reflex type. INFANTILE CONVULSIONS— A tendency to easily induced convulsive | seizures like laryngismus stridulus and tetany seems to be one expression of the Spasmophilic diathesis at present believed to be largely dependent upon a deficit f^™* 1 " 1 ' of calcium salts. Attacks precisely similar to those of epilepsy or differing only in some Malnutrition particulars may be observed in both children and adults. In the former they may be associated with indigestion, general malnutrition (whether primary or secondary to disease), rickets, fever, as is so frequently seen at the onset of acute infectious diseases, rarely in congestion of the brain and quite commonly c as reflex phenomena due to peripheral causes. Disease or irritation, such as dentition with its associated digestive dis- turbances, phimosis, diseases of the eye and ear, or possibly intestinal worms may be exciting causes. Convulsions accompany the larger number of cases of cerebral disease in children, and one observes occasionally in young infants from the time of their birth a decided though gradually diminishing tendency to convulsive seizures. Symptoms. — Aside from the usually premonitory symptoms, such as slight twitching, teeth grinding, restlessness or irritability the attack is precisely similar to that of epilepsy. The diagnosis in repeated attacks may depend upon their subsidence or disappearance after a cause has been found and removed, but the spasmophilic electric reactions are clarifying diagnostic elements.* The infant mortality from this source is considerable, and, unfortunately, a large number of true epilepsies commence during the first three years of life. Over a third of those investigated by Osier occurred in the first year. Comment. — The onset of an acute infectious disease, simple overloading of the stomach, or indigestion, are accountable for the excitation of the greater number of such attacks in predisposed children. If the condition is persistent we have to think not only of epilepsy but of the various diseases affecting the brain and its covering, of renal disease and of adenoids. STATION, ATTITUDE, GAIT Test for Static Ataxia. — Static ataxia is tested by having a patient stand with heels and toes together. Marked swaying (more than an inch or two of excursion) increased upon closing the eyes strongly suggest locomotor ataxia and is, in fact, usually associated with other evidences of incoordina- tion, lost knee-jerks and a pupil reacting to accommodation but not to light.f In Meniere's disease or a lesion of the mid-cerebellar lobe the patient may sway violently and fall unless closely watched. In cerebellar lesions the ataxia of all types is extremely coarse but is ataxia?"" much lessened in recumbency, nor is Rombergism so greatly increased Rombergism. * See "Tetany." t One sufferer from locomotor ataxia aptly described his sensation as that of a "chicken on a clothes line." Cause usually simple. Locomotor ataxii. Meniere's disease. 5o MEDICAL DIAGNOSIS Sthenic vs. asthenic ailments. Voluntary shifts. Abdominal lesions. Variable decubitus. Rigidneck. Fear of jarring or handling. High diaphragm. Acute form. A double risk. upon closing the eyes as is the case in locomotor ataxia. In ordinary vertigo and the pseudo-ataxia of hysteria, muscular incoordination usually disappears in recumbency. Decubitus {Active or Passive). — In the bedfast patient, its chief divisions are the active and passive, dorsal and lateral, and it varies with the condition of the patient and the nature and localization of his disease. Even a severe pneumonia does not always rob the patient of his active decubitus, but in severe typhoid fever the patient lies relaxed and helpless, must be moved from side to side, and occasionally lifted and straightened out to relieve a cramped posture or prevent his gravitating to the foot of the bed. The terms dorsal and lateral explain themselves, but it is important to note whether the patient changes voluntarily from one to the other decubitus or, through weakness or because of pain excitation or increase, maintains a fixed posture.* In appendicitis the patient usually lies on the back, often with the right knee drawn up, or, as in general peritonitis, with both knees so placed. In severe abdominal colics (intestinal, hepatic, renal, etc.) the knees are often drawn close to the belly and the lateral coiled position is common. In acute pleurisy the attitude is variable, the patient often lying on the affected side to limit movement and favor the vicarious respiration of the sound side. In others this attitude is primarily painful, but with the com- ing of an effusion and subsidence of inflammation it is the favored position. Acute meningitis, if established, is characterized by cervical rigidity, retraction of the head and neck giving a distinctive appearance. In severe rheumatic fever and in certain cases of infantile scurvy and rickets as well as in early acute peritonitis, the patient lies in a dorsal posi- tion, and his whole expression may evince the liveliest apprehension, when his bed is approached or any effort made to examine or move him. ORTHOPNEA.— In cases of heart disease in which the right heart has failed; in asthma whether spasmodic, cardiac or renal, and in severe emphy- sema, massive pericardial effusions, mediastinal tumors, or laryngeal obstruc- tion, one is likely to find that peculiar combination o f dys pnea and an obligatory partial or complete sitting posture which constitutes orthopnea. In cases where the diaphragm is pushed upward, as in massive ascites or severe meteorism, orthopnea may be present, though usually absent. Consciousness and a certain amount of physical strength are necessary to the voluntary maintenance of this position. An acute orthopnea is seen not only in asthmatic seizures, but with major angina pectoris, sudden cardiac weakness and infarction or edema of the lungs. Important Variant of Orthopnea. — In certain cardiovascular cases it may be impossible for the patient to resist the impulse to assume suddenly a sitting or even a standing posture, and, inasmuch as sudden death has * In acute self -limited ailments like pneumonia we may sometimes observe a profoundly toxic, apparently comatose, patient change his decubitus from passive to active and feel that the ebbing tide has turned. THE OUTWARD SIGNS OF DISEASE 51 frequently followed the natural attempt on the part of the attendant to re- strain the patient, both judgment and discrimination are required. This condition is most frequently encountered by the author in coronary sclerosis, anginas and advanced aortic lesions. In the terminal incompen- satory stage of mitral lesions there is often a peculiar listless rolling of the head from side to side, which, with the associated anasarca, blurred features, cyanosis and orthopnea, makes a characteristic picture. Modifications of this syndrome may persist for weeks and are ominous. In some cases of aneurysm, acute aortitis, asthma, extreme cardiac in- compensation, or a malignant growth involving the mediastinum, the patient not only sits up, but must lean forward so as to rest the head upon the knees or upon some special support. In several cases of Hodgkin's disease coming under the author's obser- vation, rapidly enlarging glands within the mediastinum made this attitude obligatory for weeks before the patient's death, a special bed-table or arrange- ment of pillows affording support for the head and arms. In diaphragmatic pleurisy the patient usually sits inclined toward the affected side. Rarely, in dyspnea or dysphagia, due to the pressure of aneurysm or mediastinal growths, and, in some cases of vertebral caries as well, the prone position is that of election. Most careful attention should be given to the attitude of the semi-un- conscious patient with particular reference to paralysis, for the appearance and passivity of an affected member or side is oftentimes characteristic. Common Conditions. — The curvatures of kyphosis, scoliosis, lordosis, and the compensatory spinal arching of emphysema are everyday matters. The wide " stance" of advanced locomotor ataxia and the similar attitude of osteitis deformans are also more or less characteristic. Emprosthotonus and Opisthotonus. — Spasmodic flexion of the body which makes its supports the forehead and feet (emprosthotonus) is less frequent than the backward flexion which makes the head and heels the sustaining points (opisthotonus). Either may occur in hystero-epilepsy, uremic con- vulsions, tetanus, cerebro-spinal meningitis and strychnin poisoning. GAIT. — Necessary Maneuvers. — When a special examination is necessary the legs should be uncovered from the hips down and in women the night- dress or chemise may be brought forward between the thighs and fastened above. The patient should walk briskly, then slowly, with the eyes open, then shut, stop abruptly, and also turn sharply at command and follow a rug border or crack at right angles to the previous line of vision. Due allowance must be made for nervousness and careful watch be kept lest a serious fall occur in some ataxic patient. The limping gait suggests acute or chronic joint ailments, flat-foot, corns, etc. A tilting forward of the body is noticeable in those merely "round shouldered," in paralysis agitans, extreme emphysema, kyphosis due to verte- bral caries, and certain painful abdominal affections both acute and chronic. Herald of death. Prone position. Spinal cuTva- ture and "stance." Associated conditions. Caution. 52 MEDICAL DIAGNOSIS Locomotor ataxia. Other associations. "Mowing gait.' Hysteric simulation. Foot-drop. A late symptom. Leaning backward or an actual lordosis may be due to spinal disease, advanced pregnancy, abdominal tumors, ascites or extreme obesity, and is a striking symptom of pseudo-hypertrophic paralysis and cretinism. Ataxic Gait. — The gait of the advanced ataxic stage of locomotor ataxia is striking, the feet being raised suddenly, jerked uncertainly forward beyond the ordinary limit and brought down heel first with a stamp. The patient keeps them well apart and must keep his eyes upon the ground, lest he sway or even fall. A sudden turning movement or an abrupt rise from the sitting posture is to him difficult or impossible. A patient may have the disease for years, how- ever, before this typical gait appears. An ataxic gait occurs in many conditions other than locomotor ataxia; and among these are Friedreich's ataxia, cerebellar tumor, syringomyelia, hereditary cerebellar ataxia, some cases of general paresis, and various intoxications affecting the cerebrospinal sys- tem, i.e., lead, arsenic, alcohol, etc. The Spastic Gait. — In this gait, character- istic of hemiplegia if unilateral, or some form of lateral sclerosis if bilateral, the rigid leg moves stiffly, the foot drags, necessitating a tilting of the pelvis at each step, and the toes describe an arc (" mowing gait"), thus wearing down the sole of the shoe on its inner side. In hysteria a simulated unilateral spastic condition may be observed but in most instances the foot is merely dragged and not swung inward. ' Cross-legged Gait. — Spastic contraction of the adductors sometimes produces a cross-legged "progression" also occasionally simulated in hysteria. The Steppage or Prancing Gait. — This is most often seen in multiple neuritis or peroneal muscular atrophy as a result of foot-drop, because of which the patient must lif t the foot high with each step in order to raise the toe clear of the ground and avoid tripping. The result is a peculiar "high action," the patient appearing to step over constantly' recurring, though non-existent, obstacles. The Shuffling Gait of Senility. — This is a matter of daily observation and is associated with slowly progressive loss of strength and mentality. The Choreic Gait. — When present, it is sometimes peculiarly like that of the school boy, who in the schoolroom clownishly stumbles or trips over his heel to attract the attention of his fellows, and it is seldom or never unasso- ciated with other characteristic symptoms. Spasmodic adduction, extension, and outward rotation of the legs form a sequence which soon makes progres- sion impossible if unrelieved. Fig. 14. — Tabes. Station: legs widely separated, feet everted. May be evident even when the ataxic gait is not typical or even very marked. {Gordon.) THE OUTWARD SIGNS OF DISEASE 53 The Reeling Ataxic Gait. — This is especially characteristic of cerebellar (vermis) lesions, and differs in no essential respect from that of a drunken man. A similar gait may occur in any condition accompanied by vertigo. The Waddling Gait. — In this form lordosis is marked, the feet are widely separated, the pelvis and head of the femur are jerked forward at each step, the flexed knee is advanced, extended only after the foot is placed flat upon the ground, and the patient cannot stand on tiptoe. It indicates bilateral hip disease, congenital dislocation of the hip-joints or pseudo-hypertrophic paralysis. Dromedary Gait. — In the so-called "progressive torsion spasm" of chil- dren (Flatau-Sterling) the peculiar movements in walking have given rise to the terms " camel's walk" or "dromedary gait." The Festinant Gait. — When present this is pathognomonic of advanced paralysis agitans, and, in typical instances, the patient seems as if trying to recover from a thrust from behind. He goes slowly at first; then trots of shuffles at increasing speed with the body bent forward and finally pitches helplessly forward, if unsupported. Retropulsion and lateropulsion of the same type may be present also in such extreme cases. Intermittent Claudication. — ("Dysbasia angiosclerotica" u intermittierende Hinken"). This justifies further special reference, for though it is associated definitely with arteriosclerosis and deficient circulation in the lower limbs, it is frequently overlooked or misinterpreted.* 77 is characterized by numbness, pain or muscle cramps on standing and walking, associated with a temporary rigidity, paresthesia or disability, all of which symptoms are often entirely absent when at rest. The condition is far more frequent than is generally believed and in several cases observed by the author is has been associated with serious myocardial degeneration and general circulatory embarrassment. The pulse is usually absent or extremely weak below the knee during the seizure and is usually deficient in one or both of the main arteries of the foot even when the patient is at rest.\ Thomsen's Disease. — This, a family disease, is characterized by recurrent, transient muscular stiffness or painless contraction on attempting any muscular action. This, in walking, at first checks or delays each step, but gradually wears away and permits normal progression, only to re-appear when any new muscle group is called into play or the same action repeated after a rest. Astasia-abasia. — This curious condition must be classed as a functional neurosis inasmuch as all other nervous functions are normal and the picture * The same condition may be present in the arm in rare instances. t This condition need not be confounded with the intermittent spinal claudication of Dejerine, which represents what, at first, is a mere sense of fatigue in one limb under exercise later in both and still later the development of a spastic paraplegia. Disturbances of the deep reflexes and the sphincters appear early, pain is absent, the pulse in the arteries of the foot is unaffected. The disease is, nevertheless, due to the same cause as intermittierende hinken, but the changes are localized in the arteries supplying the lumbo-sacral segments of the spinal cord. " Drunken' gait. Not rare if sought. A significant finding. A curious complex. Effect of posture. 54 MEDICAL DIAGNOSIS ■Jumpers." Importance of weight. Its many causes. strongly suggests hysteria. Walking may be impossible yet all of its move- ments may be normally performed when the patient is lying in bed. The inability may be absolute or partial, giving rise to what simulates spastic paralysis on the one hand or flaccidity upon the other. Saltatory spasm is sometimes observed, the abrupt leaps being due to violent involuntary muscular contractions induced by the assumption on the erect posture. DESCRIPTION OF NYLIC STANDARD TABLE OF HEIGHTS AND WEIGHTS Dr. O. H. Rogers, of the New York Life, has constructed from the same figures, the graphic table shown on the opposite page. "The short vertical lines marked $'6", 5V, 5'8", and so on are the height lines. The diagonal curved lines, marked 20, 30, 40 and 55, are the age lines for men; the lines desig- nated by the sign o- are the age lines for women. The intermediate ages fall at proportion- ate distances between these curved lines. The intersections of the age lines with the verti- cal height lines fix the normal weight-points. The weights at intervals of 5 pounds are recorded on the horizontal lines to the right of the diagonal curved lines. "Thus, a man s'6" in height should weigh, at age twenty, 135H pounds; at age thirty, *43/^ pounds; at age forty, 149^ pounds; at age fifty-five, 153^6 pounds. The weights for intermediate ages are found at corresponding intermediate points. "A woman $'6" in height should weigh, at age twenty, 1363^ pounds; at age thirty, 137K pounds; at age forty, 143^ pounds (the same as a man at age thirty). At fifty-five the weights of men and women are the same. In this way are found the normal weights for any height at any age. "Now, let us suppose that a man $'6" in height and twenty years of age weighs 225 pounds; how much is he overweight? His normal weight is 135 H pounds. Passing from the normal weight-point horizontally to the right until we reach the vertical line marked 225, we find ourselves just outside the 65 per cent, line; such a person is thus found to be 66 per cent, overweight. Again, supposing the weight to be 100 pounds, we pass horizontally to the left to the 100 pounds vertical line; the intersection of our weight line with this ver- tical line shows him to be 26 per cent, underweight. In the same way the percentage of any given weight above or below the normal may be obtained. "The vertical weight lines are 25 pounds apart, but for greater accuracy the intervening spaces are divided by broken lines into 5-pound subdivisions. "Mistakes in the use of the chart will be avoided if the following steps are taken in their order : "1. Fix upon the height line. " 2. Locate the age-point on that line. The point thus found gives the normal weight for the height and age. "3. If the case is very much over- or underweight — pass horizontally to the right in case of overweight, and to the left in case of underweight, to the intersection with the vertical weight line. The position of the point thus found fixes the per cent, over- or underweight." WEIGHT AND HEIGHT.— Every doctor's office should contain a pair of accurate scales, and the past, recent, present, and best weights are oftentimes of great importance in diagnosis, prognosis and treatment. Obesity. — In general, one encounters a tendency to increase in weight after the age of forty and excessive corpulence is ordinarily associated with a weak musculature, poor resistance to acute disease and a decided tendency to degeneration of the heart, blood vessels and kidneys in middle age. Emaciation. — This may arise from exophthalmic goiter, hysteria, worry and loss of sleep, the anxieties and strain of a love affair, improper or insufn- THE OUTWARD SIGNS OF DISEASE 55 o 8 iO rv CM O lO CM IO CN CM A o o CM IO O IO IO CM O c m :\ \ \ X \ ,\ X \ V \ \ \ \ \ \ V " > \ X \ s \ \ s \ \ \ i 51 k x * CM o CO h I o UJ n X \ X \ \ X \ \ \ \ ^ i K X \ CM m IS *S z < co f- G 5 - ©• □ o D a c eg X o \ "\ :% V t x\~ \ X \ i \ ^ A A 1 s CM ^ i2 C3 > \ .3 s UJ * > N N X o W J- \ s i' -fc' - \ \ N s X X X o \ * * ^ § X | \\ CM a> ft ■ * - X \ s UJ < X \ % H -i CQ ; X V v \ s S § n . 5 v cr ®\ X a " S3 X c X X X x x X y v X ■" w DC < - <0- 4s> •\ \ >v Q . s *r \ 1 Z < £ s v i r\ & 1, h co K > \ s X ^s A \ ■\ \ \ \ \ - c X X ID o s i " £ -J * \ \ L >■ z \ \ A s UJ X *> \ k i\ ^ X \ s m '6> ^ "i6^ h£ VI X v \ A- c a - o- \ A X \\ \ \ U > x\ \ *\ o - X ,4 iO 56 MEDICAL DIAGNOSIS Self-starva- tion. A cause of "nervous indigestion. Wasting. Misleading gains in weight. Weighing infants. cient food, diabetes, chronic vomiting, profuse diuresis, sweating, purging and many other exciting causes. It is pronounced in certain digestive disorders, in symptomatically active universal congenital asthenia, in all severe or prolonged fevers, true diabetes mellitus and the various wasting diseases of children. One of the commonest factors is unconscious self -starvation through whimsical or mistaken limitation of the diet as is so often seen in the asthenic forms of indigestion. Chronic starvation, unconscious, deliberate or imposed, is one of the com- monest and least recognized causes of persistent dyspepsia of the functional type as encountered in asthenic individuals and some very serious cases arise from the vicious, dangerous, and not infrequently fatal, fasting cures conducted by quacks, or self-imposed. Progressive Loss of Weight. — This is one of the most significant signs of incipient tuberculosis, carcinoma of the stomach and many other chronic ailments. A fair estimate of weight loss can be made by pinching tip a fold of skin over the triceps when the elbow is semiflexed and noting the degree of the misfit. In chronic exhausting diseases and in the emaciation of advanced age the skin is not only loose, but also relatively inelastic and relaxed. Increase of Weight. — Following illness, this ordinarily indicates an im- proved general condition and the arrest of any local disorder, but large tumors, myxedema, edema and exudates, also increase it, and in heart disease and Bright' s disease especially, the variation in body weight may reveal a transudate not shown by outward signs. Loss of weight in the renal and cardiac types of edema may at times, therefore, be a favorable symptom. Weight loss may mean little or no loss of strength and in those who have become obese from physical inaction and overeating and drinking, may ac- tually promote muscular activity, but progressive emaciation and increasing weakness are usually of serious import. Infants should be weighed weekly and should show an increase of from 200 to 250 grams per week for the first four months, from 120 to 200 grams weekly for the five succeeding, and somewhat less for the remaining months of the first year of life. During the first days after birth they may show normally a considerable weight loss. . Accurate Weighing. — When accurate results are necessary in individual cases, weighing should be done at the same hour in relation to meals, on the same scales, and with the same amount of clothing, if possible, inasmuch as the estimate of 5 to 7 pounds usually made for the clothing of adults is subject Height and weight. Standard relationship. The relation of height to weight is important and is well shown in the in- genious and accurate " Nylic" table. (Page 55). The Attitude of Life Insurance Companies. — Insurance companies regard with suspicion men whose weight runs more than 20 to 25 per cent, above or below the standard as indicated by the table, and that this prejudice is well THE OUTWARD SIGNS OF DISEASE 57 founded has been shown by the results of the "combined actuarial investi- gation" which has proven an unduly high mortality in this class of lives. Light Weight. — In connection with underweight a family history of tuber- culosis or a personal history of doubtful environment, past infection, a narrow chest, small heart and the evidence of poor circulation are extremely Demands important. The many etiologic factors, acute and chronic, naturally re- j scrutiny. ceive close scrutiny. Overweight. — So also in overweight one must distinguish between those who have big bones, firm well-developed muscles and moderate abdominal girth and the flabby, big-bellied, sedentary livers and heavy eaters, par- ticularly if these latter have a family history indicating an hereditary tend- ency to apoplexy and diseases of the heart and kidneys. Comment. — Very tall slender men, giants, professional athletes, and big- bellied heavyweights are not as a rule long-lived. Necessary dis crimination. 58 MEDICAL DIAGNOSIS Stumbling blocks. Diseases of infancy and youth. AGE— RACE— SEX— HABITS— SOCIAL STATE AND RESIDENCE AGE. — Age Estimation. — By. practice and observation we can usually estimate closely the age of patients, but hair dye and modern beauty parlors may deceive the very elect among case- takers. On the other hand, manly chivalry may be a stumbling block and, in the case of women at least, like the tactful census enumerator, we may at times be obliged to accept state- ments with a mental reservation which should find a place in the case history.* Certain ages represent a special predisposition to certain diseases, acute and chronic. In infancy and childhood we meet especially with acute digestive dis- turbances, spasmophilia, rickets, the exanthemata, affections of the lymph glands, meningitis, infantile palsies, epilepsy, chorea, croup, cretinism and congenital heart disease. Fig. i 6. — Rapid aging. An active energetic man aged forty-nine. (Compare with Figure 17, page 59.) Tuberculosis attacks the young with an especial frequency and a re- sultant higher mortality, but in those under the age of puberty it is peculiarly liable to affect the lymph glands, particularly those of the cervical triangles, the bones, or the abdomen. During adolescence, chlorosis, various forms of hysteria, epilepsy, acute rheumatism, gastric ulcer and tuberculosis are extremely common. * In certain very rare instances the appearance of youth is maintained without the use of artificial beautifiers. The author recalls one woman, thirty-five years of age, who had the face of a girl of sixteen. AGE — RACE — SEX — HABITS — SOCIAL STATE AND RESIDENCE 59 As middle age approaches, the tendency to the exanthemata and to acute infections is diminished and a predisposition to degenerative diseases of a chronic type appears. Such are arteriosclerosis, myocarditis, prostatic disease, gout, gall-stones, diabetes, the insanities, various forms of paralysis, profound blood disturbances such as leukemia and pernicious anemia, carcinoma, and chronic Bright's disease. Cardiovascular syphilis tends to become clinically prominent in middle age, even though the primary infec- tion and insidious, initial degenerative changes may date back several decades. In old age the predisposition to cardiovascular and malignant disease is intensified, and, in addition, we find chronic bronchitis and emphysema, passive pulmonary congestion, and a return to the childish tendency to broncho-pneumonia. Fig, 17. — Rapid aging. Same man six years later. In some instances diseases are wholly limited to certain age periods, but usually, in weighing diagnostic probabilities, the question is one of relative frequency only. For example, cancer of the stomach does occur in young people, but is as rare in a person under twenty, as is mumps in one over seventy. Apparent vs. Actual Age. — Two very essential points are (a) apparent as compared with actual age; and (b) unduly rapid aging. Rapid aging may bring the man of thirty to the same status as the one of seventy, and on the other hand, the latter, by reason of inherited vigor of con- stitution and right living may be physically twenty years under his actual age. Every clinician repeatedly encounters cases of marked arteriosclerosis in men under thirty and the inheritance of poor structural material, lues and dissipa- tion or mental strain are the chief factors in early aging. The degenera- tive period. Rapid aging. Extended youth. 6o MEDICAL DIAGNOSIS Woman's pre- disposition and immunity. Scope of inquiry. Specific inquiry. Age and Prognosis. — Finally, one must remember the effect of age upon prognosis. The acute exanthemata, though more readily acquired, are for the most part much more lightly borne by the child than by the adult and, on the other hand, resistance to tuberculosis is much more marked in persons above the age of thirty. Pneumonias are peculiarly fatal at the extremes of life, but "young old people" strongly resist the advance of chronic disease. SEX. — In general, men and women suffer about equally and resist in about the same measure the larger number of diseases: nevertheless, there are certain striking differences both as to incidence and severity. As compared with men, women, through the disabilities peculiar to their sex, appear to develop a superior philosophy and endurance particularly marked in chronic disease. The woman is especially liable to the multiform expressions of congenital asthenia, hysteria, myxedema, arthritis deformans, chlorosis and chronic secondary anemias, gall-stones, goiter, cancer of the breast or uterus, and gastric ulcer. On the other hand, she is relatively free from hemophilia, aneurysm and locomotor ataxia, and less liable to acute infections, gout, appen- dicitis, typhoid fever, certain diseases of the heart, progressive muscular atrophy, diabetes, carcinoma of the stomach and bowels, leukemia, per- nicious anemia and Addison's disease. With respect to aortic disease, her so-called "immunity," in the light of recent research, appears to represent a less degree of exposure to that syphilitic infection now justly held accountable for the larger proportion of such cases as first become manifest in middle age. RACE. — The special predisposition of the Hebrew to functional nervous ailments and diabetes mellitus; of the Irish to tuberculosis; of the English to gout; of the continental races to suicide, etc., etc., is well known. More- over, certain races show markedly greater resistance to disease and surgical procedure than do others. HABITS AND ENVIRONMENT.— The term "habits" should often cover a much larger Held than the patient's indulgence in tobacco, drugs, or alcoholics and include his environment and mode of life, his hours for meals and for sleep, his manner of eating and the nature of his meals, no less than the extent of his drinking. In dealing with dyspeptics, one should ask specifically what was taken for breakfast or lunch preceding the time of the examination, or just what is usually taken at such a time, how much water is drunk and when, how much time is taken for the meal, whether the food is properly masticated, and, indeed, ascertain the condition of the teeth and gums by direct inspection when examining the tongue and throat.* * As a matter of routine practice, the examination for infected tonsils, pyorrhea alveo- laris, peridental abscess, antrum disease and other foci of infection, has become a prime necessity, because of the important part played by cryptogenic infections in the causation of disease. HABITS 6l Tea, Coffee and Tobacco. — Too much stress is laid upon the mere use of tea, coffee and tobacco, and too little upon the idiosyncrasy of the patient in regard to these articles. That which constitutes excess for one may be but moderation in another, and the slight amount representing the average consumption is usually of little consequence; hence it is a positive hardship to arbitrarily shut off, rather than to sensibly cut down, the tea, coffee or tobacco which for years has been the solace of some elderly patient. As regards tobacco, especially, one may say that the signs of overindulgence are found in unrefreshing sleep, furred tongue and bad taste in the mouth, nervousness which takes the form of mental irritation and perhaps tremor, and at times a distinct disturbance of digestion and irritability or palpita- tion of the heart. In the man under middle age these symptoms mean little; in the elderly man much, and for the latter, persistence in excess is fraught with danger. Snuff Habituation. — The very extensive and steadily increasing use of "Copenhagen" snuff now is known to be attended in many instances by distinctly toxic symptoms. It is used not only by "snuffing," but also, and perhaps more generally as a "quid" held persistently in the mouth in the gingival buccal angle. " Snuff- or Copenhagen-heart" often differs in no essential respect from the irritable, labile and arrhythmic "tobacco-heart." In addition one must consider snuff as a possible cause of obscure chronic indigestion, chronic headache, psychasthenic states, and actual exertion dyspnea due to cardiac insufficiency, usually of minor grades. The Use of Alcohol. — The common mistake of the novice is a failure to bring out tactfully yet fully the facts bearing upon a patient's alcoholic indulgence. He is too easily satisfied when the patient says he is u not a drinking man," or he "takes an occasional drink," or u not enough to hurt him," " a drop now and then," "just a social glass," etc., etc. An absolute denial of overindulgence is usually proudly made by the man who has been a hard drinker for years but has stopped, it may be only a few days before examination. The "now and then" kind, or those who say "often not for a year," frequently represent the worst type of periodic spree drinkers. One should, therefore, inquire tactfully about the present and the past, the extent, the hour, the kind, in what relation to meals and with what apparent effect upon the health. It is impossible to lay down an absolute rule as to what constitutes excess and it is probable that the man who takes a little liquor, even two or three times a day well diluted and on a full stomach, may suffer little or no bad effects, but the American style of drinking is peculiarly harmful as taking the form of "cocktails" before meals and of a multiplicity engendered by the pernicious custom of "treating." A Genuine Risk. — The danger in "moderate" drinking lies doubtless much more in the risk of forming a habit than in the physical damage wrought by the Individualiza- tion necessary. Excess a relative term. Tobacco poisoning. Its dangers. Snuff -heart. Misuse of terms. Euphemisms of the bibulous. Specific inquiries. What consti- tutes excess 62 MEDICAL DIAGNOSIS Relation to disease. Bastard complexes. Hypodermic marks. intoxicant itself, but the reality and insidious nature of this risk is but too well known to every practising physician. Relation to Disease. — The three diseases most often due to such over- indulgence are: delirium tremens, alcoholic neuritis, and cirrhosis of the liver, but it is a powerful contributory factor in an enormous number of chronic diseases. It depresses vitality, diminishes resistance and thus invites and promotes their development and accelerates their progress. In severe acute diseases, such as pneumonia, the confirmed drunkard stands little show. DRUG HABIT. — Opium and Cocain. — As regards the use of drugs, we have chiefly to deal with the various forms of opium and with cocain. Neither produces in every individual a clear and definite syndrome, but nervous insta- bility and a peculiarly baffling and bastard symptom-complex are suggestive. A markedly dilated pupil in cocain users or a markedly contracted one in the victim of the opium habit may attract attention, but in either at the time of examination the pupil may be normal. If one examines such patients thoroughly, he will often find recent hypo- dermic punctures, black dots representing old ones, or evidence of recent or old multiple abscesses due to the use of dirty needles. Such are usually on the right thigh or left arm of a right-handed person, and the needle is usually introduced directly through the clothing. The peculiar pallor sometimes present has been referred to elsewhere, the skin is likely to be dry in morphin users, the appetite poor and bowels constipated and the victims of either drug are subject to fits of profound depression succeeded by periods of buoyancy. " Nose rubbing " may suggest opium, and in the case of cocain users especially, formication is not an infrequent symptom. The excessive use of cocain may be honestly denied by one who has unwittingly contracted the habit through the use of the drug in the nasal passage or throat, the patient not realizing that absorption takes place in such instances as readily as if the drug were actually taken into the stomach. The overuse of such drugs as acetanilid may become a fixed habit and lead to serious or even fatal illness. Clouded or Misty Case Histories and Physical Findings. — Baffling and indeterminate histories and findings should particularly suggest the possibility of larval syphilis, drug habit, some abnormality of the internal secretions, mineral poisoning, hysteria, or actual malingering. MARRIAGE. — The question of marriage is important chiefly in rela- tion to the matter of pregnancy or child-bearing in women and its after- effects. Many obscure ailments in the female are traceable to unrecognized or neglected lacerations, while endometritis, uterine" displacements, pelvic abscess and epithelioma are especially common in multipara. The number of pregnancies, the duration and severity of labor, miscarriages, the stage of pregnancy at which they occurred, and the circumstances attending them, the number of children living and dead, the health of survivors and the causes of death of those diseased, are important. Marks of syphilis in a child at once direct attention to the parents and Mental state. Innocent victims. Pregnancy, childbirth and miscarriages. OCCUPATION AND OCCUPATIONAL NEUROSES 63 vice versa, and tuberculosis and other diseases may be suggested in a similar manner. Bachelor vs. Benedict. — Insurance experience seems to show that the benedict is a superior risk and, on the average, outlives his bachelor fellow. OCCUPATION. — Sedentary vs. Active. — Occupation and environment are important factors in diagnosis and prognosis and may throw light upon degenerative processes, functional and organic nervous disease and accidents. City dwellers and indoor workers in sedentary occupations sutler especially from dyspepsia, tuberculosis, and similar disorders. On the other hand, even country dwellers and out-of-door workers may suffer from the poor ventilation and deficient sanitation to be noted in many farm houses, and among them the transmission of tuberculosis from one family member to others is equalled only in the city slums. Exposure. — So also must one consider the effect of unusual exposure to cold, wet, and to such poisons as malaria. The best conditions are to be found in camp life or in the homes of the better class of agriculturists, the worst in the slums, sweat shops or improperly ventilated factories of great cities. On the one hand, there is the maximum of fresh air, sunshine, and healthful exercise; on the other, foul air in the shop and home, constant use of the same muscles and in cramped positions, and, as a rule, deficient or improper food. The Fatigue Neuroses. — Certain occupations involving the continuous use of one neuro- muscular unit produce specific ailments as dp those involving pressure, or irritation of a particular portion of the body. Cases of nystagmus have been reported as due to the cramped position of miners working with eyes fixed upon a particular point. "Penman's cramp" or "scrivener's palsy" is a familiar example, and the chronic laryngitis of military men, clergymen, auctioneers and public speakers falls under the same head. Among the commonest examples of these localized impairments of co- ordination are: "telegrapher's cramp," "dancer's cramp," "piano-player's cramp," "tennis-player's cramp," and "seamstress's cramp," but the list might be extended indefinitely. Another example of occupational disease is the inflammation of the patellar bursa especially common among floor scrubbers and known as "housemaid's knee. ,} This condition is encountered also in roof shinglers, tile layers and others working under similar conditions. "Charlie Horse." — This is a peculiar occupational disease affecting professional athletes, especially base-ball players, and to some extent the amateur as well. It is characterized by a localized myositis causing induration of the muscles of the thigh and a peculiar limp. "Going to boarding school" is one of the worst of occupations if the school work is overhard, the heating and ventilation insufficient, the food poorly prepared, lacking in quantity and variety and out-of-door exercise scant. City vs. Country. Tuberculosis. Best and worst conditions. Miner's nystagmus. Housemaid's knee. Potent for good or evil. 64 MEDICAL DIAGNOSIS Barkeepers. Combined factors. Value of vacation. A neglected topic. Nothing breeds more chlorotics than a poor boarding school or makes healthier women than a good one. Habits in Relation to Occupation. — The excessive use of intoxicants is often definitely related to certain callings. The manager of a large hotel syndicate has said that he has yet to see one barkeeper who failed to develop the drinking habit, and this statement undoubtedly expresses a rule subject to few exceptions. A traveling man who sells bar supplies, cigars, or even mineral waters is constantly subjected to a pressure which too often results in the formation of the liquor habit. Occupation Involving Continuous Mental Strain. — In this day of great enterprises a not inconsiderable proportion of the chronic ailments en- countered by the physician may be traced in part to continuous mental over- strain, usually combined with lack of exercise, improper diet and too often with overindulgence in liquor or tobacco. No one who has seen the remarkable improvement in chronic disorders of the heart, stomach, kidneys, or various diseases of the nervous system that follows a period of complete rest and freedom from worry can doubt the potency of mental overstrain as a factor in the etiology and prognosis of disease. Railroad men, financiers, and especially board of trade operators suffer greatly from this cause. The Physician. — The life of a practising physician is of such a nature as to readily explain the high early mortality encountered in this class, for in the physician's calling are combined constant exposure to infections, defi- cient and interrupted sleep, lack of exercise and recreation, excessive and con- tinuous mental strain, and an exhausting demand upon his kindly emotions. MINERAL POISONING.— A complete volume would be required to do justice to this aspect of our topic, and there can be no doubt that too little attention is paid to the possibility of occupational poisoning by physicians other than those practising in large manufacturing centers, where the condi- tions are exceptionally favorable to the development of occupational disease. Arsenic. — Aside from poisoning due to the inhalation of fumes or dust during the processes of milling, grinding and smelting, one encounters cases among workers in anilin dyes, toy or artificial flower ' makers, dyers of woolen or cotton goods, playing-card makers, taxidermists, lithographers and shot makers. Anilin. — This derives its harmful effect from three sources, viz. : itself, the arsenic often combined with it,, and the nitro-benzol used in its manufacture. Bromin and Iodin. — The fumes of this substance cause bronchitis and predispose to tuberculosis. Carbon Bisulphid. — This highly poisonous substance is used as a solvent for sulphur, iodin and oils, and is largely used in the manufacture of rubber goods. Chlorin. — In the bleaching of linen, cotton, bones, ivory and rags the fumes are irritating to the bronchial mucous membranes and predispose to tuberculosis. OCCUPATIONAL POISONING AND STIGMATA 65 Chromium. — This enters into chrome yellow and chrome green, and is used in staining glass or porcelain, printing bank notes, and dyeing linen, wool and silk, and, as potassium bichromate, is used in photography. Copper. — Workers in brass, nickel platers, bronzers, copper-sheet scrap- pers, pin makers, bell-metal workers, stone workers, engine wipers, and others handling, copper, bronze, brass or nickel may suffer from chronic poisoning. It should be remembered that brass is composed of copper and zinc, with or without tin and lead; bronze, of all four metals, and that nickel plating is sometimes done with an alloy composed of copper, nickel, iron and tin. It is further combined oftentimes with lead and arsenic. One of the most severe cases of lead poisoning ever encountered by the author was caused by polishing an alloy of this kind. Lead. — The possibility of lead poisoning in obscure gastrointestinal affections as in connection with its well-known nervous manifestations should never be forgotten. Not only is it found in lead smelters, refiners, sheet- lead rollers, lead-pipe makers, shot makers, typesetters, plumbers, toy makers, and painters, but also in lacquer polishers, gilders, bronzers, enamel workers, glaziers, pot, pan, card, cardboard or brick makers, makers of brass instruments, file cutters, flint glass workers, workers in white or red lead and litharge, calico printers and those engaged in the manufacture of lace, artificial flowers and wall papers. Mercury. — Chronic mercurial poisoning may result from idiosyncrasy, long-continued overdosage, or employment in smelters, quicksilver mines and felting rooms. Phosphorus. — This is now comparatively rare, and is almost wholly limited to those engaged in the manufacture of the parlor match. Turpentine. — Some persons are peculiarly subject to turpentine poison- ing, and painters working in poorly ventilated rooms may become chron- ically affected. Occupations Involving Excessive Heat. — Extreme dry heat can be borne without serious results in persons habituated; nevertheless, firemen on ocean steamers or naval vessels, and bakers suffer from heat, moisture, foul air, and the effects of chill and exposure due to extreme temperature variations. Miscellaneous Diseases of Occupation. — Millers, potters, file cutters, grinders of edged tools, wool and cotton spinners, marble and stone cutters are peculiarly susceptible to tuberculosis, particularly in its fibroid form. Handlers of rags and skins occasionally acquire anthrax, internal or external. Female domestics are peculiarly liable to anemia, gastric ulcer and tuber- culosis. Butchers or slaughterhouse men suffer from septic infections, stablemen from tetanus and glanders, brewers, saloonkeepers, bartenders and others of the same class show an enormous mortality from alcoholism, tuber- culosis, diseases of the nervous system, pneumonia, diseases of the liver and kidneys, and suicide. OCCUPATIONAL STIGMATA.— Those who follow certain occupations often present somewhat characteristic deformities: the lowered shoulder of Alloys. Moist vs. dry heat. Tuberculosis. Anthrax. Sepsis, tetanus, glanders. The lowered I shoulder. 66 MEDICAL DIAGNOSIS the desk worker, pack peddler and tailor are familiar to everyone. Few railroad trainmen escape the loss of one or more fingers. Furthermore, even the study of the callosities associated with certain callings prove helpful occasionally in identification, and a few of the occupations thus suggested are given briefly below. Callosities are shown at the points indicated: Banjo, Guitar, and Harp Players. — Finger-tips both hands. Zither Player. — Finger-tips of left hand, under surface and tips of index, middle and ring finger of right. Violoncello or Violin Players. — Tips of fingers, left hand only. Hand Compositors. — Palmar surface of thumb and index finger, right hand. Fencing Masters. — Ulnar border, right palm. Hand-organ Man (carrying own organ). — Outer side of right hip and thigh. Seamstresses. — Roughened radial border of terminal phalanges of left thumb and index. Tailors. — Ring-shaped callus on right thumb and index finger, left thumb and index roughened, enlarged bursae over external malleoli. Turners. — Outer border of right little finger. Clerk, Using Pen or Pencil. — Outer surface of terminal joint, right little The rough callous hand of the day laborer contrasts sharply with the soft hand of the sedentary worker, as does that of the seamstress or domestic with those representing the lighter occupations of her sex. The tan of the sailor contrasts sharply with that of the soldier, the one wearing his shirt open at the front, the other a high collar and close-buttoned coat. Idleness a Disease Breeder. — Want of occupation, mental and physical, is often deleterious and the psychasthenic hysteria, morbid irritability and ennui so commonly seen in spoiled, pampered, pleasure-loving, and responsibil- ity-free women, are seen rarely in the hard-working housewife. The man who for years has given his attention to active business or pro- fessional work may find complete idleness both boresome and dangerous, and few men or women, can be well mentally or physically without some definite occupation, however trivial. Every man who in later years forsakes his life's work should cultivate a hobby. RESIDENCE. — The novice frequently fails to secure the full name and Postal address, postal address of a public service patient under examination, forgetting that future communication is sometimes most important, in that some of the most valuable information results from following unusual cases. With respect to the medical history proper, both present and past residence should be known, and in general, information upon this subject is of value in relation to the following points: (a) The possible introduction of epidemic disease by persons coming from an infected area. Sailor and soldier. The domestic parasite. Value of a "hobby." RESIDENCE AND FAMILY HISTORY 6 7 (b) In tracing its distribution, as in an epidemic of cholera or typhoid affecting certain portions of a city or larger district. (c) In tracing its individual sources as illustrated by the detection of care- less dairymen, who spread infection along their route; and finally, (d) The special liability to certain diseases in definite districts or countries, as illustrated by diseases of the tropics, such as malarial fever, dengue, yellow fever, and plague, the hydatid disease of the Icelander, or the leprosy of the Sandwich Islander. The Home. — Specific inquiry concerning the exact situation of the patient's house, its elevation, exposure, the character of the surrounding soil, and the location of the sleeping chamber, is sometimes important. FAMILY HISTORY. — The transmission of special structural vulner- ability and predisposition is just as marked and as well-proven as is inherited likeness in form or feature. In taking a family history, one should secure full information as to the terminal illness of family members, often going back two generations and including collateral branches if significant facts develop. It is often of the utmost importance that the state of health or cause of death of the husband, wife and the children of the patient be established. It is seldom sufficient to ask whether any members of the family, immediate or remote, have suffered from hereditary disease, or even to put the question in the somewhat more specific form of an inquiry concerning tuberculosis or cancer. j Apoplexy, heart disease or Bright's disease may be readily admitted, but I insanity, epilepsy, tuberculosis and malignant disease are often concealed, either intentionally or quite as often, innocently. Deliberate concealment or actual lying are far from infrequent in ordinary case histories and are especially so in life insurance applications. The questions must bring out if necessary, the leading symptoms of the illnesses of deceased family members. One may ask if there was chronic cough, spitting of blood, emaciation, night sweats, or fever, the vomiting of blood, or the presence of a tumor, associated with emaciation and failing strength, in the given case. Certain Euphemisms of Case-taking. — Deaths from "childbirth," "ex- haustion," "grief," "broken heart," "general decline," etc., must never be accepted without careful and tactful cross-examination. "Senility" and "old age" are much abused terms and in the lay mind cover death at any age above fifty. No man ever passed his novitiate as a casetaker without saying hard things of "malaria," "chills," "fever," "decline," and especially "marasmus" and "don't know," and no student can give better evidence of his skill and tact than is furnished by an adequate, unambiguous family history. Alternatives in Heredity. — Few diseases are directly transmitted as such, hereditary influence usually taking the form of more or less marked predisposition. Thus the disease of the descendant may be but the congener of that of the forebear and is then termed an alternative, or the inheritance may be that of marked vulnerability or its opposite, relative invulnerability. Tracing epidemics. Climate an etiologic factor. Inherited predisposition. Extension of inquiry. Specific inquiry. Concealment common. Direct trans- mission raie. 68 MEDICAL DIAGNOSIS Resistance and non-resist- ance. Congenital asthenia. Alternatives. Specific inheritance. Cardiovascular alternatives. Age and sex incidence. Short- vs. Long-lived Families. — To the former class belongs the family whose members show a low average lifetime, the ready acquisition of, and feeble resistance to, acute or chronic ailments. To the latter class apper- tains a vigor of constitution and strength and harmony of structure which ensures resistance to disease and long life. Congenital weakness of structure, imperfect or unstable function, and a peculiar nutritional instability, characterize large groups of people in all civilized countries, and the condition has been well named by Berthold Stiller "Asthenia Universalis Congenita.'''' This is now widely accepted by European clinicians as the condition underlying many bastard syndromes which, in the past, have been considered and treated as clinical entities. Nearly all cases of so-called "nervous dyspepsia" ("gastric neuroses") fall under this head and an understanding of this fact supplies the means of their successful treatment.* The Nervous System in Heredity. — A strong alternative relationship exists between alcoholism, insanity, epilepsy, hysteria, and criminal impulse. In some families, however, there is little variation, insane grandchildren follow insane grandparents and epilepsy in the father means the same disease in the child. Some remarkable cases of hereditary alcoholism have come under the author's observation. In one, especially, it seems impossible for any male family member, or even collateral branches, to escape the curse. Apoplexy. — The hereditary tendency to cerebral hemorrhage is one of the most striking facts in medicine but is of course inseparable from its etiologic causes and apparent alternatives, arteriosclerosis, chronic Bright' 's disease, aneurysm and the degenerative diseases of the heart, f Cancer. — Few physicians of experience will be found who deny an hereditary predisposition to cancer, yet it is well to minimize it and to avoid too radical statements in regard to.it, as tending to create undue appre- hension in the minds of members of tainted families. Like apoplexy, the tendency in this disease is toward death in middle age, the tendency to transmission seeming to be more marked from mother to daughter than from father to son. J Diabetes. — Few diseases are more distinctly hereditary than diabetes, if we regard it as one of the alternatives of inheritance in nervous and mental diseases. According to recent observers it is possible to separate from other types a distinctly hereditary form which is characterized by an equality in predisposition as between male and female, or even the predominance in the * The author has been especially interested in these dyspepsias and in the narrow, atonic, dilatable, symptom-producing heart which is associated with this condition, and deals with both, in their appropriate sections. f The author has reported a case in which, of nine family members, five died of apoplexy, two of chronic Bright's disease, and one of heart disease, every death occurring between the ages of forty and fifty-five. The then surviving brother has since died of the dominant disease. In each case, doubtless, chronic interstitial nephritis, and associated arterioscler- osis, myocardial degeneration, and arterial hypertension coexisted. J Undoubtedly the hereditary element has been exaggerated in the past, but quite as certainly the present tendency on the part of some writers to deny it represents an over- reaction. HEREDITY 6 9 female. The best examples of inherited disease are found in the race showing the greatest vulnerability, namely, the Hebrew.* Gout. — This distinctly hereditary ailment is potent in the production of arteriosclerosis, apoplexy, Bright's disease, gastrointestinal ailments and certain forms of diabetes as well as all forms of gout. Hemophilia. — This extraordinary disease is atavistic in its transmission, the deadly tendency to excessive bleeding, spontaneous or induced, being transmitted through the females of a family to certain of their male issue. In certain families it has been traced back for hundreds of years in an unbroken sequence. Syphilis. — In relation to family history direct inquiry is usually im- possible and the physician must ordinarily depend upon the disclosures of parents or the recognition of inherited syphilis in the patient. TUBERCULOSIS.— Direct Transmission vs. Environment.— That, in excessively rare instances, tuberculosis may be transmitted from mother to child in utero cannot be doubted, and it is certain that the incidence of tuber- culosis is greater in those of tainted family record. Inheritance is due chiefly to a congenitally asthenic structure and a con- stitutional Junctional inadequacy, which render the tissues of the child of tuber- culous parents more vulnerable and less resistant to the tubercle bacillus than is the case in one of sound, vigorous and untainted stock. Even predisposed children, if favored in climate, nutrition, and environment, need seldom or never develop the disease under conditions eliminating the pos- sibility of contact with the living germ, the exception being found in a latent prenatal glandular or bone infection. Unfortunately, however, these child victims of predisposition born in tuberculous households are in every way exposed, during the earlier years of life, through their creeping over dirty floors, their tendency to carry dirty hands and infected articles to the mouth, and especially through the em- braces and caresses of the infected parent, brother, or sister. The peculiar shape of the chest associated with tuberculosis and found most frequently in those of tainted stock is merely one of those many struc- tural peculiarities and deficiencies of chronic congenital asthenia which become factors in infection and favor the progress of the disease. Naso -pharyngeal Obstruction. — Of great importance are the obstruc- tions in the naso-pharyngeal passages, especially adenoid growths and hypertrophied tonsils. These, in themselves favorable soil for the tubercle bacillus and other microorganisms, embarrass respiration, hamper the development of the lungs and permit collapse of the lower chest, while further contributing to infection through frequent recurring colds and chronic catarrh. Life Insurance. — One has only to consult insurance manuals to under- stand the importance of physique and family taint as factors in tuberculosis, yet, admitting certain exceptions, it is generally true that, the attainment of * M. Loeb: The Hereditary Form of Diabetes. Zentralblatt fiir innere Medizin, Aug 12, 1905, No. 32, p. 786. Race and heredity. Potent and protean. Atavism Direct trans- mission rare. Inherited physical deficiencies. Importance of environment. Direct exposure. Thoracic conformation. Invites infec- tion and lowers vitality. 7o MEDICAL DIAGNOSIS Physique vs. Heredity. Degree of relationship. Vitally impor- tant data. "White plague" households. Ground ailments. Use plain language. full manhood, an exceptional physique, and freedom from direct exposure, largely overbalance a bad family history. The victims of congenital universal asthenia possess every characteristic of tuberculous predisposition and an astonishingly large proportion of them show positive tuberculin reactions or skiagraphic signs suggesting or proving past infection of the lungs even though at the time free from active symptoms. It must be remembered that the greater number of men and women have at some time become infected and will yield signs under tuberculin tests or the X-ray, even though they may never afterward show any evidence of an active lesion. Special Conditions Affecting Heredity in Tuberculosis. — With respect to the individual of tainted stock, the significance of tuberculosis in the parents is apparently but slightly greater than that in brothers or sisters, but probably this is because arrested tuberculosis in the mother or father is seldom to be traced in case-taking, such past events being usually either forgotten or concealed. Anyone who has practised in a region frequented by cured con- sumptives will appreciate the truth of this statement. Physical Resemblance. — Mere facial resemblance is of little impor- tance, but general structural likeness is of decided import. Direct Exposure to Infection. — The health of living family members and especially of the children of parents under examination, or vice versa, as well as the condition of parents affected by, or dying of, tuberculosis at or near the time of the birth of any individual under examination are vitally important factors. The member of a family or household in which active tuberculosis exists, and the individual who associates with infected persons outside the family, is exposed to great risks from infection if proper precautions are not faithfully and intelligently observed. PREVIOUS ILLNESSES.— Cardinal Importance.—^ knowledge of the general state of health and past illnesses of a patient may assist the diagnosis, either by excluding some immunity-conferring disease, or by fitting a symptom group to the known after-effects of some previous illness. The exanthemata and yellow fever illustrate the one, syphilis both. A patient reporting "stomach trouble" may present a clear history of previous gastric ulcer, appendicitis, gall-stone colic, or the morning vomiting of advanced interstitial hepatitis. Another may have repeated attacks of acute rheumatism or gout and our attention is thus specially directed to the heart, blood vessels and kidneys which may reveal changes wholly adequate to explain his symptoms. A history of severe nocturnal headache may be explained by an ancient syphilis, an intractable periodic neuralgia, by past malaria, or of tener by a history of accessory nasal sinus infection. In such interrogation the simplest and most homely phraseology should be used in dealing with the ignorant, and leading questions cannot wholly be avoided* * An ignorant patient of the author dying of perforating but previously unrecognized duodenal ulcer readily admitted having formerly "puked" blood and suffered much "mis- ery in his guts," though on repeated questioning he had denied "pain," "nausea" and "vomiting." FEVER THERMOMETRY 71 HISTORY AND ANALYSIS OF THE "PRESENT AILMENT" Interrogating the Witness. — The patient should be led to tell, almost 0} his volition, but in as few words as possible, the symptoms of his disease and their duration. Any attempt to theorize or drag in immaterial facts should be tactfully checked. To guide and direct the disclosures, check garrulity, verbosity and triviality, to systematize the disclosures and yet use few leading questions, constitutes an art both valuable and rare. General vs. Specific Symptoms. — One should discriminate between symp- toms that are general in their nature, common to a large number of diseases and subject to various interpretations and those that are local, peculiar or specific. Some of the principal general symptoms will be described in this connection and only their special features referred to in other sections or under the symp- tomatology of specific ailments. FEVER. — Thermometry. — Fever as a clinical manifestation is merely an elevation of the body temperature, formerly determined roughly by the hand, but nowadays accurately registered by the clinical thermometer. In such diseases as pneumonia and typhoid the skin is dry and hot, yet on the other hand, a high rectal temperature may exist in cholera even when the surface temperature is as low as 70 . The thermometer is ordinarily applied to one of four points, those being in the order of frequency, the mouth, the rectum, the axilla, and vagina. Rectal readings will exceed mouth temperatures by about one degree Fahren- heit and constitute the only accurate registration in the aged and in cases of pro- found weakness. There is no poorer investment than a cheap thermometer and the test scales supplied with some of those of the lower grades are worthless by reason of improper calibration and imperfect seasoning of the instrument and mis- representation on the part of irresponsible manufacturers. Precautions to be Observed. — In the use of a thermometer , certain precau- tions must be observed: (a) It should be cleaned before and after use. (b) The scale should invari- ably be inspected, as the thermometers are self-registering and require to be shaken down after use. (c) If used in the mouth, it should be placed well under the tongue and held by the tightly closed lips (not teeth) of the patient. If for any reason the lips cannot be closed, if the patient be unconscious or delirious or if an acute stomatitis or tonsillitis be present, the temperature should be taken per rectum. (d) Axillary temperatures should be avoided whenever possible, as being subject to maximum error variation. If so taken, the thermometer should be placed deeply in the previously dried axilla and the corresponding elbow should be kept close to the body and carried well forward. Axillary readings are particularly misleading in incipient or but slightly febrile tuberculosis and their use is seldom necessary or justified. Tactful guidance. Checking garrulity. Misleading surface temperatures. Selective points. Worthless thermometers. 72 MEDICAL DIAGNOSIS Temperature Range in the Human Body. — Subfebrile temperatures are classification, those running from 99 to ioi.5°F.; moderate fever, 101.5 to io3°F.; high fever, 103 to io5°F.; hyperpyrexia 105 plus. •Note. — To convert Fahrenheit readings into centigrade subtract 32, multiply the remainder by 5 and divide the product by 9. To convert centigrade readings into Fahren- heit, multiply by q, divide by 5 and add 32. There is a normal daily variation reflected in nearly all fevers, the range Diurnal range, being about I C to i. 5 °F. The lowest reading occurs in the early hours f ollow- „A dubious normal." Obscure infections. ing midnight, the highest between four and six oclock in the afternoon. Faulty Figures. — Granting that 99°F. to 99. 5 or even 99. 8° may represent a normal variation in infants, the author believes that the body temperature range in adults, as ordinarily given by the physiologist, is too high and is based upon collective observations which included persons having unrecog- nized chronic infections or an incipient disease, such as pulmonary tuberculosis. Years of observation in private and public practice have convinced him that in adults under ordinary conditions, a persistent maximum mouth temperature exceeding or even reaching gg°F. is strongly suggestive of existent incipient tuber- culosis, chronic infections of the tonsils, accessory nasal sinuses, prostate, gall- bladder, the appendix, the ovaries and tubes in women, peridental abscesses, or the insidious onset of some acute ailment. * Tropical Diseases and Endocarditis. — In the case of persons returning from, or resident in, the tropics, the possibility of amebic dysentery and malaria should receive special investigation if any fever be noted. Endo- carditis of the chronic recurrent type gives rise to many errors. Heat and Exercise. — It should be remembered that violent exercise and excessive heat slightly and temporarily raise body temperature and that in Age and youth, infants and very old persons it may range half a degree or more higher than in those of intermediate age. The temperature of children is extremely labile and may reach a high degree without serious significance, often subsiding as suddenly as it came. Febricula (Ephemeral Fever). — Fevers of short duration and unknown causation affect adults, but with the advances made in diagnosis, have become relatively rare, and "febricula" means little more than an obscure, trivial and transitory fever, and is unworthy of further description. For variable periods in certain cases of tuberculosis, acute or chronic, the morning temperature represents the daily maximum. PATHOLOGIC VARIATIONS IN TEMPERATURE.— Malingerers.— Hyperpyrexia of extraordinary degree has been reported, but has probably been due to deception on the part of the patient, it being a common trick of the malingerer or hysterical patient to heat the thermometer bulb by friction, by taking hot drinks just before the tube is applied or by cleverly utilizing a hot water bag. The highest genuine temperature observed by the author was no°F. * A recent investigation of nurses' temperature undertaken by the author in a local hospital has further strengthened this opinion. A nonentity. Inverse temperature. Clever artifices FEVER 73 under the tongue, and occurred in a woman of hysterical temperament suffer- ing from the extreme pressure pain of a spinal caries.* Fever in Hysteria. — Elevation of temperature may occur in hysteria alone, a fact never to be forgotten. The highest personally observed (io4°F.) was obtained during an hysterical paroxysm following great emotional shock, and the attack and the fever subsided almost instantly under sharp ovarian i pressure. In this particular instance the physical exertion represented by the violent convulsive movements might account for the high temperature in part, at least. Some authorities claim that temperature may persist for weeks in hysteria and even simulate typhoid, but until we know more of the real nature of hysteria i and find fewer examples of its confusion with organic ailments, it might be safer to assume that genuine, long-continued fever excludes it. Interaction of Infection and Resistance. — The significance of high read- ings is variable and depends upon the nature and virulence of the toxin, the age and nervous condition of the patient, and also upon the degree of his vital resistance. Certain hyperpyrexias seem to indicate little more than an intense infec- tion associated with vigorous constitutional resisting power, such cases being seen in connection with lobar pneumonia, in which a temperature of io5°F. is neither uncommon nor necessarily of fatal import. On the other hand, one finds instances of virulent and fatal infection with but slight febrile reaction. Extremely high readings, if long sustained, indicate a most serious prognosis, and a sudden rise ("agonal fever") sometimes precedes death. Subnormal temperatures may be observed in those suffering from Subnormal „ ,.,.,. ,. . . temperatures. collapse, extreme exhaustion, chronic exhausting or wasting diseases, insanity (especially melancholia), chronic incompensated heart disease, adrenal insufficiency and myxedema. Oftentimes the surface temperature is subnormal and the rectal reading high, notably in cholera and certain cases of tuberculosis. Febrile Types. — Fortunately for the clinician, the fever in many of the acute diseases pursues a more or less characteristic course or bears a peculiar relation to the appearance of other symptoms of the disease. Fevers may be placed under four general heads: (i) Intermittent. (2) Remittent. (3) Continuous. (4) Indeterminate or irregular. An intermittent fever, however far it may rise, drops to or below normal during some part of the twenty-four hours. A remittent fever shows marked remissions during the twenty-four hours ; while in continuous fever the remis- sions are slight. These are but the types and one must understand that a continuous fever may at some stage show remissions, or a remittent fever encroach upon the intermittent; indeed, the temperature charts covering long periods may in such diseases as tuberculosis show every type of fever and yet be predominantly intermittent. The intermittent fever of this disease is often given the name hectic. * The record case reported by Teale was one of spinal injury and the temperature recorded was i2 2°F. 74 MEDICAL DIAGNOSIS Rough standards. Fastigium and defervescence. Differential value. A deceptive type. Ptomains and metabolic poisons. Cerebral. Starvation. fever. Roughly speaking, one may say that when the maximum daily variation in a moderately severe fever is less than 2 it is continuous. When more than 2 and yet with an average minimum distinctly above the normal, it is remittent, and any fever showing a tendency to periodically fall below normal is intermittent. The maximum stage of fever is known as its fastigium, the term being applied especially to the fevers of the continued or remittent type and to the stage of the disease as well as to the fever itself. Its opposite is called the period of defervescence or decline. Diagnostic Import of Fever. — Putting aside the rare cases of hysterical temperature and excluding deception and faulty technic, one may say that fever is primarily of diagnostic value in proving the existence of some organic ailment or definite toxemia, as opposed to a functional disorder, a matter of no little importance in dealing with neuropaths and malingerers. Afebrile Cases. — The absence of fever, however, does not rule out any one of these conditions, for there is no disease ordinarily febrile that may not, though in rare instances, exist without fever or even with subnormal temperature. This fact is best exemplified in the case of typhoid, occasional pneumonias, especially those of old age, and certain cases of general peritonitis. Chief Causes of Fevers. — By far the greater number of fevers are due to the action of pathogenic germs and their toxins, whether these be developed within, or, more rarely, without the body, as in the case of ptomains. Some nevertheless are due apparently to other toxic substances, even such as are generated by the vital processes of the living body itself. Such are the curious auto-intoxications associated with deficient or faulty metabolism as illus- trated by acute gout.* The terminal stages of diseases of nutrition, malignant disease, and certain of the severer types of anemias are associated with fever and doubtless in many such instances obscure infections play an important part. Fever of central origin may be encountered in cerebral embolism, thrombosis, apoplexy, brain tumor, and direct injury, or even \he changes incident to heat- exhaustion and sunstroke. Inanition is sometimes associated with fever, usually of mild grade, which ' ordinarily occurs after severe exhausting ailments associated with much wasting of tissue and loss of strength, f * This statement may require modification in the near future if \ the increase in our knowl- edge of basic sub-infections continues. The author confesses his inability to believe that the clinical phenomena of acute gout are adequately explained by any existing knowledge of its metabolic disturbances. t The so-called "hunger" temperature may be most misleading in convalescent typhoids who have been too long starved. It is seldom observed under modern methods of feeding. DAY OF DISEASE 1 2 3 4 £ 6 HOUR A ? A P A. m £££ PAP 107 106 105 2 104 s ■3 103 3 102 -4h- t3 < 101° s 10 ° — Vf- 98' 97 96 Fig. 18. — Clinical chart of tertian ma- laria. Typical and extreme example of the "intermittent" type of fever. (From Wilcox's "Fever Nursing") PHENOMENA OF FEVER 75 Occurring under such conditions, it is more likely to be due to a smouldering infection but it cannot be denied that cases of exhaustion temperature do occur and subside promptly when proper nutrition is attained. THE PHENOMENA OF FEVER.— Owe must first determine whether the fever came on suddenly or gradually, whether it was associated with chill or, in the child, convulsions, for liow long it has endured, whether it is to be classified Consider as distinctly intermittent, remittent or continuous, and, furthermore, whether anTckSe! it is associated with any history of infection or with the appearance of an exanthem. If the latter be the case its exact time of appearance and its rela- tion to any rise or fall in the temperature must be noted. Condition of the Skin.— Heat and Moisture. — In most fevers the skin is dry and palpably hot, but occasional cases depart from this rule and certain diseases such as acute rheumatism and cholera almost consistently violate it. Digestive Organs. — Nausea, vomiting or diarrhea (initial, persistent or terminal), consti- pation, loss of appetite and a coated tongue are present in varying degrees in all severe acute febrile ailments. The Nervous System.— Headache, and pain in the limbs are present in nearly all cases of fever, though often only at its onset. Mental Condition. — The mind may be clear or clouded and delirium may be present at the onset only or for long periods, continuously, or only at night. Delirium. — This may take the form of transitory illusions or hallucinations, may be violent and maniacal, mild, or of the low mutter- ing, mumbling type of the typhoid state, the patient perhaps lying with open but unseeing eyes (coma vigil). Persistent delirium of the violent or low muttering type is of unfavorable prognostic significance and the exhausting effect of the former constitutes a serious peril and demands prompt therapeutic measures. Children show an especial tendency to delirium even in fever of moderate Readily intensity, whereas, it is rare in adults save in the most severe types of infection, children? in the intoxications or in central disturbances. Acute Febrile Delirium {BelVs Mania). — This consists essentially of a violent, continuous, exhausting and maniacal delirium, associated with high fever and a typhoid state. It is a rare condition, peculiar to women and of unknown causation, is Probably initiated by shock or other emotional strain, and may be associated with the sepsis? 6 " OAY OF DISEASE 1 . 8 4 5 b a 9 HOUR A P A V V V PAP V> V A P A PAP A P A P 107 106 ■5 105 | 10M — \ — Tl~ ! *"* 103 ^h- *- /- w — 2 102* -| — i Hr 3 ? 101 | s H 100 99 . 1 V^ 96 97 96 150 140 130 a m 5 no \ D 100 k * "90 ^ >, 80 / -^ NT7 \~ -v 60 7p 50 40 L Fig. 19. — Clinical chart of a yellow fever patient, showing a pulse typically slow in com- parison to the height of tem- perature. (From Wilcox's "Fever Nursing") Its many varieties. 7 6 MEDICAL DIAGNOSIS Pulse-respira- tion-tempera- ture ratio. Watch the heart. Myocardial "weakness. 1 Pulse, strength and weakness. convalescent state. No specific pathologic findings are present after death and the disease may readily be confounded with the acute maniacal delirium occasionally present at the onset of pneumonia, typhoid and uremia. It may be rapidly fatal, running its course in from one to three weeks. The differential diagnosis is one of exclusion and the author's experience would indicate that the condition is usually one of acute cryptogenetic sepsis.* The Pulse and Respiration in Fevers.— Both pulse and respiration bear a definite relation to the temperature curve. The increase in pulse rate is ordinarily from 8-10 beats per minute for each degree of fever, but a departure from this rule is commonly noted in typhoid fever, yellow fever and lobar pneumonia, and favorably affects prognosis in these diseases. Heart -muscle Impairment. — The heart muscle suffers to a variable degree in all severe infections and intoxications and must be carefully watched for signs of weakness, degeneration or valvular inflam- mation, this being especially true, as re- gards the valves, heart muscle and pericar- dium alike, in attacks of acute or subacute rheumatism, scarlet fever, severe true influ- enza, and diphtheria. In any infection, the examinations of the heart should relate, not alone to mur- murs, but to variations from the normal in the heart sounds, extension of the cardiac borders and important variations in the cardiac rhythm. The author believes that much of the weakness associated with acute infections is due to myocardial toxemia and that in no other way can one explain the rapidly induced and unduly persistent exhaustion evident upon exertion in various acute infections even though actual power on the part of the skeletal muscle groups is relatively well retained. "Sthenic" vs. "Asthenic" Fevers. — The pulse of high fever- of the so- called sthenic type is not only rapid but full and bounding. In asthenic fevers (those attended by profound exhaustion) it becomes soft, weak, and in the typhoid state, dicrotic. * In three instances the author has encountered precisely this disease picture with recovery, as a late and apparently isolated sequel of child-bearing. Blood cultures were negative but each attack showed a sharp leucocytosis at the onset. It is at present described by some authorities as an "exhaustion psychosis" but the element of infection cannot well be disregarded. It may present many variants and need scarcely be considered as a clinical entity. DAY OF DISEASE 1 2 3 4 5 6 ; 6 9 10 11 12 13 HOUR A F A P ^ ? A P A P fflS A P A P A P MM A 'P A P A P M M A P M M 107 106 , 105 : e — 1 % 104 .a 2 103 ~*~K w 102 W — P, 101 2 c ?iuo rV 3 H 99' 98 97 L*» Fig. 20. — Clinical chart of measles, showing "fastigium" developed with eruption, primary rise, secondary fall, and defervescence following appear- ance of exanthem. (From Wilcox's "Fever Nursing") FEVER — TYPES — ONSET — TERMINATION 77 OAT OF OISEASE 1 . •3 1 5 6 • 8 9 10 HOUR A P A ? V V m|m V V A p A PAP M f.' M P M 107 ,. •§ 105 ~T 1 104 "" T r d^(w 3 a — a S 101 100 .88 . — __ OAY OF -i DISEASE ! 4 5 6 ; 8 'j 10 HOUR * PAPA P A,P A f A r> A P A P h|h A P 107- "=ft^ =P % a 104 - ^ v-* 2108 - S ^= = -~Y — • a 14 §M8 _ ^ = = i 101 B 4rrt £ r"*i : , \ §1Q0 _ 89 - gU V^- M 97 - 1 96 - - — - Fig. 2i. — Clinical chart of acute lobar pneumonia. This typical case has termi- nated by crisis on the seventh day of the disease. (From Wilcox's "Fever Nursing.") Fig. 22. — Clinical chart of scarlet fever. (From Wilcox's "Fever Nursing.") Measles. — In measles the temperature recedes twenty-four hours or there- abouts after the onset, rising with the coming of the rash on the fourth or fifth day. German Measles (Rotheln). — In rotheln the eruption appears on the first day or more rarely the second, and is usually the first thing noted. The fever rising much the same, but usually less than in measles. Scarlet Fever. — In scarlet fever the rapidly spreading rash appears on the first or at the beginning of the second day, following an abrupt onset with high fever. Varicella {Chicken-pox). — In varicella the rash appears within twenty- four to thirty-six hours, associated with trifling fever. Variola (Smallpox). — In variola the violent onset, usually with chill and high fever, is followed by a marked remission, usually at the end of the third day, during which the rash appears in its papillary stage. During its sub- sequent changes the temperature rises, reaches its maximum with the purulent transformation of the vesicles and then gradually subsides. The diagnostic toneal" pulse. Temporary extrasystolic irregularity or even partial and temporary Hypertension, heart-block may occur and in acute and chronic affections of the kidney the pulse may be of high tension. Such a pulse should always direct attention to the kidneys and calls for examination of the urine if this duty has been j wiry "peri- neglected. In inflammation of the peritoneum it is small, hard and wiry. Helpful Types. — The accompanying charts show the peculiarities of fever in certain diseases, but the student must not demand in his practical work that infections shall conform invariably to the text-book description. It is most important that the ride be known, but the common exceptions also must be recognized. Rash on 4th or 5th day. Rash on 1st or 2nd day. Rash on 1st or 2nd day. Rash after 24-36 hours. True eruption on 4th day. 78 MEDICAL DIAGNOSIS Adults vs. Children. Overwhelming infections. Insidious onset. Lysis vs. Crisis. value of these differences in the relation of body temperature to the eruption is readily appreciated. The Mode of Onset and Termination. — In adults, the more severe acute Fig. 23. — Typhoid fever chart, showing temperature typical, and unmodified by treat- ment. A rare combination at the present time. Serves to illustrate the so-called "step- ladder" temperature of the first week, "continuous" and "remittent" fever curves, and termination by "lysis." (From Wilcox's "Fever Nursing") fc infections are usually preceded by a decided " chilliness" or actual chill, with or without gastric disturbance* and, in children, by either chill or convulsions and frequently, by nausea and vomiting. In the malignant forms of typhus fever, smallpox, bubonic plague, yellow fever, malaria, and even of scarlatina, certain cases may die before the disease has reached its frank development, f In several febrile diseases, the onset is insidious and without marked initial phenomena, and in senile cases this may be true of ailments ordinarily frank. Abrupt Cessation vs. Gradual Recession. — The termination of fever is in most cases a gradual recession (lysis), but certain ail- ments of which classical lobar pneumonia is the type terminate suddenly (crisis). The critical phenomena vary somewhat, but usually the temper- ature falls to or below normal within DAV OF DISEASE 1 2 3 4 5 6 7 8 9] 1 12 13 1 4 15 16 HOUR A P M M » \ P A it M M P> A p A P A P A P A P A P A P A|P A|P A P A P A P M W M M M 107 106 -§M ^~— -a| L - - g QD ~ - Em — £&--- 105 — SJ So- ^ 104 kT \ 3. 1 = 1: .LI. am 3 J02_ ^ ioi c S 100 99 96 Z 3==== Fig. 24. — Clinical chart of smallpox, showing high initial temperature, rapid tem- porary defervescence following appearance of eruption, and the abrupt secondary rise just preceding pustulation. (From Wilcox's "Fever Nursing") * A severe rigor is certainly less generally observed even in pneumonia than the student is usually led to believe. f In an epidemic of malignant scarlet fever observed by the writer a considerable pro- portion of the cases proved fatal within a period of less than twenty-four hours. COMA AND ITS CONGENERS 79 twenty-four hours, or often yet more abruptly. Profuse sweating, copious urination or perhaps profuse diarrhea may occur, suffering being replaced by relative comfort, and the contrast often most dramatic. Pseudo -crisis. — A similar fall in temperature in diseases not associated with true crisis points usually to a serious complication, in typhoid, for example, to a hemorrhage or perforation. In pneumonia, a false crisis of marked degree is often followed by renewal of fever, the true defervescence occurring ordinarily on the day following. If true crisis does not follow one must suspect an extension and renewal of the process or the onset of some complication such as myocarditis, endocarditis, pericarditis, or empyema. Profound myocardial toxemia may be associated with most misleading temper- ature recessions. In one case of migratory pneumonia observed by the author, lobe after lobe of the lungs went through a typical pneumonic cycle, the critical fall being promptly followed by chill, renewed fever and the usual signs of con- solidation in the adjacant lobe. COMA AND ITS CONGENERS.— Coma covers any state of prolonged unconsciousness from which a patient cannot be aroused by external stimuli.* The dividing line between different states of unconsciousness and profound sleep is ill-defined and one merges into the other. The term coma vigil is applied to the peculiar complete or semi-unconsciousness of certain cases of typhoid fever associated with an open-eyed, low muttering delirium. Stupor and lethargy both represent morbid sleep, the former profound as in alcoholism, the latter a mere drowsiness as in the premonitory stage of freezing. COMA. — Assuming that a patient is seen for the first time on the street, in the ambulance, hospital, or the home, and is comatose or stuporous, the difficulties in diagnosis are so great as often to baffle the diagnostician, but many avoidable errors occur through lack of proper method, ordinary knowl- edge and carefulness. Information as to the conditions under which the attack of coma occurred should be first sought through some friend, relation or bystander. The appearance of the patient at the time of the attack, his movements and the direction and force of any fall he may have sustained, are also to be considered and oftentimes his habits or even his previous health may be ascertained. The state of the atmosphere may at once suggest heat^exhaustion or sunstroke. Inquiry must be made as to what the patient has taken into the stomach, having in mind the possibility of ptomain or drug poisoning, or sudden deaths or severe prostration following the overloading of the stomach in victims of the diseases of the heart and arteries. In public services, and es- pecially ambulance cases, the history is often entirely lacking or untrust- worthy, and the physician is thrown upon his own resources. *In most instances profound coma is associated with a relaxed jaw, stertorous breathing and dry tongue, e. g., morphia poisoning or apoplexy. Five crises. Coma vigil. Sources of error. Falls. Heatstroke. Stomach con- tents. Ambulance] cases. 8o MEDICAL DIAGNOSIS Poisons. Flushing and cyanosis. Usually complete. Useful tests. Conjugate deviation. Consciousness long maintained. One must consider epilepsy, malingering, uremia, apoplexy, cerebral embolus, brain tumor, meningitis, diabetic coma, poisoning by opium, chloral and other narcotics: if delirium is present, belladonna; if convulsions, strychnia or uremia, and investigate the following points: (a) The Eyes. — Are the pupils equal or unequal, contracted or dilated? Do they react to light, is the conjunctival reflex present, and is there resistance to the separation of the lids? Unequally dilated pupils (the larger usually on the side of the lesion) suggest cerebral hemorrhage or general paralysis of the insane. Contracted pupils suggest opium poisoning, or pontine hemorrhage. In uremia they are usually dilated* and in all these conditions they fail to re- spond to light and the conjunctival reflex is absent. The same is true of cocain and the latter stages of chloral poisoning. If convulsions are present with fixed, dilated pupils and the conjunctival reflex is absent, epilepsy or poisoning by strychnia, belladonna, or some other convulsant is at once suggested. In alcoholism the pupils may be dilated, but usually respond to light. Hysteria and malingering are, as a ride, readily detected by the prompt response to light, and the resistance almost invariably offered to the separation of the lids by the physician. (b) Color. — In alcoholism the face is usually flushed. In cerebral lesions it may be flushed but is also usually cyanotic. In uremia there are ordinarily pallor and cyanosis and the latter condition may be excessively marked in the coma of acetanilid poisoning. (c) The Degree of Unconsciousness. — In the more serious forms of coma, insensibility is, as a ride, complete. The conjunctival sensitiveness and resist- ance of the eyelids to separation shoidd be tested in all cases and deep, sharp and unexpected pressure over the ovarian region may resolve doubt in hysteric females, being often accompanied by a sudden complete or partial return to consciousness. The malingerer and even the "alcoholic" can seldom resist moving if the skin of the inner surface of the upper arm is suddenly and sharply pinched. (d) The Character of Attendant Convulsive Movements.— In cerebral hemorrhage conjugate deviation of the eyes and head is most common.- In the comatose terminal stage of strychnia poisoning both head and trunk muscles are convulsed, opisthotonos or emphrosthotonos are likely to be present, but between the attacks the patient may be conscious and rational. In tetanus the convulsive seizures are likely to be limited to the neck and jaw, and complete relaxation between seizures does not usually occur. Neither in strychnia poisoning nor tetanus does complete, persistent un- consciousness supervene prior to the terminal stage, and often not at all. In epilepsy the sequence of the seizures, if present or, as described by eye witnesses, i.e., clonic followed by tonic convulsions, involuntary micturition, and perhaps tongue-biting are suggestive. *A widely dilated pupil and moderate photophobia may precede the outbreak. COMA AND ITS CONGENERS 8l The ordinary malingerer is foolish to attempt convulsions on account of the many difficulties attending accurate simulation which can be overcome only in exceptional instances by certain of the elect of the brotherhood. The Ophthalmoscope. — Albuminuric or diabetic retinal changes may be present or the choked disk of brain tumor may be revealed, and the ophthalmoscope often proves invaluable. Hysteric Coma. — Although the convulsive movements are often strikingly epileptiform or tetanic, they are usually irregular and are associated with the typical hysteric fades. Furthermore, though the lips may be bitten, the tongue is not, whereas in true epilepsy biting of the tongue is a frequent accident and incontinence of urine almost a constant accompaniment of major seizures. In hysterical tetanus the eyes are usually closed during a seizure and emotional utterances, sobbing, and crying are prominent. The peculiar premonitory exhilaration and hyperacuteness of the special senses observable in strychnia poisoning are absent in hysteria and the onset of spasm is atypical. In females sudden sharp pressure over the ovarian region may resolve doubt. Frothy Lips. — Froth about the lips, if blood-stained, points to epilepsy, but is common to many of the convulsive states attended by unconscious- ness. Malingerers usually use soap in the mouth for this purpose. (e) Paralysis. — The limbs should always be handled to ascertain if paralysis be present in any member, the peculiar lack of all muscle tonus being usually readily determined and paralysis of the eye and face easily noted. Atrophy. — Paralysis of the extremities associated with marked atrophy suggests an old lesion which may or may not be related to the patient's present state. (/) The Pulse. — In cerebral compression the pulse is slow, in uremia and apoplexy its high tension may be suggestive, in malingerers and hysterical persons it is the pulse of exertion, rapid, full and bounding and in -other conditions it is, as a rule, of little value. (g) The Heart and Blood Vessels. — A searching examination of both the heart and the accessible arteries is usually demanded and arterial hyperten- sion, and sclerosis, together with an increased cardiac area, may prove of great importance. If valvular lesions are evident and especially if mitral stenosis be detected, the question of cerebral embolus at once arises and one might encounter the dying victim of a ruptured, slowly draining aneurysm which is emptying the patient's life blood into some closed cavity such as the pericardial sac, though death from aneurysm is oftener sudden. (h) The Temperature. — In all cases the rectal temperature should be taken, even in those comas apparently alcoholic in their nature. One of the commonest mistakes on the part of ambulance and police surgeons results from the failure to remember that pneumonia, like cerebral lesions both central and traumatic, is extremely common in the drunkard. As before stated, the presence of fever does not absolutely exclude hysteria and it is present in cerebral hemorrhage, the surface temperature being usually a degree or more higher on the paralyzed than on the non-paralyzed side. 6 Simulation difficult. Bright's and brain tumor. Many signs lacking. Muscle tonus Antecedent lesions. Arterial hypertension. Acute dilatation. Embolus. Aneurysm. Fatal errors. 82 MEDICAL DIAGNOSIS (i) The Lungs. — Extensive pulmonary infarction, the acute onset of a Unusual but ; massive pleural effusion, the sudden production of pneumothorax and the I internal rupture of a large pulmonary abscess constitute some of the unusual causes of sudden unconsciousness observed by the author, and one must \ always bear in mind the possibility of internal hemorrhages and, as before stated, of fulminant acute disease. (j) The Breath. — An alcoholic odor, though suggestive, does not prove drunkenness. The so-called uremic breath is reasonably characteristic, but closely approximated by that encountered in other conditions, and is a dis- agreeably aromatic odor that must be learned by actual experience. The sweet breath of diabetic acidosis is far more characteristic and often extremely penetrating.* Certain poisons, like laudanum, carbolic acid, hydrocyanic acid, ether and chloroform, yield a characteristic odor. (k) The examination of the blood often proves of decided diagnostic value and should be applied in doubtful cases whenever possible. Open hemorrhage may have occurred and at once suggests injury, self- inflicted or otherwise, hemoptysis, hematemesis, aneurysmal rupture or possibly the hemorrhagic accidents of hemophilia, leukemia or purpura. (I) Examination of the Urine. — At the earliest moment a specimen of urine should be removed by catheterization and carefully examined with reference to contained solids, serum albumin, pus, blood, casts, or sugar, drug reactions and the like. Diagnosis often Impossible. — In conclusion it must be emphatically said that but few of the differential points given are absolutely distinctive, and there is no condition that more severely taxes the skill and common sense of the practitioner. If the breath of a patient smells of laudanum, the pupils are contracted, the breathing stertorous, the skin cyanotic and clammy, and particularly if a bottle that has contained laudanum is found empty, the proof is suffi- ciently conclusive. Stertorous breathing, a flushed countenance, slow, hard pulse and the evidences of paralysis are sufficiently characteristic of a cerebral lesion. On the other hand, one often meets with conditions in which he is misled by a reversal of ordinary symptoms, confused or contradictory findings and a failure on the part of the 'underlying ailment to strictly observe the man-made laws of differential diagnosis. Diabetic Coma. — (Coma of -acidosis). Usually this form is readily Fruity breath, recognized by the fruity, vinous, odor of the breath and the character of the breathing which is usually that of strong, deep, deliberate or unhurried inspiration and a somewhat short, sighing, expiratory phase (so-called " ' Kussmaul dyspneic type")-t * The author not long since detected it in passing upon the open street the little babe of a friend, which was supposed to be in perfect health, but was suffering from terminal diabetes, as determined by the family physician upon notification. f Inasmuch as this type of breathing has been noted by all clinicians for centuries, the propriety of such a descriptive term is questionable. Few pathog- nomonic signs Simple cases. Blind cases. PHENOMENA AND SIGNIFICANCE OF PAIN 83 The onset of such attacks always is preceded by an excess of diacetic acid and acetone in the blood and urine and, often, by irritability, fretfulness, headache and dyspeptic symptoms, concerning the possible significance of which family members should be warned. Constipation, often extreme, is often present and may be a factor in exciting an attack, and starvation, colon flushing and brisk catharsis will often abort one presenting prodromal symptoms. According to the author's personal observation, these attacks are quite frequently precipitated by cardiac overstrain, the heart being atonic and even readily dilatable in many advanced cases. Showers of short, broad casts may precede the attack. The pupils are usually widely dilated during a seizure. The term "air hunger" as applied to the typical breathing described is peculiarly apt and interprets exactly the clinical picture. The author feels that two distinct types of breathing encountered in practice merit the application of this term, viz: (1) The deep, urgent, strong, dominantly inspiratory type; (2) the superficial, hurried, gasping type with inspiratory dominance seen in many conditions associated with states of unconsciousness and extreme weakness. To him, at least, the latter clearly expresses "air hunger," usually justi- fied by the oxygen shortage present, from whatever cause, terminal or otherwise. PAIN A Purely Subjective Symptom. — Pain as a symptom is purely subjective and may be trivial or agonizing, true or false, localized, referred or diffuse, mo- mentary, temporary or persistent. Descriptive Terms. — Its differences are indicated by such descriptive terms as "dull," "aching," " sharp," " acute," " stabbing," "boring," "gnawing," "lancinating," "shooting," "colicky," "radiating," "diffuse," "tearing," "rending," "suffocating," "griping," "bursting," "smarting," "scalding," "burning," "grasping," "clutching," and the like, all of which doubtless reflect accurately the sensations of the victim. It may be deeply seated or superficial and may or may not be associated with tenderness due either to actual inflammation or to hyperesthetic areas. Deceptive "Zones." — In this connection the student is warned against a too implicit faith in the so-called "painful zones" which, though valuable and in general fairly suggestive, cannot be wholly trusted and too often lead one far afield. A painful area, dedicated by the usual diagram wholly to appendicitis, for example, serves as well for a local growth, post-operative adhesions, arrested ureteral calculus, incipient hernia, and even for the referred pain of certain pneumonias or an obstruction of the ileocecal valve. Furthermore, the early pain of appendicitis is likely to be diffuse and far removed from "McBurney's point." Danger signals Cardiac overstrain. Air hunger. Two types. Sources of confusion. 8 4 MEDICAL DIAGNOSIS Transposed pain. Acute inflammation. Parenchyma insensitive. Activity and pain. Effect of exudate. Neuralgia and neuritis. Referred Pain. — The site of pain is often far distant from its true source, and indeed certain referred pains may be dangerously misleading. The author has observed a case* in which an aneurysm of the left iliac artery caused pain over the appendix; others in which appendiceal pain was referred to the left side; yet others in which the pain of gall-stone colic first appeared in the region of the heart, and vice versa. As has already been suggested, nothing is commoner than for the pain of pleurisy and pneumonia to be referred to the surgical regions of the abdomen along the terminal endings of an* intercostal nerve, or for renal calculi, lodged in the lower portion of the right ureter, to closely simulate appendicitis. The referred abdominal pain of the insufficient heart is extraordinarily common and misleading. The Character and Seat of Pain in Relation to Diagnosis. — The pain of an acute inflammatory disease is usually associated with fever, and often with localized tenderness, the degree of either depending upon the nature of the affected structure, the individual susceptibility and resistance and the extent and situation of the inflammatory process. In surgical diseases of the extremities, for example, the pain is ordinarily associated with distinctly localized tenderness and is of great value as a symptom. On the other hand, a central or a senile pneumonia may exist with little or no pain, or in other cases, by involvement of the pleura in a dry pleurisy, produce excessive distress. Pain in Solid vs. Hollow Viscera.- — In any disease of a solid viscus inflam- mation of its parenchyma is a relatively or wholly painless process until extension to the internal or external limiting layers occurs; and even the hollow viscera are relatively insensitive to rough handling and trauma, though intense pain may attend their abrupt overdistention or violent contraction. Pain usually is distinctly related either to bodily movement in general or to functional activity of the part affected. Friction of the dry and inflamed serous surfaces causes respiratory pain in pleurisy, while in acute rheumatism the slightest movement of the affected joint is distressing. In all such instances nature seeks to relieve the condition by pouring out a fibrinous or serous exudate which fact explains the partial or complete relief of pain in fully developed cases of exudative pleurisy and pericarditis. Radiating pain is most characteristic of neuralgias and neuritis, and is recognized by its tendency to follow the known distribution of nerve trunks and by its association with marked tenderness over certain nerve paths or points of emergence. Dull pain may take the form of general aching as in acute infectious dis- eases, or may attend congestion, capsular stretching or chronic low-grade inflammations, particularly such as affect the mucous or serous membranes. Recent vs. Old Ulcers. — Irritation, acute inflammation, or recent ulcera- tion of certain mucous membranes may be attended by severe pain, such, for example, as that of renal colic and of certain cases of gastric or duodenal * Through the courtesy of my colleague, Dr. Archibald MacLaren. PHENOMENA AND SIGNIFICANCE OF PAIN 85 ulcer. On the other hand, extensive but ancient ulcerations may be strik- ingly painless. Gnawing or boring pain is frequently encountered in caries of the spine, aneurysm of the aorta, carcinoma of the stomach and inflammation of bone. It is also met with in some cases of old gastric ulcer, in gout, gall-stones and renal calculus. Misleading Absence of Pain. — In many of the conditions ordinarily asso- ciated with more or less severe pain this symptom may be wholly lacking in certain cases, even in the absence of stupor or coma. This statement applies, for example, to -pericarditis, pleurisy, cholecystitis, cholelithiasis, gastric and duodenal ulcer, high grade coronary arteriosclerosis, pneumonia, certain cases of appendicitis of the gravest type, and even cancer of the stomach or bowels. Actual perforation of the appendix, stomach or duodenum may occur with entire absence of pain. When Delay may be Fatal. — Abrupt, atrocious abdominal pain with local- ized or general tenderness or decided defensive rigidity, symptoms of shock or collapse and an initial sharp drop in blood pressure, will represent almost invariably a critical surgical emergency. PAROXYSMAL PAIN. — Gall-stones, renal colic, colon colic, splanchnic arterio-spasm, spasm of the pylorus, appendicitis, locomotor ataxia, neuralgia and angina pectoris furnish the best examples of paroxysmal pain and nearly all radiating pains are of this type. Colic. — The term colic applies chiefly to paroxysmal abdominal pain caused by overstretching or spasm of a hollow muscular organ, and more often, both combined. It includes that of biliary or renal calculus, appendi- citis, lead poisoning, floating kidney (Dietl's crises*), mucous colitis, spastic constipation, strangulated hernia and abdominal aneurysm. Many of these attacks were formerly covered by the convenient term "gastralgia," but modern progress has proven that an actual primary gastral- gia (neuralgia of the stomach) is so rare as to be almost negligible. Cases of simple transitory colic due to acute indigestion are common in both children and adults, but the utmost caution must be observed in the inter- pretation of an apparently simple abdominal pain, particularly if unduly persistent and associated with fever and tenderness on deep pressure. Intestinal Parasites. — In all obscure cases of abdominal colic or indeed of chronic intestinal disturbance the stools should be carefully examined for parasites or their ova. Appendicitis. — Many cases begin with general abdominal pain of a colicky type and twelve or twenty-four hours may elapse before it becomes distinctly localized at a point of maximum tenderness in or near the area lying midway between the anterior superior iliac spine and the umbilicus (McBurney 's point) McBurney's and associated with a more or less sharply defined defensive rigidity of the right rectus muscle. The tenderness may be apparent before the pain becomes localized and * Much less common than formerly supposed and usually attributable rather to pyloro-spasm, gall-stones, duodenal ulcer, spastic constipation, renal calculus or pyelitis. Hollow viscus pains. An almost obsolete term. Transitory colic. Onset. 86 MEDICAL DIAGNOSIS Ureteral colic. Chronic cases. Colon inflation. Pain, character and distribution. Usually afebrile. Pressure point. Ureteral and vascular kinks. Somewhat passi. Pain and tenderness. both are simulated by certain cases of renal colic in which a small calculus has become engaged in the lower portion of the ureter and, in children especially, by certain right lobar pneumonias. Nausea and vomiting at the onset, with fever, assist the diagnosis. In many instances encountered by the author, the referred pain of a developing pleurisy or pneumonia has been mistaken primarily for appendicitis . Chronic appendicitis often remains unrecognized or is only revealed by exploratory operation, but usually it may be determined by the history, by temporary exacerbations, or rarely by actual palpation of the affected member or manipulative roentgenography. The disease is frequently associated with symptoms of chronic indigestion of an indeterminate type. Appendix pain induced by inflation of the colon is said to resolve doubt in many cases and sharply localized distress occasioned by pushing inward upon the cecum, the fingers having first been deeply forced to its right side, is a sign of considerable value. Renal Colic. — Sudden, intense and agonizing paroxysmal pain may result from stone or gravel, either in the kidney pelvis or when passing downward through the ureter. It has a maximal point over the kidney posteriorly and tends to shoot downward over the course of the ureter into the groin along the inner portion of the thigh and into the testicle, which is oftentimes retracted during the paroxysms. There may be grunting and straining expulsive movements. Unlike appendicitis, with which it is not infrequently confounded, renal or ureteral colic is usually afebrile, and dysuria and frequent micturition are asso- ciated with albumin, blood, and oftentimes with gravel or actual calculi in the urine. Nausta and vomiting are common, and in several instances of such colic, as well as in acute lobar pneumonia, the author has known of narrow escapes from or actual operation for appendicitis, apparently because of temporary lodgment of calculi in the lower end of the ureter on the one hand or mis- leading referred pain on the other. In renal colic, tenderness is usually found over the kidney posteriorly, and often anteriorly, being best elicited by deep pressure over the twelfth rib or, according to the author's experience, just beneath it at the acme of deep inspiration. The DietVs crisis of floating kidney may be associated with pain of the same type, with more or less tenderness over the region occupied by the displaced or displaceable organ or even a decided intermittent hydro- nephrosis, but it more closely simulates gall-stone colic than renal colic, so far as pain distribution is concerned. The incidence and severity of supposed DietVs crises bear but slight relation to the degree of kidney mobility and in the light of recent knowledge we must regard this condition as a possible but extremely rare manifestation. Gall-stone Colic. — In typical cases this is indicated by the sudden onset of intense paroxysmal pain in the epigastrium or right hypochondrium, radiating both downward and upward, but chiefly upward, being often felt in the right shoulder-joint and under the right scapula. It is associated with localized Till NOMINA AND SIC'.Nl F1CANCK (IK 1'AIN 87 tenderness on deep, forcible, sustained, upward and backward thumb pressure over the gallbladder throughout a deep inspiration followed by deep expiration. It is accompanied by nausea or vomiting, which latter does not give as much relief to pain as in the case of ulcer of the stomach or duodenum, and may or may not be associated with jaundice. Colon Colic. — A paroxysmal attack oftentimes nearly or quite as severe as that of many renal colics may occur in cases of mucous colitis or spastic constipation* It is usually left-sided, the maximum point being over the region of the kidney, posteriorly, but ordinarily it lacks the typical thigh and groin radia- tion of renal colic and is either wholly or in a considerable measure relieved by emptying the bowel with hot enemata. Lead Colic. — A paroxysmal, diffuse, persistent pain, associated usually with obstinate constipation and relieved rather than increased by pressure, should lead one to search for a "lead line" on the gums or that substance in the urine and inquire as to sources of possible lead poisoning. Tabetic or Splanchnic Crises and Abdominal Aneurysm. — The curious paroxysmal pain associated with the crises of locomotor ataxia, the obscure pain of spastic splanchnic abdominal crises, the referred pain of myocardial origin or abdominal aneurysm must always be borne in mind. Colic Due to Gastric Ulcer. — Violent paroxysmal pain may be encountered in connection with certain cases of active gastric ulcer and the pain is usually epigastric, deep-seated and often seems to pass through to the back. It is usually associated with nausea and vomiting which ameliorates or relieves the pain and in its recurrences bears a definite time relation to the taking of food. Pressure Tenderness in Ulcer. — During acute attacks the pain of gastric ulcer may be relieved by pressure; more often, however, as in the chronic form, any pressure is distressing and the maximum tenderness is distinctly localized. Dyspepsia, anemia and often a history of antecedent hematemesis may assist the diagnosis. In by far the greater number of ulcers, such violent and local- izing symptoms are lacking. ACUTE INTESTINAL OBSTRUCTION.— In general, acute obstruction is characterized by severe or extreme, paroxysmal, colicky pain, becoming con- tinuous, the vomiting of stomach contents, bile, and ultimately of fecal material. The obstinate constipation is often preceded by evacuations from that portion of the bowel lying below the point of obstruction, and in acute intussusception there is a characteristic or suggestive bloody dysentery. Tenesmus without bowel discharges is present in some cases of volvulus. Symptoms Vary with Site. — If the obstruction involves the colon there is less vomiting, but marked abdominal distention and a relatively slight indicanuria. In obstruction of the lower ileum or ileocecal valve, the dis- tended coils may form a "ladder pattern" on the abdominal wall and, if in the sigmoid or rectum, the descending, transverse and ascending colon may be projected by distention as a visible horseshoe curve. * Of late, this condition is attributed by some authorities to insufficiency of the ileocecal valve but the sequence may be the reverse. A source of error. Seek gingival "lead line." Diagnostic pitfalls. Misleading diarrhea. Important distinctions. "Ladder pattern" and "horseshoe 88 MEDICAL DIAGNOSIS Ileocecal tumor. Adults chiefly. Sigmoidal cases. Many possible causes. Often a deadly combination. Common and often misleading. Channeled impactions. Cause and associations. Ancient ulcerations. Meteorism, vomiting and indicanuria. An actual tumor is rare save in fecal accumulation or intussusception. In the latter condition three-fourths of the cases represent an obstruction at the ileocecal junction. It is most often encountered in infants, rarely in young adults. Volvulus. — Obstruction due to axial twist seldom occurs in youth, most often involves the sigmoid flexure or the region of the cecum and is associated with marked meteorism, rigidity and tenderness. Antecedent constipation and flatulence usually exist and in sigmoidal cases the obstruction may be so low as to make the condition evident when an attempt is made to introduce a large enema. Strangulation. — In the adult this is the most frequent source of acute obstruction and is usually caused by old adhesions, various openings and pockets, slits in the mesentery and omentum, rupture of the diaphragm, hernias, and adhesions of the tip of a persisting Meckel's diverticulum. Intestinal Paralysis. — In connection with abdominal operations and as a result of sepsis and peritonitis, there may be an entire absence of intestinal motility which constitutes what is essentially an acute obstruction associated with general distention. The stomach is often acutely dilated and overdis- tended with liquid, and there is an entire absence of normal sounds upon auscultation of the abdomen.* Fecal Impaction. — A fecal mass gradually accumulating in a sluggish or neglected bowel may be found either at the cecum or sigmoid flexure. It less frequently occupies the splenic or even the hepatic flexure, and may occlude the lumen wholly or contain a central channel through which a certain amount of material may pass. A localized peritonitis with pain and tender- ness may or may not be present in extreme cases, and in the absence of marked distention or a very thick wall, the mass is readily palpable. The condition occurs as a result of chronic neglect of the bowels, chronic partial obstruction, and in the aged, apathetic, hysterical or insane, may lead to serious errors in diagnosis if not considered in the differentiation of abdominal tumors (see " Abdominal Tumors"). Of tumors, strictures and occlusion by foreign bodies little need be said. Cicatricial contraction results usually from old ulcerations, whether syphilitic, tuberculous, dysenteric or simple; less often from adhesion. Occlusion by tumor may be due to development of local growths, direct pressure, or associated adhesions. General Comment. — Early and correct diagnosis is of cardinal impor- tance in connection with intestinal obstruction, hence the leading features should be kept clearly in mind. Important Diagnostic Points. — The higher the obstruction the less is the meteorism, the earlier the vomiting, the more rapid the transition to fecal vomiting, the higher the grade of indicanuria, the earlier and more severe the collapse and urinary suppression. * Prompt emptying of the stomach by the stomach tube, maintenance of the prone position, and elevation of the foot of the bed, is oftentimes of the utmost importance in such cases, huge amounts of fluid being present in many instances. PHENOMENA AND SIGNIFICANCE OF PAIN 89 Associated tumor points to an actual growth, intussusception or a fecal impaction. Intussusception is most frequent in infancy and childhood, and the tumor is usually in the ileocecal region or in the sigmoid flexure. Marked tenesmus and bloody stools are most frequent in intussusception. In intussusception and in volvulus the lack of fluid capacity of the lower bowel as tested by enemata may be an important aid. Volvulus is most common in the fourth decade. The passage of ribbon-like or greatly narrowed cylindrical stools suggests partial obstruction, but may occur in cases of fecal impaction possessing central calibration or be due to spastic constipation, hemorrhoids or rectal spasm. Furthermore, although acute constipation with retention of both gas and fecal matter is the cardinal sign of complete obstruction, the unoccluded lower portion of the bowel may still be able to eject its original content. Fecal vomiting may require twenty-four to forty-eight hours to develop fully its characteristic brownish color and specific odor. Foreign bodies of any kind may cause obstruction and are seldom suspected unless a clear history is obtained. Most frequently the victims are children or mentally defective patients. Obstruction by Drugs, Worms, Etc. — The persistent administration over long periods of large doses of bismuth or magnesia may cause obstructive masses, and among other rare conditions are bunches of intestinal worms, masses of hair, or massive gallstones, which have made their way by ulceration from the gall-bladder to the bowel.* Obstruction may be so low down as to be felt by rectal palpation; and in descending colon and sigmoid obstructions the sphincter may be strikingly relaxed. Fever is usually present, but is ordinarily slight, thirst is excessive and in a few days, the obstruction not being relieved, collapse appears and terminates promptly in death. Diagnosis of Obstruction of the Lower Bowel by Inflation and Liquid Injections. — An anesthetic is necessary and should be pushed to full relaxa- tion. Rectal palpation and direct inspection with the proctoscope and sigmoidoscope should be followed by the introduction of a long tube (Kelly's tube). Oftentimes the whole hand may be inserted though this procedure is not without danger. For the injection of water which is in every way superior to air, the patient should be placed in the knee-chest position, the warm water injected slowly under gentle pressure and its passage determined by both percussion and auscultation. Normal Colon Capacity. — A normal colon should hold about 8 liters (quarts) and the ileocecal valve usually blocks any flow into the lesser bowel. In children the injection may be varied according to age, though even an infant can take from 1 toij^ liters. COMMENT. — The following points should be remembered in connection with abdominal pains : (a) Jaundice when present and associated with colic and localized tender- * The only way that an excessively large gall-stone can escape. Tumor and bloody stools. Ribbon or pencil-like stools. Misleading stools. Unusual causes. Anal '■ relaxation. Sigmoidoscopy and palpation. Injection of air or liquid. Ileocecal valve a barrier. go MEDICAL DIAGNOSIS Afebrile vs. febrile colics. Significant findings. Sudden onset. A fact of importance. Often determinative. Examine for hernias. Weakened hernial rings. Necessary data. ness suggests gall-stone colic, but its absence is of little consequence in disproving that diagnosis. (b) Fever is entirely absent, as a rule, in colon colic, spastic constipation, lead colic, gastric ulcer, and abdominal aneurysm. It is almost invariably present in acute appendicitis, frequent and sometimes of a septic type in gall-stone colic, and absent usually, but not invariably, in renal colic. (c) The Urine in Abdominal Colics. — The examination of the urine should never be omitted and may reveal the blood, pus cells and albumin of calculus or pyelitis, the high-grade indicanuria of ileus, the pale color and increased quantity suggestive of hysteria, actual gravel or the stone fragments of renal calculus. (d) Blood. — The examination of the blood may reveal a leucocytosis pointing to an acute infective process; an anemia of etiologic or diagnostic importance; blood parasites, or the basophilic granulation of red cells suggestive of lead poisoning. (e) Onset. — In nearly all forms of abdominal colic the onset is sudden, with few or no prodromata, and nausea and vomiting almost invariably occur in the obstructive or inflammatory conditions. (/) Misleadingly Referred Cardiac Pain. — One of the most interesting manifestations of cardiac insufficiency is pain or discomfort in the upper abdomen, which may be so severe as to simulate gastric or duodenal ulcer or even gall-stone colic, though usually of the milder type which leads the patient to blame his stomach for a peculiar sense of constriction or oppression which may or may not also be felt under the sternum or over theprecordium. One of the commonest symptoms of cardiac insufficiency or overstrain in middle- aged patients is epigastric discomfort. (g) Past Illnesses. — These are of ten of great importance in the differential diagnosis of obscure abdominal pain. Preceding attacks of renal colic, appendicitis, spastic constipation, gall-stones, gastric or duodenal ulcer and the like, may have been clear and well-defined, and often lead one to an earlier and more accurate diagnosis of the individual attack than would have been possible in the absence of such a history. (h) Hernias. — Owing to the common failure to systematically examine hernial regions in cases of obscure abdominal pain, nothing is more commonly misinter- preted or overlooked than an incomplete hernia or one of unusual location. Abdominal pain occurring during the day and absent at night when the patient is in bed, is especially suggestive, and actual protrusion may be absent though the application of a good truss to a relaxed hernial opening may relieve all symptoms. Important and Obscure. — Obscure dyspeptic symptoms, painful or pain- less, with or without nausea or apparently causeless vomiting, may arise from a tiny umbilical hernia, so small as to escape the eye or finger. Pain, localized or widely diffused, follows firm pressure over the umbilicus in such cases. HEADACHE. — The following points should be considered, viz. : (a) Location, (b) Character, (c) Severity, (d) Radiation, (e) Time of occur- rence. (/) Duration, (g) Local tenderness, (h) Hereditary predisposition. PHENOMENA AND SIGNIFICANCE OF PAIN 91 (i) The effect of internal medication (in syphilis, anemia, malaria, etc.). (j) The effect of external medication (shrinkage of turbinates, paralysis of accommodation, etc.). Anemic headache affects cither the forehead, orbits, vertex or occiput, being more often neuralgic in type. It is usually moderate and associated with a sense of pressure, but in extreme chlorosis is occasionally so severe as to resemble the headache of meningitis. Bilious or Dyspeptic Headache. — This toxemic variety includes as etiologic factors or associated conditions, gout, jaundice, the dyspepsias, and constipation. 77 is irregular in duration and occurrence, frontal and congestive in type and associated with nausea. There is a subjective sense of pulsation; it is increased by motion and by stooping, and more or less promptly relieved by emesis and catharsis. Frontal sinus headache is often interpreted wrongly as bilious headache. Brain Tumor. — This causes persistent headache, usually increased at night, associated with nausea and vomiting, and sooner or later with optic neuritis. Brain Abscess. — This may cause severe and persistent headache resem- bling that of brain tumor, but is usually accompanied by a septic tempera- ture curve, and optic neuritis is usually absent. Eye-strain headaches may be either occipital, orbital or frontal. They are usually associated with the use of the eyes for close work, or, in certain cases, for distance; are relieved by sleep and properly fitted lenses and are frequently associated with conjunctivitis, tenderness of the eyeball or eye muscles and, sometimes, blurred vision. SINUS HEADACHES.— These headaches have only recently been as- signed the important place they deserve. Inflammation of the accessory nasal sinuses with blocked drainage is one of the most frequent causes of headache of a type often attributed to other causes, and it would be humiliating to know how many headaches of this origin have been treated vainly as sick headache, uterine headache, facial or cervical neuralgia, bilious headache and especially that of eye strain. Sinus headaches vary somewhat in their manifestations but are alike in their tendency to start with mild or dull pain and increase more or less rapidly to an almost unbearable intensity. They are, moreover, for the most part, strikingly and suddenly ameliorated by the reestablishment of sinus drainage, by means of vasoconstricting douches or special local pro- cedure, and are significantly associated with and responsive to naso- pharyngeal congestion. Frontal Sinus Headache. — The pain is chiefly frontal, usually throbbing and more intense in the early morning and often increased by the movements of the eyeball. Tenderness may be marked over the frontal wall of the sinus or the inner aspect of the orbital roof. Like the bilious headache, it may be intensi- fied by stooping, sneezing, or coughing, and is often associated with intervals of vertigo, nausea, and even vomiting. Ordinarily mild. Toxemic. Frontal and congestive. A common type. Source of error. Significant factors. 02 MEDICAL DIAGNOSIS Silent cases. Inquire as to use of drugs. Arterial hyper- tension the rule. Unrecognized factors. Therapeutic test. Antrum of Highmore Headache. — This is characterized by a sense of pressure and tension over the outer wall of the sinus and very often by severe frontal pain and toothache. Ethmoidal Headache. — In this form the pain, though often diffuse, usually affects chiefly the region of the root of the nose. Sphenoidal Sinus Headache. — This may be widely diffused but is usually manifested by maximal pain at the occiput. 77 should be remembered that each or all of the sinus lesions may cause general headache and that chronic sinusitis may be quite silent except at intervals when, through a coryza, an acute or subacute process supervenes and blocking occurs. Drug Headaches. — The overuse of drugs may lead to headaches which have no distinguishing features. A dull throbbing headache associated with ringing in the ear often follows the administration of a salicylate or quinin in full doses. Blight's Disease. — The headaches of nephritis are of varying localization and for the most part associated with arterial hypertension. Neuralgia is a frequent complication of Bright's disease, but the true uremic headache, which in chronic interstitial nephritis may appear years before any acute outbreak, is usually maximally occipital, and in all forms of nephritis may be the immediate precursor of uremic coma or convulsions. It is often an early morning headache of modemte or extreme intensity and relieved by black coffee, but sometimes closely simulates migraine. High arterial pressure from other causes produces heaaache of a similar type.* Arteriosclerosis. — These headaches are seldom severe, though often per- sistent; are associated with transient vertigo, impaired memory and intellection; and are often forerunners of cerebral hemorrhage. The cause is suggested by rigid temporals or radials and by the fact that the headaches are often relieved by the administration of such a drug as nitroglycerine. In the author's experience the so-called arteriosclerotic headaches have been seldom unassociated with chronic renal changes and arterial hypertension. Furthermore, they are often accompanied by distinct cardiac weakness and vary- ing degrees of dilatation and may respond promptly to treatment directed solely to the relief of this latter condition. Malaria. — Both persistent headache and obstinate neuralgia may be encountered in connection with malaria. Unless it is distinctly periodic, the only characteristic feature is its subsidence under appropriate drug treatment (quinin). Migraine ("Sick headache," "megrim," "hemicrania"). — Heredity plays a large part in migraine which is regarded by some authorities as an epileptic * Unilateral, predominantly temporal headaches are quite common in certain cases advanced chronic nephritis with hypertension and in such instances apoplexy constitutes a relatively common complication. It would seem from the author's observations that in such instances the corresponding side of the brain is the more likely to be the seat of such a lesion. PHENOMENA AND SIGNIFICANCE OF PXlN 93 equivalent or actual variant.* It is characterized by its unilateral localiza- tion, nausea, vomiting, and subjective ocular phenomena. Females are attacked most severely and typically and a considerable proportion of the cases (30 per cent.) commence in childhood (fifth to tenth year. Eye strain, adenoids, carious teeth, pelvic disease, food sensitization, gastric disorders, overexcitement, overstudy, shock, unhygienic sur- roundings, and dietetic errors are common exciting factors, but all are often lacking. The author has seen a large number of typical cases of the most extreme and persistent type, occurring in middle-aged women especially, associated with a renal insufficiency, without other signs of the chronic nephritis with which headaches of this type are occasionally associated, f Periodicity may be marked even to the hour of the day, or it may bear a definite and invariable time relation to menstruation. Unquestionably, as suggested, this condition is often confounded with the headaches of renal insufficiency and arterial hypertension. Symptoms. — The attack appears usually in the early morning, often preceded by localized numbness and tingling, hippus, vertigo, visual pares- thesias (flashes of light, % fortification figures), cramps, spasms, or even aphasia associated with mental excitement or decided depression. The headache is unilateral, usually right-sided and sharp, stabbing or boring in character. Nausea and vomiting are common symptoms, movement, light and sound increase it; it may become bilateral and extensive and pallor or flushing may be marked. Usually the duration is one day or less, sometimes two or three days, a night's sleep and oftentimes a long day nap bringing relief. In children the possibility of a larval meningitis or brain tumor must be remembered. It may be present in childhood and absent in adult life and even when persistent often becomes less frequent and less severe in middle age. Hysteria. — There is no headache characteristic of hysteria and the classical " clavus" (pain at the vertex as if a nail were being driven into the skull) has been encountered but rarely by the author and in such instances it was associated with extreme anemia or arterial hypertension. * Both statements rest upon decidedly insufficient grounds one would think after examining the testimony. Of 3000 individuals questioned, only 2 per cent, were found to have been wholly free from headaches identical with or closely allied to migraine. "With such a wide prevalence heredity is a negligible factor. It is like the doctrine of original sin" (JeUiffe). As to the close relation of migraine to epilepsy one can say only, that when radical differences exist between two ailments and absolutely nothing is known as to the pathology of either, we have no right to link them together because of minor and frag- mentary resemblances. To attach, either by direction or indirection, the taint of epilepsy to this common condition is wholly wrong, until some substantial proof is obtainable. Exactly the same protest may be made against the universal assumption that somnambulism is an epileptic equivalent. Anaphylaxis is assuming great importance as an etiologic factor. t Several of these interesting patients, originally recorded about fifteen years ago, have since died of a frank interstitial nephritis with hypertension. X "Scintillating scotoma." Renal cases. Periodicity. Aurae. Hemicrania. Duration. Clavus. 94 MEDICAL DIAGNOSIS A common form. Points of tenderness and distribution. Seek source of toxemia. Sinuses, teeth and kidneys. Seek focal infection. Often agoniz- ing and intractable. Herpes frequent. Asthenic and Psychasthenic* Headache. — Usually mild and indetermi- nate, frequently occipital, as in mild uremic headache, the important char- acteristic of this form is its morning maximum and the tendency to disappear after eating and under physical exercise and mental preoccupation. NEURALGIA. — The pain of severe neuralgia is acute, radiating, distinctly localized and associated with superficial points of tenderness. Its character- istic feature lies in its definite relation to known nerve trunks, their points of exit and their distribution. It may affect any portion of the body, though most common in the head, and is probably always an expression of chronic infection, toxemia, pres- sure or injury, though frequently initiated by extreme fatigue, particularly when this is associated with subnutrition and exposure to cold and damp. Severe attacks are remarkable for their persistence, intractability, and tend- ency to irregular or periodic recurrence. Sinus infections and peridental septic foci doubtless account for a large proportion of so-called neuralgic cases affecting the head, and neck and an astonishingly large number of such headaches occurring in the author's middle-aged patients are associated with high arterial tension. The possibility of an actual nephritis or a renal inadequacy, as indicated by an insufficient excretion of urinary solids should always be borne in mind, and invariably a definite source of chronic infection or toxemia must be considered and sought. The tender points in neuralgia represent points of nerve trunk emergence, their entrance into muscles, or their terminal filaments. Maximum tender- ness is usually easily determined and widely diffused sensitiveness of the most extreme type is sometimes encountered. Trifacial Neuralgia {Tic douloureux). — Either the ophthalmic, the upper maxillary or the lower branches of the trifacial nerve may be affected; the last being the most common; the first, the most severe form. In all varieties the pain is intense and the points of tenderness marked. Ophthalmic. — If the ophthalmic division be chiefly affected, the pain is especially severe about the region of the eye, which is often injected and tender. Lachrymation may be present, and there is marked tenderness in the supraorbital region, over the bridge of the nose, and occasionally at the occiput and upper cervical spines. Transient blindness may occur in severe cases. This form and the next one are frequently associated with accessory sinus and dental infections. Superior Maxillary. — If the upper maxillary is chiefly affected, the maxi- mum tenderness is at the infraorbital canal and disease of the antrum of Highmore is often a cause. Inferior Maxillary. — With involvement of the lower branches the pain radiates to the ear, and along the lower teeth, the maximum painful points corresponding to the auriculo-temporal nerve. All branches are usually more or less affected, and a severe herpetic eruption * The term is used in its literal sense as meaning "brain fag" or the mental instability usually called "neurasthenic" (see "Neurasthenia"). PHENOMENA AND SIGNIFICANCE OF PAIN 95 , ^ may occur along the track of the superficial nerves in all three forms. The condition of the maxillary and frontal sinuses should always be determined. Cervico-brachial Neuralgia. — This variety, frequently associated with rheumatic affections, involves especially the sensory nerves of the brachial plexus. It is not infrequent, occurs chiefly in women, may be due to remote primary causes, such as locomotor ataxia, uterine disease, sinus or tonsillar infections or carious teeth, and is characterized by the distribution of the pain and points of maximum tenderness, which may be over the ulnar nerve, Maximal at the elbow, near the wrists, in the axilla, at the inferior angle of the scapula . tenderness - over the deltoid muscle, or even on either side of the lower cervical spine. Herpes, anesthesia and vasomotor disturbances may occur. Cervico-occipital Neuralgia. — This affects the sensory branches of the upper cervical nerves, is often caused by cervical caries and usually associated with a point of maximum tenderness midway between the mastoid process and the atlas. Intercostal Neuralgia. — This occurs most frequently in those debilitated by overwork, malnutrition, toxemia or co-existing diseases, and chiefly in young adults of the female sex. It is characterized by sudden pain in the chest, of the neuralgic type and but slightly affected by respiration, yet following the intercostal distribution. The maximum points of tenderness correspond to the exits of both dorsal and anterior branches an d it chiefly affects the left side. It is ordinarily of brief duration, but may last several weeks. A Source of Erroneous Diagnosis. — Intercostal neuralgia is of special importance in connection with angina pectoris, pleurisy and the acute pain of intra-abdominal diseases. Furthermore, the hitherto accepted statement that intercostal neuralgia chiefly a common affects the left side is significant. Mild pains of cardiac origin and even the e " 01 ' severer atypical manifestations of angina pectoris are frequently so miscalled. Xo less important is the relationship of thoracic pain and tenderness to the dilated, insufficient drop heart so often encountered in the asthenic individual. Herpes zoster cannot be distinguished from intercostal neuralgia until the eruption appears. It is usually unilateral, rarely bilateral and is asso- ciated with an herpetic eruption appearing in patches over the affected inter- costal nerve. Its pain is atrocious, and inasmuch as it may precede the eruption by many hours, is oftentimes most puzzling and misleading if zoster be forgotten. Sciatica (Sciatic neuritis, sciatic neuralgia). — In the presence of the ordinary etiologic factors, toxemia or actual infections, sciatica is usually initiated by exposure to cold, wet and excessive fatigue, direct injury, pressure from pelvic tumor, a faulty chair seat, chronic constipation, preexisting dis- ease of the vertebrae, disease or relaxation of the sacro-iliac joint or lesions of the spinal cord. Leading Symptoms. — Acute seizures are characterized by a sudden onset, Painchar- the intense pain following the course of the sciatic nerve, and often extending well up into the lumbar region. Intervals of comparative immunity alter- 9 6 MEDICAL DIAGNOSIS Tenderness. Common cause of backache. Easily tested. Long symptomless. Source of symptoms. Effect of posture. nate with paroxysms of a most excruciating type, the pain sometimes shoot- ing from above downward and giving the sensation of an actual shock as it reaches the heel. Subjective numbness, tingling, and disturbed temperature sense may be present. Many cases with imperfect clinical manifestations occur. Very similar symptoms may be encountered in cases of impaired circulation due to productive or obliterative endarteritis of the lower extremities. The pulsation of the dorsalis pedis and posterior tibial arteries should, therefore, invariably be tested and bilaterally compared. Pressure Points. — Pressure applied to the middle of the thigh posteriorly, the sciatic notch, the posterior aspect of the knee and calf, the external malleolus or the dorsum of the foot reveals the points of tenderness. Sacro-iliac Pain. — This is usually a dull pain felt chiefly over the sacro- iliac joints, and, aside from actual disease, is encountered usually in joint strain or displacements. It is relatively common in pronounced "chronic congenital asthenia" in association with the tendency to poor nutrition, deli- cate physical structure, gastroptosis, nephroptosis, and the generalized muscu- lar and ligamentous relaxation which characterizes that common ailment. It is one of the commonest causes of chronic backache in women and may often be promptly relieved by a proper hip band, belt, or special corset which steadies and fixes the sacro-iliac joints. The condition, if of any marked degree, is readily detected by the pain in the joint and spasm of the musculature which results from any attempt to stoop low with straight knees. Cervical Ribs. — This congenital anomaly may be bilateral (80 per cent) or unilateral, palpable or impalpable, troublesome or symptomless, and the accessory rib itself may be either long, or, short and "stubby," but all, or practically all arise from the 7th cervical segment. If bilateral they may be wholly unlike in the degree of development. If symptom-producing, this effect is manifest only in adult life, coincident with increasing rigidity of the bony structures and the dropping of the shoulders which usually initiates and confirms the pressure symptoms. Even when bilateral and palpable as to one, the other may be revealed only by roentgenography. Oftentimes both are easily detected by the fingers in the supraclavicular fossa. The condition is unquestionably commoner than previously assumed, but, relatively, is rare. Symptoms reflecting pressure upon the brachial plexus (chiefly repre- sented by neuralgia or neuritis along the area supplied by the nerve of Wrisberg or the ulnar), the subclavian artery and its vein. The phrenic is sometimes affected and in a few instances disturbances of the sympathetic have been reported. The condition should ever be in one's mind when meeting obscure symp- toms such as might result from this condition. In some instances pain is present only when certain postures are assumed PHENOMENA AND SIGNIFICANCE OF PAIN 97 and is relieved by standing erect with shoulder- thrown back, raising the arms above the head or sleeping on the back without a pillow. Miscellaneous Neuralgic Pains. — Pains of a neuralgic type may of course occur in any region of the body, and be confined to a single trunk or even a single terminal. Thus it may be limited to the breast (mastodynia), finger (digital neuralgia), the plantar nerves (plantar neuralgia), or be associated Fig. -Double cervical rib. A frequent source of diagnostic errors, with relation to«neuritic or neuralgic pain and obscure localized circulatorv disturbances. 5. Bissell.) {Dr. Frank with the stretching of the plantar ligaments in incipient flat-foot, in which case the pain is in some instances limited to the third and fourth metatarso- phalangeal joints (Morton's foot). Persistent moderate pain or discomfort, associated with hyperesthesia about the lower zone of the left breast, is a common and important, though inconstant, sign of a cardiac insufficiency, often temporary, with or without associated valvular lesions, and in most instances easily remediable. 7 9 8 MEDICAL DIAGNOSIS Tenderness extreme. Trophic changes. Tenderness on pressure. In many cases the area of maximum tenderness follows the lower left border of a dilated insufficient laboring heart as it contracts toward the median line under rest and cardiac stimulation.* Lumbo-abdominal neuralgia is characterized by pain in the back, buttocks and loins, radiating to the genital and hypogastric regions, and by areas of superficial tenderness. It is commonly associated with chronic toxemia, general debility, chronic constipation, disease of the pelvic organs and exposure to wet and cold under conditions of fatigue. In femoral neuralgia the pain is limited to the front of the knee and outer front of the thigh. In diseases of the hip-joint the reflex knee pain (inner aspect) is extremely common. NEURITIS.— The distribution of neuritic pains and their general char- acteristics are of necessity much the same as in neuralgia, though much more severe and persistent. Pain Severe and Persistent with Exacerbations. — The disease may be acute or chronic, circumscribed, and limited to a single trunk, or widespread and multiple. Distinctly inflammatory in type it tends to produce primarily and essen- tially a degeneration of the affected peripheral nerves. Aside from the more persistent and constant character of the pain, and its intensification by movement or passive congestion of the affected area, the exquisite tenderness on pressure over the nerve itself is characteristic. Furthermore, in severe cases there is a special tendency to marked cutaneous hyperesthesia followed by anesthesia and such marked changes as redness or pallor, edema or joint swelling and herpetic eruptions. In the extremities the skin often becomes characteristically glossy through trophic changes, and the disturbances of nutrition are indicated by muscle atrophy, the reaction of degeneration, loss of dependent reflexes, changes in the nails, loss of hair, desquamation of the epidermis, etc. True swelling of the nerve trunk and an erythema indicating its course may be present and if the. motor fibers are affected, changes appear, varying from easily induced fatigue and slight loss of power to actual paralysis. Many, if not most, of the cases characterized by shoulder -girdle pain, a type extremely common and usually termed neuritis, are attributable to bursitis rather than neuritis. MUSCULAR RHEUMATISM.— This common and painful ailment most often affects the lumbar muscles {lumbago), muscles of the chest {pleurodynia) and the cervical muscles {rheumatic torticollis). In all its forms, the chief characteristic is pain on movement, which produces more or less characteristic attitudes, almost complete loss of function and voluntary rigidity. Fundamental Diagnostic Points. — One of the most important points of distinction as between this painful affection of the muscles, and neuralgia, * A beautiful demonstration of the onset of such pain and localized tenderness was recently given by an acute gross dilatation of the heart, occurring in the author's office, from the effect of fright. PHENOMENA AND SIGNIFICANCE OF PAIN 99 neuritis, pleurisy, and such other affections as it may simulate, lies in the fad that diffuse tenderness of the involved muscles themselves, when grasped, is a prominent feature; that pain is distinctly related to muscular contraction, and that it is absent or greatly ameliorated when the muscle is at rest. The disease is due undoubtedly to a definite infection in most instances and is closely allied to that form of acute or subacute rheumatism which primarily and chiefly affects the tendons. GENERAL COMMENT. — In the majority of painful ailments the seat of pain represents more or less exactly the location of the affected part, and any attempt to list the enormous variety is j 'utile and useless. The more important referred pains are described under the diseases of the different organs. Shoulder Pain. — It should be remembered, however, that shoulder pain may be due to local disease of the joint, sprains or fractures, neuralgia, neuritis, bursitis, tenosynovitis, myalgia, trichinosis, disease of the diaphragm or of the colon flexures, angina pectoris, aneurysm, the minor anginas of cardiac insufficiencies of various types, and, on the right side especially, to inflammatory diseases of the liver, gallbladder, duodenal abscess, and, it is said, to movable kidney.* Pain at the inside of the knee suggests hip-joint disease; down the front of the thigh, ovarian and testicular disease, or sometimes a developing or established femoral or inguinal hernia. Pain radiating to the fold of the groin or to the testicle is common in renal colic. Headaches have already been discussed and the author is convinced that they will not conform to any arbitrary classification according to location, though such has been attempted under the older, etiologically inaccurate, grouping. Sacral and mid-lumbar pain is frequently due to the drag of a large, fat, pendulous abdomen or is of uterine origin, and movable kidney is often asso- ciated with a painful area over the corresponding sacro-iliac joint, probably due to coincident ligamentous relaxation so common in the congenital asthenia of which visceroptosis is part and parcel. Neuralgic coccygeal pain indicates coccygodynia, but equally sharp pain may accompany rectal fissure. Aside from these factors backache, usually low down, may indicate asthenia, pelvic disease, excessive fatigue, spinal caries, renal disease (loin weariness is especially common), excessive venery, sacro-iliac disease, strain or displacement and various other conditions. "Flat-foot" must be borne in mind as a cause of pain, not only in the feet and legs, but, occasionally, of the back as well. Pain under the scapula, when not pleuritic, most commonly indicates hepatic lesions if on the right side; cardiac, gastric, colonic or splenic disturbances, if on the left; but may be due to any one of many other causes. * The last is a most dubious statement with relation to one of the commonest of con- ditions. No such connection has been observed by the author. Muscle con- traction pain. Seek a focal infection. Knee, groin, or thigh pain. Futile classification. Lumbar pain. Lower spine. Common and important. roo MEDICAL DIAGNOSIS Often cardiac. Lower-abdominal-quadrant pain suggests colitis, sigmoid irritation, ap- pendicitis, hernia, ovarian or uterine disease or varicocele. Pubic pain is chiefly attributable to the pelvic organs and cystitis. Epigastric pain covers gastric and duodenal ulcer, certain cardiac insuffi- ciencies and actual anginas, splanchnic arteriosclerosis, early appendicitis, functional gastric disease (pyloro-spasm, neuroses, displacement), pancreatic and vertebral diseases, the referred pain of pleurisy, pneumonia, etc. The "girdle sensation" follows the waist line, represents constriction rather than pain, and points to injuries or tumors of the spinal cord and its meninges, chronic myelitis or locomotor ataxia. In the back interscapular pain is often troublesome and usually indicates mere indigestion or flatulent distention, though aneurysm, cardiac insuffi- ciency, gastric ulcer and caries must not be forgotten. Median dorsal pain at the shoulder level may also occur in aneurysm, pericarditis, and diaphragmatic irritation. Ulcer of the stomach may pro- duce median pain lower down, with tenderness to the left of the spine over the tenth and eleventh interspaces. Pain in' the heel may be due to sciatica, gout, ovarian and testicular lesions, intra-abdominal growths or prostatic disease. General aching is a common symptom of nervous and muscular debility or fatigue, usually precedes the onset of acute infectious diseases, and is common in acute and chronic rheumatism, trichiniasis, scurvy) locomotor ataxia, gastrointestinal or hepatic diseases and anemia. A loaded, overstretched colon, spastic constipation or mucous colitis may produce most extreme paroxysmal distress. TENDERNESS Usually Indicates Structure Involved.^ — In inflammations of accessible structures tenderness is associated with pain and usually conforms in position to the organ affected. The Head. — A tender scalp suggests syphilis, hysteria, rheumatism, neuralgia and migraine; tenderness of the malar bone, neuralgia or antrum disease; of the mastoid process, a neuralgia, periostitis, inflammation of the local gland or mastoiditis. Tenderness at the back of the neck suggests caries, sinusitis or asthenia; linear or interrupted spinal tenderness, asthenia, rheu- matism, caries, periostitis, actual spinal disease or hysteria. Lumbar tender- ness is common in lumbago and inflammatory disease of the related intra- abdominal structures; dorsal tenderness in advanced thoracic aneurysm or posterior, mediastinal tumors of any kind. A tender sternum or ribs suggests ostitis or periostitis but is often encountered in the major and minor anginas of cardiovascular disease. Abdominal tenderness is related to all acute and many chronic diseases of the contained viscera, and if wholly superficial suggests neuralgia, referred pleuritic pain or hysteria. Hypogastric tender- ness is usually directly related to acute or chronic inflammation of the under- VARIOUS SENSORY PHENOMENA TOI lying structures. The tenderness of sciatica like its pain occurs chiefly at the sciatic notch, the middle of the thigh and knee, the ankle and heel. Joint tenderness is often puzzling and suggests rheumatism, arthritis defor- mans, synovitis, gout, gonorrhea, tuberculosis, sepsis, hysteria, or simple sprain according to the conditions developed by the case history. PERVERSIONS OF SENSATION.— Paresthesias.— Those disturbances of sensation so denominated may be wholly unrelated to organic disease of the brain and cord. Among the more important are: 1. Subjective Sensations of Heat and Cold. — These sensations suggest asthenia, malnutrition and anemia, as well as hysteria, lateral sclerosis, syringomyelia and locomotor ataxia. In profound toxemias, such as alcoholism or in actual disease of the cord, they are usually combined with other paresthesias. The distribution may be general or local, the sensation indefinite or exactly like actual contact with a hot or cold object. Hot flushes both subjective and visible are among the commonest events of the menopause. 2. Formication and Itching. — Itching may be pronounced in hysteria, neurasthenia, chronic alcoholism or gout, lead poisoning and various diseases of the cord. It is almost invariable in jaundice and one of the signs indicating the taking of morphin (nose rubbing). Both itching and formication may antedate or foHow an apoplexy and the latter is a common symptom as. a result of actual irritation, diseases of the brain and cord, diabetes, cocainism and pelvic disturbances. 3. Numbness and Tingling. — Often associated with decided burning sensation, these symptoms are especially common in connection with the exacerbations of high arterial pressure of chronic interstitial nephritis, in productive or obliterative arteriosclerosis of the extremities, neuritis, or pressure irritation of nerves and the use of such a drug as aconite, in addition to the causes of formication and itching before mentioned. Oppression.— The sensation known as precordial oppression or compres- sion is common in mediastinal tumors, cardiac and aortic disease and arterial hypertension with myocardial disease as well as in certain pulmonary lesions. In hemoptysis it may either precede or accompany the visible hemorrhage. Epigastric oppression may also be present in gastric and hepatic disease, but is more common in the functional digestive disorders or in hematemesis. It is a very common symptom of minor, but important, cardiac insufficiency. Head constriction is almost invariably associated with hysteria or psychas- thenia, and pelvic oppression or "bearing down," is usually due to actual pelvic disease or in the male to diseases of the bladder or prostate. Faintness and "Sinking" Sensations. — In major angina pectoris such sensations, together with severe precordial oppression, extreme pain, and a sense of impending dissolution, form an agonizing and terrifying complex. Lesser degrees are common in gastrointestinal ailments (chiefly functional), concealed or open hemorrhage, in all of the cardiac diseases, in asthenia with dilated or readily dilatable drop heart, hysteria, and especially in asthenic hypochondriasis. Morphinism and cocainism. Precordial type. Epigastric type. The "band sensation." Serious vs. trivial causes. 102 MEDICAL DIAGNOSIS Wide etiologic range. The attack. Fatal syncope. False syncope Heart-burn. Psychic vs. Physical fag. Test of brain fag. May be cardiac. Important distinction. Syncope. — This maybe purely a nervous manifestation, sometimes related to terrifying sights and sounds or violent emotion. It may accompany actual disease of the heart or blood vessels, follow the aspiration of ascitic or pleural exudates, a large hemorrhage, or surgical operation, arid may also be the result of pain, exhaustion, excessive heat, or the overadministration of certain drugs. The sudden and extreme pallor and the weakness of respiration and heart action which may cause the loss of the pulse beat at the wrist and an apparent arrest of breathing, are usually momentary and often preceded by vertigo and nausea. Temporary loss of consciousness occurs in all severe seizures and in some instances, demonstrable, transitory cardiac dilatation is coincident. Fatal syncope is a not uncommon event in many serious diseases and may constitute a most distressing accident in pneumonia, diphtheria, pericardial effusion, endocarditis, the removal of large exudates or transudates, and many other conditions aside from primary diseases of the heart muscle. Hysterical women frequently simulate syncope but the hysterical facies, retained color, the pulse and usually, a lack of the absolute immobility and relaxation characterizing true syncope, make detection easy. In doubtful cases, sharp and sudden pressure over the ovaries may resolve all doubt as the malingerer often shows an excessive tenderness in the ovarian region. Subjective Sensations of Heat and Morbid Flushing. — Fatigue, hysteria, pelvic disease and the menopause are the most frequent causes of troublesome flushing (" hot flashes") and in certain individuals causeless blushing is a troublesome phenomenon. The sensation of epigastric heat known as pyrosis is frequently associated with a sense of excessive fullness as distinct from the pressure sensation previously described and is most common in the functional disturbances of the stomach. Subjective Weakness. — In hysteria and asthenia or in mere temporary "brain fag," a patient may experience a sense of positive physical fatigue; or, in the former, pseudo-paralytic symptoms either transient or persistent may occur. In mere "brain fag" the factitious sensation of physical " exhaustion" may entirely disappear under active and strenuous exertion or be forgotten in the interest excited by a good play or book. It is frequently due to lack of exercise, the overuse of tea, coffee. and tobacco, or to insufficient sleep. Fatigue, persistent or readily induced, is also one of the commonest symptoms of cardiac insufficiency, as is demonstrated in the myocardial toxemias of acute infections and must be given its full value in diagnosis and treatment. "Globus hystericus ,, is a sensation of obstruction, constriction, pressure or tickling referred to the throat. It is common in hysteria, and may be associated with troublesome spasm, but represents too often a misinterpreta- tion of the genuine choking, sense of oppression, compression, or clutching so commonly present in minor and major cardiac insufficiencies, with result- ing errors of omission more or less disastrous to the patient. INSOMNIA AND VERTIGO IO Causes manifold. Scope of inquiry. INSOMNIA. — This troublesome symptom may take the form of inability to sleep, disturbed sleep, starting during sleep, early waking or prolonged wakeful periods. Its causes, too varied to permit full discussion, vary from mere worry or temporary nervous excitement to actual disease of the cardiovascular system or of the brain itself. Inquiry should include the condition of the stomach and bowels, a careful examination of the urine, heart and blood vessels and the estimation of arterial tension, the mental work done, quantity of tea, coffee, tobacco and alcohol consumed, exercise taken, unusual sources of worry and mental strain, excessive study at night, eyestrain, and the age of the patient. Frequently a light lunch at bedtime, slight modification in the diet, hours of meals, relation of exercise to the meals, the cutting off of excesses I of any kind or the mere admission of fresh air at night to the sleeping-room Trivial or 1 mi , , • * , , . intractable. will put an end to attacks of insomnia. If asthenia be the cause, nothing short of a prolonged rest or recreation cure is of any use. Occasionally climatic change alone will produce sleep and permanently correct the dis- turbance, while, not infrequently, relief follows a complete cessation of all conscious efforts or devices to induce slumber. In both acute and chronic disease the amount of sleep obtained by the patient is important and should be as carefully noted as is the food intake. Insufficient sleep during the twenty-four hours is always the chief point to be determined, rather than the question of how the nights pass. One frequently finds that naps during the day are accountable for dis- turbed and broken nights and that the total slumber for twenty-four hours is actually in excess of the needs of the patient. ' It is perhaps unfortunate that a minimum of eight or ten hours of sleep has become a fixed standard regardless of occupation and individual require- ment. The small amount of sleep which suffices for the needs of healthy indi- viduals who are habituated is oftentimes most striking. Drowsiness during the day and early waking or disturbed sleep at night a much constitute a common symptom of cardiac insufficiency, and are often promptly cause. relieved by appropriate measures directed to the strengthening of the heart. Old people undergo a slowly progressive circulatory inadequacy and are, as a rule, early wakers and light sleepers, the conditions of childhood being reversed. VERTIGO. — (Giddiness, li Swimming of the Head"). — Vertigo is , in most instances, a trivial and transitory symptom depending upon impacted wax in the auditory canal, disturbances of digestion, eye- strain, or asthenia, but nevertheless should always receive careful attention. In the young the causes are usually trivial and removable, though in per- sistent cases brain tumor and minor epilepsy must always be considered. The young vs. Usually trivial. In the middle-aged and old it is much more significant, gation indicated are as follows: The lines of investi- 104 MEDICAL DIAGNOSIS Varieties of Vertigo. — Vertigo is usually sudden in onset and intermittent or periodic in type. Usually a sudden change from the recumbent to the erect posture initiates it, and it may be limited to the early morning hours. It may take the form of a subjective sensation of whirling or falling which persists with the eyes closed, or may occur only when looking at moving objects, as in riding, driving, swaying, or swinging. 77 usually disappears or is greatly relieved when the patient is tying down, but in some instances, and, notably in its arteriosclerotic form, is often increased by lying down. Points to be Remembered. — Persistent vertigo not distinctly associated with the eye, accessory sinuses, ear, digestive disturbances, or asthenia, demands a thorough investigation of the heart and blood vessels, the urine, the reflexes, syphilis, possible epilepsy and even brain tumor and shoidd include an examina- tion of the fundus oculi. (a) The Existence of Asthenia. — This condition covers by far the greater number of persistent or persistently recurrent cases in persons under the age of forty and is often associated with coincident digestive trouble, cardiac overstrain, eyestrain, anemia, hysteria, malnutrition, or even the habitual use of narcotics or stimulants. (b) Meniere's Disease. — This condition is supposed to be due to disease of the labyrinth or semicircular canals and is characterized by the association of vertigo with tinnitus aurium and a tendency to fall to the left or right (see "Meniere's Disease"). (c) Arteriosclerosis and Cardiac Disease. — This vertigo covers the greater number of cases observed in elderly people. It is important as re- lated to exacerbations of high arterial pressure and the threat of apoplexy, to aneurysm, aortic regurgitation, arteriosclerosis, arterial spasm, and other cardiac lesions or cerebral disturbances due to other causes. (d) Sunstroke or heatstroke sometimes leaves behind a marked vertiginous tendency. (e) Eye Strain. — Errors of refraction and ocular insufficiencies should be carefully investigated. (/) Epilepsy. — Vertigo may be either an aura of major epilepsy, or repre- sent an attack of petit mal. The condition of the stomach and bowels is of great importance and constipation is frequently responsible for recurrent vertigo and pseudo-epilepsy in spasmophilic cases. (g) Lesions of the Brain and Cord. — Brain tumor, abscess, meningitis, cerebellar and pontine lesions, cerebral syphilis, cerebral thrombosis, general paresis, locomotor ataxia and disseminated sclerosis may be associated with varying degrees of vertigo. (h) General Diseases. — Vertigo is frequent in auto-intoxication, gout, Bright's disease, febrile states, extreme weakness, as in severe anemias, the cachexias and convalescence from acute diseases. (i) Reflex. — Auditory vertigo due to conditions other than Meniere's disease, as in cases of ear-drum pressure; naso-pharyngeal vertigo due to pressure within the nose or in the sinuses; laryngeal vertigo associated DYSPNEA 10 usually with a coughing tit in laryngeal affections — are the leading reflex types. (j) Gastric Disturbances. — These are held accountable for one of the commonest forms of vertigo. (k) Excesses. — The habits in relation to the use of tea, coffee, tobacco, alcoholics, and the question of sexual excess, should be carefully investigated. DYSPNEA Clinical Definition. — The term "dyspnea" should be limited to those cases of labored, regular, arrhythmic, or greatly accelerated, respiration in which there is insufficient oxidation of the blood, whether this be due to heart weakness, actual obstruction to the free ingress or egress of air, a diminished pulmonary area, or to other causes of impairment of its chemical exchanges. The term il accelerated breathing" or a specific descriptive term should cover other varieties. Subjective vs. Objective Dyspnea. — Dyspnea may be purely subjective and represent a sensation of oppression or respiratory inadequacy without marked increase in frequency or disturbance of rhythm, but severe dyspnea is usually both subjective and objective and associated with varying degrees of cyanosis. Subjective Dyspnea. — The mere sensation of dyspnea is practically limited to cardiac insufficiency, uremia, and psychasthenia, and even though orthop- nea be present there is oftentimes no associated cyanosis. Obstructive Type. — Any condition preventing the free entrance of air into the lungs will cause dyspnea, hence it accompanies severe quinsy, and marked narrowing or stenosis of the glottis, trachea or bronchi, whether the cause be direct obstruction, tumor or foreign bodies; inflammation, as in the case of laryngeal diphtheria and pneumonia; or spasm, as in croup or asthma. Stridor. — (Usually due to glottic obstruction). — Stridulous breathing is invariably of laryngeal origin and usually due to spasm, paralysis, edema, foreign bodies, membrane, tumor or severe inflammation of the glottis. In certain cases it represents pressure on the nerve trunks and resulting spasm or paralysis of the laryngeal musculature, as in aneurysm, enlarged bronchial glands, massive pericardial effusions, etc. It is typified by the "crowing" of a croupy child, and invariably represents true dyspnea of the obstructive or stenotic type. Its diagnostic features are stridor (whistling, hissing) and a pronounced inspiratory descent of the larynx; this movement being so great oftentimes, and especially in short-necked children, as to embarrass the surgeon in tracheo- tomy. The breathing is slow in obstructive dyspnea so long as respiratory power re- mains good. Circulatory Dyspnea. — Other cases are referable to circulatory dis- turbances, especially those of incompensated mitral and tricuspid lesions, in which instances the condition is largely one of pulmonary stasis, the aeration Both are important A vitally im- portant sign. Crowing." Pulmonary stasis. io6 MEDICAL DIAGNOSIS Emphysema and pneumonia. Lung fibrosis and tuberculosis. Anemia, uremia, and diabetes. Snoring respiration. Diabetes. Of great importance. Significance. Inspiratory vs. expiratory dyspnea. Misleading paroxysmal dyspneas. areas being normal, but the blood current obstructed and its chemical ex- changes diminished. In other instances both factors are concerned, as, for example, in emphy- sema and acute lung diseases where there is both pulmonary stasis and insuf- ficient air exchange. To a less degree the same conditions prevail in pulmonary fibrosis, the pressure of tumors or of pleural or pericardial effusion and in advanced pul- monary tuberculosis. In the last instance the amount of dyspnea present when the patient is at rest is often strikingly disproportionate to the area of lung involved though usually evident upon exertion. In severe anemias the impaired hemoglobin content alone or a combination of circulatory and hemic insufficiency is accountable, and, in uremia and diabetes, toxemia is the prominent feature. Stertorous Respiration. — In cases of profound coma, extensive post-nasal adenoids or chronically enlarged tonsils, as well as in ordinary sleep in certain individuals, there is a snoring respiration which is not, however, a true dyspnea. Air Hunger. — This peculiar form of dyspnea is best illustrated in diabetic coma and best described by the name given. (See Diabetic Coma.) Dyspnea on Exertion. — This symptom, vitally important whether sub- jective or objective, accompanies severe chronic bronchitis, emphysema, early tuberculosis, pleural effusion of the latent type, anemias, uremia, ex- hausting diseases or debility, obesity and imperfectly compensated cardiac lesions. Persistent Dyspnea. — This indicates severer grades of the conditions mentioned in the preceding paragraph, stenosis of the air passages or certain profound toxemias. It is particularly marked in obstructive lesions, terminal cardiac incompensation and advanced emphysema. Inability to Hold the Breath. — Inability to hold the breath may be a part of any severe dyspnea, and is not infrequently the only evidence of that con- dition in certain minor cases of cardiac incompensation. Paroxysmal Dyspnea.- — The commonest pulmonary forms are croup, laryngismus stridulus, and true asthma; the two first mentioned being of the type of inspiratory dyspnea, the other predominatingly expiratory. Spasm of the glottis is a component of the spasmophilic diathesis but in various forms and degree may be associated with hysteria as well as with organic nervous disease. True Bronchial Asthma. — This may be perfectly simulated by the dy spneic paroxysms sometimes observed in uremia, by similar seizures due to medias- tinal pressure, and by that paroxysmal- dyspnea alternative of angina pectoris for which alone the term " cardiac asthma" should be reserved. The ordinary form of dyspnea associated with cardiac disease is non- paroxysmal, and extreme only under exertion, in cases of massive pulmonary embolus, or as the result of the pressure of secondary transudates. In terminal decompensation, certain cases of aortitis or an associated pulmonary edema, very severe types of dyspnea may occur, often paroxysmal. ORTHOPNEA AND VARIATIONS IN KJ'.SIM KA T< >K V RUN I MM IO7 Pedunculated tumors below the glottic chink may cause violent and even fatal paroxysmal dyspnea. Cases of spasmodic paroxysmal dyspnea due to aneurysm of the aortic arc/; produce most misleading pseudoastlimalic seizures which repeatedly have deceived the elect. Associated Changes in the Chest Outline. — Certain permanent changes, such as the forced inspiration type of emphysema, the unilateral enlargement of chronic pleural effusion or tumor and the unilateral retraction of fibroid phthisis and pleural adhesion, need no further description here. In asthma, the lower diameters of the thorax are increased during the paroxysm because of the expiratory type of the spasmodic dyspnea. In broncho-pneumonia and other forms of obstructive dyspnea a marked inspiratory narrowing and recession of the interspaces occurs because of the inspiratory negative pressure and the direct drag of the diaphragm. This need not be confused with the slighter contraction sometimes observed in chronic emphysema, visceroptosis and even in normal individuals. Orthopnea. — This term refers especially to a dyspnea induced or intensified by recumbency and demanding the sitting attitude for its amelioration or relief. It is most commonly noted in cardiac incompensation, spasmodic asthma, advanced emphysema, certain of the pleural or pericardial effusions, thoracic aneurysms, mediastinal growths and abscesses, or gas or fluids causing pressure within the abdominal cavity sufficient to embarrass diaphragmatic movement and obstruct the action of the heart or lungs. In some instances, as stated previously, the patient must not only sit up, but at times stand erect. In others he is comfortable only when leaning forward.* In some instances a subjective sense of suffocation may compel the abrupt assumption of a sitting or even erect posture. As stated previously, death may follow the natural attempt of the attendant to forcibly restrain the patient and outweigh the risk involved in the sudden exertion. The physician must decide whether the action is obligatory and represents a genuine uncontrollable necessity or is merely an expression of extreme nerv- ousness or intractability. VARIATIONS IN .RESPIRATORY RHYTHM.— Mere irregularity is common in children whether awake or asleep. It also appears as an ominous sign in massive cerebral apoplexies, brain tumor, meningitis, shock and collapse, and not infrequently as a symptom of chorea. Jerky Respiration. — This may be inspiratory as in hydrophobia or hy- steria, or expiratory and often grunting in intercostal neuralgia, acute pleu- risy, rib fractures, stab wounds, renal and gall-stone colic, or in the presence of any paroxysmal pain, especially of the abdomen. Wavy Inspiration. — This is characterized by an undulatory movement of the chest and may occur in severe typhoid, pneumonia, and other conditions associated with great prostration. Biot's Respiration. — This term applies to respiration interrupted regularly or irregularly by apneic intervals of varying length. Seen most frequently * It has been stated that this latter position is pathognomonic of acute aortitis, but in the author's personal experience it is a common symptom in mediastinal tumor. Aortic aneurysm. Broncho- pneumonia. The obligatory sitting posture. Extreme instances. Scylla and Charybdis? Trivial or ominous. Inspiratory or expiratory. Respiratory undulation. io8 MKDICAL DIAGNOSIS Portentous if marked. A precursor of death. Wide range of incidence. May exist for years. Exhaustion of center. Overaction. Recurring exhaustion. Prolonged seizures. An agonizing complication. in meningitis; it may be encountered in pneumonia in a moderate form, and is ordinarily a precursor of death. Cheyne -Stokes Breathing. — This term covers irregular breathing inter- rupted by apneic intervals but characterized by the fact that, following a pause, the respiration recommences as shallow slow breathing, steadily increasing in depth and frequency until a maximum is reached, when it subsides in the reverse order. It may accompany the coma of organic disease of the brain, apoplexy, tumor, uremia, opium poisoning, severe or terminal myocardial decom- pensation arid meningitis. It may also be observed in diabetes and various acute infections, such as cerebro-spinal fever, septicemia, typhoid, pneumonia and the exanthemata. In feeble children, and in the aged, it may occur during sleep and, in rare instances, in the adult suffering from the chronic diseases mentioned above it may be present both waking and sleeping for long periods. In an ambulatory case reported by Osier it was so severe and troublesome as to interfere with eating. Traube's theory of lowered irritability of the respiratory center, if com- bined with the fatigue hypothesis of Rosenbach, would adequately cover the phenomenon. This would assume a primary, progressive, preliminary ex- haustion of the respiratory center arising from the chronically insufficient blood supply, a resultant temporarily diminished excitability of the center, and a recurrent and more or less rhythmic overreaction which is due to the cumulative increase of the asphyxial stimulus during the period of apnea, and continues through the first imperfect series of renewed respirations. The deeper breathing of the fastigium temporarily adjusts the balance but so exhausts the center that no response occurs until the period of apnea has again so vitiated the blood as to. produce again an excessive stimulus. Increased Frequency. — Mere fever increases frequency as do most dysp- neas not stenotic in type, and it often accompanies pulmonary, cardiac, and renal lesions, andvneuroses. Slow breathing is commonly seen in coma, collapse, and all conditions associated with stertor. Hiccough. — This sudden spasmodic contraction of the diaphragm, often temporary and negligible, . may become one. of the most serious complications of acute or chronic disease. The attacks, ordinarily short, may be prolonged for days or. weeks and rapidly exhaust the patient. Causes. — Hiccough may be due to (a) organic or functional disease of the nervous system; (b) of the abdominal organs; (c) constitutional diseases, (d) miscellaneous causes, such as dyspepsia, flatulence, severe acute infections, the typhoid state, alcoholism, pneumonia, pulmonary gangrene, chronic heart disease, pregnancy, etc. It would be useless to give in detail the various conditions with which it is associated as it may occur in any exhausting disease, acute or chronic. Oc- curring with inflammation of the diaphragm, whether from the pulmonary or peritoneal side, it constitutes an agonizing complication. SHOCK AMi COLLAPSE iog SHOCK AND COLLAPSE.— Shock.— Patients suffering from the severer grades of shock show pallor, a lowered temperature, a cold wet body surface, a weak thready pulse, slow, shallow and often sighing respiration, great physical weakness and prostration. The Hippocratic countenance or at least an expression of great anxiety is present. All of these grave symptoms are combined in many cases with extraordinary mental calm and clearness and oftentimes with a great amelioration of, or entire freedom from, any preexisting pain. The ominous subsidence of any antecedent or initial pain and mental dis- tress is often misleading. Among other causes of shock are acute hemorrhagic or suppurative pan- creatitis, strangulated hernia, severe accidents, particularly those attended by crushing violence, and, in its lesser degrees, certain of the severe acute infections, renal and hepatic colic, angina pectoris, and other conditions associated with extreme pain* Collapse. — This is commonly associated in medicine with those intra- abdominal diseases which have a surgical side, for example, perforation of the appendix, of a gastric or duodenal ulcer or hepatic abscess, but the term applies to any case in which extreme depression of the vital forces and cir- culatory failure arise. Concealed Hemorrhage. — An extensive open hemorrhage almost in- variably alarms and excites its victim but serious internal and concealed hemorrhage presents symptoms of shock and collapse together with a certain curious restlessness and oftentimes yawning, nausea and air hunger. Sources of Concealed Hemorrhage. — Among the most common are hemothorax, aneurysmal rupture, duodenal ulcer, typhoid, gastric ulcer, ectopic gestation or pelvic hematocele from any cause, traumatism, the hemorrhagic diathesis, and very rarely in pulmonary tuberculosis a large hemorrhage into an old cavity which may for a time be concealed. In any obscure case of shock or collapse the stools should be carefully ex- amined for blood and in married women the possibility of ectopic gestation cannot be ignored. The clear mind so often encountered in the earlier stages may later yield to a low delirium and, occasionally, convulsions. * The student should read the recent papers of Dr. Crile as expressing the most modern theory of shock and its prevention. He shows the effect not alone of trauma but of psychic and toxic factors upon the cerebral and spinal nerve cells. Striking facies. Surgical associations. An important syndrome. no MEDICAL DIAGNOSIS Scope and value. Necessity of thorough training. DISEASES DEPENDENT UPON OR ASSOCIATED WITH CHANGES IN THE BLOOD OR BLOOD-MAKING ORGANS AND DUCTLESS GLANDS EXAMINATION OF THE BLOOD.— This department of medicine, valu- able alike to the internist and to the surgeon, affords a means of exact diagnosis in syphilis, malaria, the leukemias, filariasis, relapsing fever, typhoid fever, Malta fever and trypanosomiasis: fundamental evidence in cases of per- I nicious anemia, chlorosis, secondary anemia, Eodgkin's disease and diabetes mellitus, and valuable corroborative evidence in the acute pneumonias, ap- pendicitis, septic infections, trichiniasis , lead poisoning, gout, malingering, cer- tain cases of malignant disease and many other ailments. In addition one must consider the valuable information represented by negative blood findings. The blood is the circulating medium for the exchange of cell food, chemical substances acting as stimuli, and excretory and secretory products of the vital activities. The products of the glands of internal secretion, actual nutritive sub- stances and simple or complex chemical substances initiating heart action are examples. It removes alike the strictly excretory substances and the toxins of disease. Blood bacteriology, serology and parasitology and the refinements of blood chemistry and physics do not fall properly under discussion. This section has to do almost exclusively with blood morphology as modified by disease. Thorough laboratory training and accurate, painstaking work are essential to success and it is unfortunately true that a large proportion of the findings obtained under other conditions are quite worthless and often most damaging. Scope of Section. — It is obviously impossible to deal seriously with ser- ology or the refinements of blood pathology in a book of this kind and the reader is referred to the many excellent special works dealing with these interesting and complex subjects. Only such diseases and diagnostic procedures as are of direct clinical importance and ready availability are dealt with in what the author hopes may prove a practical and adequate way. Clinical Essentials. — (a) The determination of hemoglobin, (b) The red cell count, (c) The white cell count, (d) The examination of fresh blood, (e) The examination of the smear preparation (i) stained, (2) unstained. (J) The study of the various "clump" or agglutination reactions in certain acute infections (serum diagnosis), (g) The study of exudates, (h) Complement- fixation tests. Clinical Tests of Less Importance. — {a) Counting blood plates, (b) Estimation of alkalinity, (c) Cryoscopy. (d) Specific gravity determination, (e) Coagulation period. (/) Determination of blood volume and ratio of cor- puscles to plasma, (g) Viscosity tests. THE EXAMINATION OF THE BLOOD III Terms in Common Use. — Anemia, a deficiency in corpuscles, coloring matter, or total blood volume. Oligocythemia, a deficiency of red cells. Oligochromemia, a deficiency in hemoglobin. Oligemia, deficient total blond volume. The total volume of the blood is about one-twentieth (J-£oth) of the body weight* and in severe anemias may be reduced 50 per cent. This may occur temporarily in severe hemorrhage or, more persistently as the result of repeated severe hemorrhages and also in the hemolytic and cachetic or inanition anemias of the more serious grades. Hydremia. — -This state represents a disproportionate amount of water in the blood either from loss of solids or actual water increase, aside from accidental temporary variations due to sweating, excessive ingestion of liquids and the like. The color of normal arterial blood is due to the oxyhemoglobin con- tained in its erythrocytes. Normally, the hemoglobin content of such blood lies between 13 and 14 grams per 100 c.c. with which is combined loosely about 21.6 per cent, by volume of oxygen, and 13 per cent., by volume, of CO2. Double that amount of CO2 is contained in the plasma of such arterial blood and the total C0 2 content of venous blood is by volume about 48 per cent. Practically all forms of non-obstructive dyspnea clinically- encountered are due to deficient oxygen content however induced. Leucocytosis. — The term is commonly used to denote an abnormal in- crease in the number of leucocytes, the polymorphonuclear type predomi- nating. The average per cubic millimeter is normally about 7500. Lymphocytosis. — An unusual increase in the number of mononuclear non-granular leucocytes. Leucopenia. — The opposite of leucocytosis and equivalent to hypoleu- cocytosis, an abnormally or unusually low leucocyte count. Plethora. — A term covering what was formerly supposed to be a patho- logical condition, but now used to indicate an increase in the total quantity of blood. The term "plethoric" is applied to those individuals with a ruddy countenance due to dilated or unusually prominent capillary network. The condition is now of slight clinical importance, though it is certain that there is a direct relation of the blood volume to the musculature and to the size of the heart. Polycythemia, an abnormal increase in the number of red cells may, rarely, be a symptom of importance, particularly when associated with en- larged spleen and cyanosis (erythremia) or acetanilid addiction. Color Index. — The color index represents the result obtained by dividing the hemoglobin percentage by the percentage of red cells. The normal figure for hemoglobin is 100; the corresponding erythrocyte standard being 5,000,000 cells in men and 4,500,000 in women. * By Haldane's carbon monoxide method. By Keith's method it is found to vary between one eleventh and one thirteenth of the body weight. Normal count. 112 MEDICAL DIAGNOSIS Sterilization. Bleeders. Best instrument. Example i. — In a given case the hemoglobin is 30 per cent., the red cells number 3,000,000, or 60 per cent. 30 divided by 60 equals Jfo5 a l° w color index, indicating chlorosis. Example 2. — Hemoglobin 30 per cent., red cells, 1,000,000 or 20 per cent. 30 divided by 20 equals 1.5; a high color index such as is found in pernicious anemia of the hemolytic type. Example 3. — Hemoglobin 50 per cent., red cells 2,500,000 or 50 per cent. 50 divided by 50 equals 1; a color index suggesting secondary anemia. To Obtain Blood for Examination. — It is essential that the actual technic should be thoroughly understood, and intelligently and expeditiously carried out. Precautions. — One should not trust to the flow of blood for sterilization either of the skin or the instrument employed. Fig. 26. — Matthews' microscope lamp with iris-diaphragm. {Todd.) The ear lobe or the finger-tip should be carefully cleansed with alcohol, bay rum, or some similar substance always available, and the needle or lancet used should be sterilized in the flame. The patient may be asked whether he u bleeds easily" or the reverse with a view of determining the size, depth of the puncture, and avoidance of serious complications in cases of hemophilia. Two cases of this kind in the author's clinic bled steadily for several hours from a very minute puncture.* For making the puncture an instrument with a sharp cutting edge should be used. The Hagadorn needle or the spring lancet with a trocar point is most suitable, the ordinary needles being poor substitutes. Some workers prefer to use a suitable piece of broken cover-glass which is firmly grasped between the finger and thumb at the point required to permit necessary penetration and at the same time limit the depth of the puncture. I *As a matter of fact the risk of any serious or fatal hemorrhage is practically negligible. I 111 1 XAMIN'ATION OF THK HI.OOI) H3 Form and size. quickly and smartly done the stroke is almost painless and the resulting blood-flow free. The puncture itself should be sufficiently free and deep to obviate Method. squeezing or excessive friction, and, furthermore, the instrument should permit a quick, painless stroke,* and the first two or three drops should be dis- carded. The blood should flow spontaneously and, to maintain it, light brisk friction serves admirably, but pressure should never be em- ployed. To check it, firm, steady pressure is sufficient, or in the case of the finger, vertical elevation of the arm. An edematous area or one in which local cyanosis is marked should be avoided in obtain- ing specimens for examination. The former yields a diluted bl,ood, the latter a mislead- ingly concentrated specimen. Care and Preparation of Slides and Cover-glasses. — All material should be of the best sort, % inch square cover-glasses being superior to the round, and both these and the slides should be thin. When received j ^r ; Y ^ from the dealer, they should be thoroughly 1 1 • a washed in soap and water and then placed in the following solution: Hydrochloric acid 1 part, absolute alcohol 29 parts, water 70 parts, or they may be placed in solution containing equal parts of alcohol and ether: When required, they should be wiped thor- oughly, polished with tissue paper or with soft linen, and, if convenient, passed through a flame. A small drop of blood will spread satisfactorily and evenly between a perfectly clean slide and its cover-glass or between two cover- slips, especially if these are slightly warm. Making the Smear. — To make a good smear preparation the cover-glass must be absolutely clean and a small drop only, should be lightly touched by one, the other placed quickly upon it, an instant allowed for the spread \ indispensable, of the blood, and the two separated by a sliding (not a lifting) movement, as shown. The cover-glass should never touch the skin. This is the best method for general use, for neither the "scrape" method nor the cigarette-paper procedure is well adapted to all specimens Fl ord^n7ry I me d th?d. ar ' of blood, least of all to smears taken in pernicious anemia. Another method consists in using the edge of one cover-glass and drawing it lightly across the drop or gently pushing the edge of the slide over the * Blood may be taken from young children in this way without arousing them from sleep. Fig. 27. — Handle-arm micro- scope: E, Eye-piece; D, draw-tube; T, body- tube; RN, revolving nose- piece; O, objective; PH, pinion head; MH, micrometer head; HA, handle-arm; SS, substage; S, stage; M, mirror; B, base; R, rack; P, pillar; I, Inclination joint. (Todd.) Preparation. Even spreads HJ.::. 1 .: : : a :-:•' : sn I-:.: : 1 ~ - -i "- - = - another, involves the use of an ordinary sewing needle, which is :z.:z.-.i 'lz -:ly ':-: :u;:Vly i;::~ :ir riir :i :Jir 11: thwrngkomt large arras *j **f jfeatf mot look to tie eye smeary or thick. If carefully preserved the dry wmstaimed :■:■:: ■■■*; :.:'' ?-:■:•: /> ■■:;-■;'■■: J ::::: :■.:- i:: ire:-: i: iiy ;-.iit :: :ie ;::- :ri-rr. : _: ne 5iine: i:r7i:::::ii ire ~ ::e irlllii::: :■:•:•: .:' lie r_: ii ■ e-ii-L'.r'.y 11:1x1 =l:-*iy ii: :i:ei_lly _.1;.'_*;1 .- irlei :'::" r 1 line may :e (cvcotd 1 emmbU ome to make gxd smears fort the resmlt is wefl worth ^%£tte< : 7::'.: ire: :es::i::::i :: lie :l:er ne.li.'ii : - ;::::;" 5~eir= m; : t ll: :':•: 117 :i -^::k ~ 111 ::: : _ : -..-.7 .t r.i:i :y iiy ::e of four shnple methods: (r) Passing the cower-siip through a - - - , ■ ■ ,T ■ ■ " - "■', ' "■ T • -'• ■ ~ ; ■ : ;' ?.*. ;;,-'•; ; l';:--zzi index, (f) Appro X : :lei : e ■ : : e-: — "Jl i li~.-_lr viicll ;';- : :■:' '■•-:: ..:■: : ; ; : /:' v-,.; ;.,"■;._- ; ;.;,":-: ;.; J :.:',:•", :;'■;■"-. :- ". : ^ I /■;::•:: —,:;'/> ;;'-. ::/,-;i; ;,y>~,;.; :•*, r^p;' Tie :l:e: ieirlm ~e:li:.:E ire :el::i:e :e:__:e ::: :•: : :::..:: : ?ie::il : ei :: :::yz; 5::re 2.1: ire -:■: leie^iiry :':: ::z\Lzzir/ :lm:il -:ri: :ei iily :::::.::: :y ill:— m 1 5 -ill 11:7 : : -ireiieveily . - t: i 7e:.e::ly iem n:'ie:i:e.y -urn ::ve:-5l;i i"i rare is valuable in the observation of : (a) Umkemia. (I) i~i iielr me': ::: n:ve-ei:i J ::t r.irt :i iiei: -i:~ x lapsing fever, (e) Trypanosomiasis, (f) Roulemmx forma- affltrim. (A) /jurrase o «,W >bfws. (i) Z#ar «Ifr rimate mmmber of red amd white eeOs. (h) Ceil deformity. --:•::-! .f .: ::l::lfii i^ily :r::i::_T _ii:i - _ :.t:: :: :t_ ::zzzz-z:~ :: txzz r:ZT— — Ii::fiic :: ir-:rfii if.emizei :: _rliy if:er lie y> 1: -Jir :: ixr-ilv :e my :e - _ 1 1 : es llir EXAMINATION HE BLOOD "5 No smear is made, but the cover-glass lightly touches the blood drop and is then placed upon the slide. The stage should be dimly illuminated to show the nbrin threads which frequently radiate from groups of blood plates. Fibrin is increased in pneumonia, acute rheumatism and various septic infections, and diminished in leukemia and pernicious anemia, typhoid Hyperinosis. fever, malaria, measles, variola. Graves' disease and various conditions associated with extreme inanition. In general the hbrin increase (hyperinosis) occurs in diseases in which leucocytosis is present though in leukemia itself a diminution (hypinosis) Hypinosis. occurs. Examination of the Stained Specimen. — Modern staining methods de- pend upon the selective affinity shown by the different constituents of the Basis of stain- cellular elements of the blood for certain anilin dyes, which are divided into three groups: (a) basic, (b) acid, (c) neutral. By using combinations one may in a single step attain differentiation. The basic dyes, such as methyl violet, methylene blue or hematoxylin (chrom- atin stains act chiefly upon nuclei. Acid dyes, such as eosin, orange G. or acid fuchsin are protoplasm stains, while neutral dyes (resulting from the mixture of acid and basic colors in solution) color beautifully the "neutro- phile" granules of the leucocytes. Staining Solutions. — Ehrlich's triacid or triple stain now has been dis- placed bv Wright's modification of Tenner's stain, an alkaline eosinate Rapid and . . . .... simple. of methylene blue, which, by at once fixing and staining the specimen, eliminates the laborious and delicate heating process of the older method. Wright's Modification of Louis Jenner's Stain. — The student or practi- tioner had best purchase the "soloid" tablets* or procure a solution ready made through some drug supply house, as the formula is somewhat complex.* It should be kept tightly corked to prevent precipitation.! * The "soloid" tablets of Burroughs & Wellcome offer a ready method of making up fresh stain. One soloid is tritrated with 10 c.c. of pure methyl alcohol, the dissolved stain decanted and the undissolved stain again extracted with another 10 c.c. of alcohol. This process is repeated a third time so that 30 c.c. in all is used. The stain should then be passed through a filter. + Formula. — (a) Make a 0.5 per cent, aqueous solution of sodium bicarbonate, place in Erlenmeyer plaque, add 1 per cent, of Griibler's medicinal methylene blue; place in steam sterilizer for an hour, (b) After cooling, add while stirring with glass rod. a 1-1000 aqueous solution of Griibler's water-soluble yellowish eosin until the color of the original mixture changes to purple and presents a lustrous yellowish scum upon its surface. (About one-fifth as much eosin solution as methylene blue solution will be found necessary.) (c) Collect this scum by filtration, dry it, and with it saturate methyl alcohol (100 c.c. of the latter will dissolve about1%o of a gram of the dry precipitate), (d) Filter and add 25 per cent, of methyl alcohol. The stain is now ready for use and, if kept tightly corked, should neither precipitate nor show impairment though kept for a long period. I The Giemsa stain is another Romanowsky modification of great value, but does not yield the best results with neutrophilic granules. T. M. Wilson's stain, yet another Romanowsky modification is used in many laboratories, but has no decided superiority to Wright's modification of the Jenner stain. n6 MEDICAL DIAGNOSIS Technic of Staining. — (i) The dried but unfixed smear is completely covered with the stain for one minute. (2) Distilled water is added to the stain on the cover-slip drop by drop until a greenish metallic scum appears and the margins sJtow a reddish tint. (3) After three minutes the stain is washed off with water leaving a purplish specimen, which is washed until the film is yellowish or pink (4) gently dried between filter paper, and (5) mounted in balsam. Results. — The appearance of the various cellular elements is as follows: Action on ceils i the erythrocytes are orange or pink throughout. Erythroblasts show deep blue nuclei, blood-plaques are purple, mast-cell granules deep purple, poly- morphonuclear leucocytes show lilac or dark blue nuclei, neutrophile granules lilac, eosinophile granules pink, fine basophile granules a deep blue stain, bacteria and such organisms as malarial parasites blue. Myelocytes show a purplish or dark lilac nucleus and reddish or dark lilac granules. Ehrlich's Triacid Stain. — The ready-mixed powder for making this stain may be bought of any drug supply house and the student or practitioner should not attempt to make the original. Formula: Ehrlich-Biondi powder, gr. xv. Alcohol {absolute), 1 c.c. Distilled water, 6 c.c. Fairly good rapid work may be done with a good triple stain in the absence of Wright's stain by heating the smear carefully as in the staining of tubercle bacilli and staining for thirty seconds or less, washing, drying and mounting (Cabot). Other heat fixation methods are now so little used that a description is not deemed necessary. Scott fixes by a few seconds' exposure to formalin fumes before applying Jenner's stain and shows beautiful results. HEMOGLOBIN. — Hemoglobin or, more properly, oxyhemoglobin con- stitutes about nine-tenths of the bulk of the red corpuscles. It is a proteid substance containing 4 per cent, of hemochromogen, an iron-holding body, and 96 per cent, of concentrated, almost insoluble albumin which readily forms unstable compounds with oxygen. The great value of its determination by clinical tests may be readily appreciated. Tests for Hemoglobin. — An expert observer can make a rough estimate of the percentage of hemoglobin from the appearance of the ordinary stained or even the unstained smear preparation as may be readily appreciated by referring to Fig. 36, but for accurate work several forms of apparatus have been devised, all depending upon a comparison of a given specimen of blood, either whole or in a known degree of dilution, with a fixed color scale. Tallqvist's Hemoglobinometer.— 77ws, the simplest and least reliable, inaccurate. consists of lithographed color bands. Each has a central perforation and represents the color of blood in dilutions running from 10 percent, to normal.* A drop of the patient's blood is taken up by the absorbent paper and the resulting stain is placed under the central perforation of the color bands and comparison is made as soon as the stain has lost its wet gloss, not after, complete drying. * The color scale is bound with 50 sheets of special paper, each divisible into three parts, furnishing material for 150 tests. THE EXAMINATION OF THE BLOOD 117 This is a simple, rapid, but inaccurate method, permitting an error of at least 10 per cent., and the color scale fades, if not kept from the light. It is distinctly inferior to Dare's instrument which takes hardly a minute more of time. Dare's Hemoglobinometer. — A circular disc of tinted glass, representing variations in blood-coloring matter of a known degree, is brought into direct contrast by transmitted candle light with a film of the fresh whole blood drawn by capillary attraction between two glass plates, one transparent, the other translucent and white. A detachable observation tube and a circular shield protect the eyes from extraneous light, and the per- centage of hemoglobin may be read directly from the scale. This ex- cellent instrument may be used in daylight if pointed at some dark object, and its readings are not materially affected by an excess of leucocytes.* Von Fleischl's Hemoglobino- meter. — This well-known instrument or its more accurate modification has been largely superseded by the simpler and cheaper instrument of Dare. If it is used one should pro- cure Miescher's modification. The following precautions are necessary to good results: (a) The capillary tubes for taking the drop must be absolutely clean and should be tested out for equality of calibration when purchased. ib) All blood must be removed from the surface before mixing, leaving the caliber exactly filled, (c) The blood must be taken quickly, washed out into the chamber, and thoroughly mixed in the shortest possible time, (d) The observer should \ face the end of the movable colored wedge with the thumb-screw on his right, (e) Decision as to color should be made quickly to avoid- uncertainty and confu- sion. (/) The thumb-screw should be sharply turned in order to obtain as vivid a contrast as possible until the final match of color is achieved, (g) Should the blood solution appear turbid and lack proper color, as in the case of leukemia, add a few drops of a dilute aqueous solution of potassium hydrate, (h) Where the hemoglobin is below 30 per cent., double or treble the usual amount of blood should be used, the percentage obtained being divided proportionately . (i) The examination should be made in a dark room, or by means of a light- proof box by candle light, and in any case some form of tube shoidd be used for observation, a simple roll of black paper being ordinarily sufficient. Hemoglobin Estimation by Specific Gravity. — By the use of tables to be * This instrument is now made with a battery handle and pushbutton circuit breaker which adds greatly to its usefulness. Fig. 31. — Dare's hemoglobinometer- U. Observation tube. T. Shield. W- Removable plate with capillary opening for holding blood. X. Thumb-screw holding same. Y. Candle holder and candle. S. Case holding color disc R. Milled wheel or revolving color disc. Simple and reliable. n8 MEDICAL DIAGNOSIS found in all the larger works dealing with this subject the hemoglobin present in a given specimen may be very accurately estimated by Hammerschlag's modification of Roy's method. The procedure is too cumbersome and fussy to be recommended to the practitioner and will not be described. Oliver's Hemoglobinometer. — As shown by Fig. 33, this instrument de- pends upon the scale of colors based upon diluted blood. Its use is suffi- Axt excellent instrument. Courtesy of A. H. Thomas 6* Co. Fig. 32. — Von FleischPs Hemoglobinometer (Miescher's Modification). — Description. — Milled wheel at left (T) moves a tinted glass wedge (R)' under the fixed metal stage sur- mounted by double chamber reservoir which receives light from the calcium sulphate reflecting disc (P S) below. Half of the same chamber is filled with the diluted blood con- tained in the measuring capillary pipette (Mel) . The other contains only plain water but receives its light from the colored wedge. By moving the wedge back and forth the colors are matched and the percentage reading is shown on a scale visible through the opening (M) just in front of the supporting-upright. The blood is obtained in exactly the same manner as for a blood-count, the diluent being calcium carbonate solution (0.1 per cent.) and the tube permitting the observer to use dilutions of 1 1200, 1 1300 or 1 1400 according to the height to which the blood column is allowed to rise (marks }{, %, % respectively) before diluting and thoroughly mixing. Increased accuracy is obtained by the use of a grooved cover glass (D') which fits over the slightly raised partition dividing the two chambers, which must each be so filled as to present a convex meniscus. The necessary narrowing of the field is secured by cap-diaphragm (Bl') The average of at least ten determinations is required for accurate work. ciently indicated by the diagram and it has no advantage over the two preceding methods. Gower's Hemoglobinometer. — This little instrument has the merit of extreme simplicity, yet in practice one may lose more time by its use than with the other more elaborate instruments, inasmuch as a slight error in dilu- tion means a repetition of the whole process. Sahli's Hemoglobinometer. — This admirable instrument resembles Gow- er's hemometer, but is well adapted to quick, accurate work. THE EXAMINATION OF THE BLOOD 119 The cm ply graduated tube is filled to the mark 10 with a deed normal solution of IICl which is saturated with chloroform. The blood is then added by means of a measuring pipette and the mixture made thorough and complete. Finally, after mixing for exactly one minute, dis- tilled water is added, guttatim, until the color corresponds to that of the control tube which contains an acid hematin solution. The color comparison is easy and definite, but 90 should be considered an average normal and the instrument should be kept in its case or in a dark place and inverted once or twice before using.* Fig. 33. — Oliver's hemoglobi- nometer. The discs shown as white in the illustration are colored to represent the various blood dilutions and direct com- parison is made with a solution of the actual blood obtained by a measured mixing capillary pipette furnished with the instrument. Intermediate readings are ob- tained by placing squares of tinted glass over the fluid under examination. Fig. 34. — Sahli's hemoglobinometer. The author believes that the hemometers of Dare and of Sahli best combine simplicity with adequate clinical accuracy. Universal Micro-colorimeter. — Dr. Theodore Kuttner of New York has ; devised a pocket-size colorimeter which apparently is well adapted to several procedures chief of which are (a) the hemoglobin test, (b) the estimation of j glucose in the blood by a modification of Benedict's method, and (c) the phenolsulphonephthalein test.f * The instrument registers a maximal normal represented by the blood of healthy young Swiss males. Ninety per cent, would represent fairly an average normal. ^Journal A. M. A., July 17, 1915, pages 245 and 246. Journal A M. A., April 29, 1916, 1370-1373- 120 MEDICAL DIAGNOSIS An abstract of Dr. Kuttner's description is appended covering its appli- cation to these three procedures. Description of the Instrument. — The same calibrated and color tube em- ployed in the Sahli-Gower hemoglobinometer has been adopted for this instrument. The Sahli allows both the calibrated and m color standard tubes to be viewed at full length; the new instrument, however, shows only a small part of the tubes when making color comparisons. This facilitates the color reading and is less fatiguing to the eye. An additional feature is a prism (A), to be described, which visually causes the contents of the tubes to approach each other more 10 11 closely, thereby accomplishing greater accuracy in the com- parison of colors. The instrument consisting of a closed upright box (dimen- sions 2.5 cm. by 8.5 cm.) is smaller than the Sahli. At the top there are two openings : one for the color tube, the other for the calibrated tube. Near the lower front part is a window provided with the above-mentioned prism (A — Helmholtz double plates), which serves the purpose of having the colors of both tubes appear close together, forming one continuous color band. The prism is easily removed for cleansing and can be quickly readjusted. A sliding door (B), which can be raised and lowered, protects the prism from dust and injury. The color standard and calibrated tube are separated from each other by a partition, which prevents light from being reflected from one tube to the other. Directions for the Estimation of Hemoglobin. — (Standard color tube " Hematein" = 15 gm. Hgb = 20 ex. 2 .) — Into the calibrated tube No. 9 enough of a 34 normal solution of HC1 is poured to reach the mark 10. With the capillary pipette No. 1 blood is drawn to the 20 cmm. mark, the sides of the pipette wiped with absorbent cotton and the blood expelled while dipping the pipette to the bottom of the calibrated tube. Water is sucked up 2 or 3 times and these washings added to the tube. This is set aside for 1 to 2 minutes and then compared with the standard color tube in the in- I strument. Water is added drop by drop, the solution well mixed after each addition, until the color matches that of the standard. When this is accom- plished, the percentage can be read off directly by noting the figure which the meniscus has reached on the scale. As percentages occurring much below 50 are liable to error, it is best to use more blood when such anemic cases are encountered. Thus, in order to obtain greater accuracy, 2, 3 or 5 times the amount of blood should be taken, with capillary pipette No. 2 also twice the THE EXAMINATION OF THE BLOOD I 21 amount of ] 10 normal HC1 and the same process should be followed, but the result must be divided by 2, 3 or 5. Directions for the Estimation of Sugar in the Blood. — (Standard Color Tubes A and B). — According to Dr. Epstein's modification of Benedict's method, the procedure is as follows: 0.2 c.c. of blood is drawn with pipette No. 3 and discharged into a gradu- ated test-tube containing 1 drop of 2 per cent, fluoride of sodium solution or calcium oxalate, the pipette rinsed 2 or 3 times with water, the rinsings added to the test-tube, then water to the 1 c.c. mark. Saturated solution of picric acid is added up to the 2.5 c.c. mark, the mixture well shaken and now either filtered or centrifuged. Of the clear, supernatant liquid 1 c.c. is measured with a pipette and boiled down to 2 or 3 drops in a boiling test-tube, 0.5 c.c. of a 10 per cent, sodium carbonate solution added and again boiled to crystallization, which occurs when the contents are concentrated to about 2 to 3 drops and becomes brownish-red in color, according to the amount of sugar present, when the process is completed. A few drops of water are added, the tube w r armed and contents transferred to the calibrated tube of the micro-colorimeter. The tube is rinsed with sufficient water, a few 7 drops at a time, the total volume reaching the mark 50 and compared in color with the standards. If it is darker than A, but lighter than B, then the former is used as standard, and compared in the instrument by adding w r ater drop by drop to the fluid and mixing. When the colors have exactly matched, the height to which the fluid has risen is read off on the scale, this figure divided by 1000 representing the percentage of sugar in the blood. If the darker tube B is used, the result must be multipled by 2. Using this tube with the meniscus having reached mark 85 on the scale, then 85 X 2 = 170. 170 -r- 1000 = 0.17 per cent. As it often happens that diabetic blood may contain 0.3 per cent, or more of sugar, it would be necessary to use less blood. It is better to take two specimens, one as already stated and another with pipette No. 2, which measures only 0.1 c.c. of blood, then proceeding in the same manner as already described, but multiplying all obtained figures again by 2. Com- putation would then be as follows: If the color matched the darker tube B at 85, but using only 0.1 c.c. of blood then 85 X 2 X 2 = 340 340 -s- 1000 = 0.34 per cent. If the color matched the darker tube B at 140, the computation is thus: 140 X 2 X 2 = 560 560 -T- 1000 = 0.56 per cent. Normal blood contains from 0.06 per cent to 0.12 per cent, sugar. It is best to take the blood before breakfast. Directions for the Phenol-sulphon-phthalein Test. — (Color Standard Tubes Xo. 1, Xo. 2 and Xo. 3). — The patient's bladder is emptied (if necessary 122 MEDICAL DIAGNOSIS with catheter), about 250 c.c. of water given to drink and 34 hour later 1 c.c. of phenol-sulphon-phthalein solution containing 6 mgm. of substance is injected intramuscularly in the region of the buttock. Each ampule contains somewhat more than 1 c.c. of the sterile solution. The urine is collected in small beakers containing a few drops of Sodium Hydroxide solution every 2 or 3 minutes. When the first pink is seen as the urine comes in contact with the alkali, the time is noted. The patient is then required to urinate again in 1 hour and in 2 hours in two separate con- tainers. Each quantity is then measured, 10 c.c. of 10 per cent, of sodium hydroxide solution added and each made up to 200 c.c. with water. Of this red colored fluid 2 c.c. is withdrawn, using the 2 c.c. pipette and made up to 10 c.c. with water in graduated test-tube (No. 5 or 6). Enough of this solution is placed in the calibrated tube of the Micro-colorimeter by means of the transferring pipette to the 50 mark on the scale. It is now com- pared to the color standards 1 and 2. If it is darker than 1, it is diluted drop by drop with water until the color matches, the percentage being read off the same as in the Sahli-Hemoglobinometer. If tube 2 is used, the reading must be divided by 2. Should the color be too light, after it had been diluted to 10 c.c., then only a dilution to 5 c.c. may be used and compared the same way, but the final figure obtained is to be divided by 4. If the urine contains very small amounts of the excreted dye, then the urine should be used without further dilution directly in the calibrated tube up to the 50 mark, but it must be compared to special color tube No. 3, which has a yellowish tint, and the reading divided by 10. Between 40 and 60 per cent, (average 50 per cent.) of the dye is eliminated during the first hour and from 60-85 per cent, totally after 2 hours and only traces eliminated during the following hours.* Care and Use of the Pipettes. — Four pipettes are furnished with the instrument: No. 1., up to 25 cmm.; No. 2. 34 c - c - divided into ten divisions; No. 3. %0 c.c. divided into ten divisions; No. 4. 2 c.c. divided into ten divisions. Pipettes must be clean and dry before use. When the required amount has been drawn into the pipette the tip of ] the tongue should be placed against the mouthpiece attached to the rubber tubing of the pipette. Before expelling its contents, the pipettes are held in a horizontal position and wiped with absorbent cotton. After use, they should be immediately cleaned, first with water, then alcohol and then ether. Chief normal forms. ERYTHROCYTES AND LEUCOCYTES Classification of Leucocytes. — The simplest modern classification deals with six normal varieties: (1) The polymorphonuclear neutrophiles which constitute from 60 to 75 per cent, {average 70 per cent.). (2) The small lympho- cytes, 20 to 25 per cent, {average 20 per cent.). (3) The large mononuclear * The test is described more fully in its proper section. PLATE I. ~ ■ ■ v. "• #0 ' '" ,2 1 lHw ■ 6 MR v I....I....I....I Chief varieties of cells encountered in health and disease (Wright's stain), i. Normal red cell. 2. Common form of polymorphonuclear leucocyte. 3. Lymphocyte. 4. Eosinophilic myelocyte. 5. Eosinophilic leucocyte. 6-6. Neutrophilic leucocytes: upper left, transitional form, on right neutrophilic myelocyte. 7-7. Large mononuclears. 8. Normoblast. 8. Normoblast showing division of nucleus. 9. Normoblast nucleus. io-ii. Basophilic leucocytes. 12. Megaloblast. THE EXAMINATION OF THE BLOOD 123 (averages 5 per cent.). (4) The transitional forms, 2 to 4 per cent. (5) Eosinophils 0.5 to 5 />(•/• cent, (average 4 />£r cew/.). (6) Basophiles, "mast" cells 0.1 to 0.5 />- FOR ATthurK.TKomas Co. Fig. 43. — Thoma-Levy counting chamber with original Thoma ruling. " The Biirker type of counting chamber, of either the new or old construc- tion, has a further advantage over the original Thoma construction — which consists of a circular ruled disc cemented on the slide in the center of a circu- lar cell, also cemented on the slide — in that capillary attraction is used to fill the Biirker cell after the cover glass is in position. This method insures a much more uniform distribution of corpuscles over the entire field and the effect of atmospheric pressure upon the depth of the solution is materi- ally lessened. These new Thoma-Levy counting chambers of the Biirker type are now supplied with various rulings, i.e., Thoma, Zappert, Tiirck, Neubauer, Fuchs-Rosenthal, etc. The Neubauer ruling is now recommended as the most sat- isfactory for modern tech- nic. The method of ruling used in the manufacture of these chambers provides a line with absolutely clean-cut edges and of distinctly increased visibility when the chamber is filled with solution for the count. This increase in visibility of the ruling greatly lessens the eye fatigue experienced in making repeated counts. "In the old type of Biirker chamber two ruled areas are provided upon rectangular pieces of glass cemented on the main ± sq.mm.. ^ mm. deep. — PHILADELPHIA.PA.; : At thur^ Thomas Co. Fig. 44. — Thoma-Levy counting chamber, Biirker double type with two Neubauer rulings. Fig. 45. — Mixing pipette for red corpuscles. 46. — Mixing pipette for white corpuscles. slide. These ruled rectangles were separated by a small moat to allow free passage of the diluted blood. On either side of these ruled rectangles two unruled rectangular pieces of glass were cemented which extended the en- tire width of the slide. These were exactly Ko mm - thicker than the ruled rectangles, so that when the cover glass rested on these the required depth of solution over the ruled area was attained. "In the Levy construction a rectangular depression is cut into the slide itself extending across the entire width. In the middle of this depression is permanently fixed a rectangular strip of glass, also extending entirely across the slide, and on this are the rulings. When the cover glass is placed in position on the slide itself the solution over the ruled areas is of the re- 134 MEDICAL DIAGNOSIS quired depth. The method of construction entirely removes the possi- bility of the loosening of the cell by the drying out of the balsam cement and reduces the possibility of the loosening of the ruled counting surface. "In the Burker-Neubauer counting chambers the rectangular glass in the center of the cell is divided by a central moat; each half being pro- vided with a Neubauer ruling, so that both red and white counts may be made at the same time without the necessity of cleaning and refilling the counting chamber." (Fig. 44.) Fig. 48. — Eye-piece ruling of Thoma-Metz. Courtesy of E. Leitz, New York. Fig. 47. — Hemocytometer (the Thoma-Metz). The Neubauer modification of the original Thoma ruling is probably the most satisfactory of all. In it the central square millimeter is exactly the same as in the original Thoma ruling. Surrounding this there are 8 addi- tional square millimeters, each subdivided into 16 smaller squares, and these are of extreme value by reason of the greater accuracy and convenience which they afford in counting the white blood corpuscles. (See Fig. 41.) The actual technic for using the Burker chamber is extremely simple and may be briefly summarized as follows: 1. The ruled areas and slide are carefully cleaned and made absolutely free from dust. 2. The cover glass is applied and Newton's rings* must be obtained as evidence of the approximation of the two surfaces. 3. The tip of the projecting ruled rectangle is quickly touched with the point of the rilled red or white blood pipette, permitting the diluted blood to * The Newton's interference rings are not readily obtainable in the Levy construction as in the older type because of the mat or ground surface of the slide upon which the cover glass rests. Because of this mat surface accurate approximation of the surface of the cover glass and slide is readily obtained. The original Burker instrument and Gorgajew-Pappenheim modification of it carry clamps which aid in obtaining and maintaining accurate contact. {Author.) THE EXAMINATION OF THE BLOOD 135 flow under the cover glass to just the extent sufficient to cover completely the ruled rectangle but not flow over into the moat on either side. No bubbles should form in this process. 4. After allowing three minutes for settling, the evenness of distribution is determined either by low-power examination with the microscope or by placing the counter upon the stage of the microscope, which is illumi- nated by a mirror with the diaphragm open as wide as possible. If now the counting surface is viewed obliquely with the unaided eye, any irregularity in the distribution of the cells is easily recognized by variations in the density of the blood film. If such irregularities are observed, the cover glass should be removed, the chamber carefully cleaned, and the procedure repeated. The Thoma-Metz Hemocytometer. — The counting plate is mounted in the plane of the ocular diaphragm of eyepiece No. n. The Leitz ob- jective No. 6, is used in connection with it. The dilution of the blood is carried out with the aid of two Thoma pipettes of regular type, fol- lowing the known method. The large square in the center of the counting plate (Fig. 48), is divided into four smaller squares and serves for the counting of the red blood cor- puscles. The large square is surrounded by a circle which is divided also into four parts of equal area, serving for the counting of white blood corpuscles. Figure 48 represents a diagram of the counting plate itself. The regular chamber of 0.1 mm. depth is used for the counting by this method. Directions for the Counting in a Solution of 1 Cu. Mm. — (A) For Red Blood Corpuscles. — The dimensions of the large square of the counting plates are so calculated that one side of same covers 0.1 mm. of the object. The area, therefore, is equal to 0.1 X 0.1 = 0.01 sq. mm., and the cubic contents of that area of the object as covered by the entire square is equal to 0.01 X 0.1 = 0.001 cu. mm. The number of red corpuscles in the solution — diluted 1:100 — amounts therefore, to 100 X 1000 = 100,000 times the corpuscles found in the square counted. Example. — 52 red corpuscles found in the square. 52 X 100,000 = 5,200,000 red corpuscles in one cu. mm., solution. In order to achieve a reliable average count it is advisable to move the slide and count in various zones of the solution. (B) For White Blood Corpuscles. — The circle established for the counting of white corpuscles covers ten times as much area as does the square for the counting of red corpuscles. This circle, therefore, covers an area of 10 X 0.01 =0.1 sq. mm. of the counting chamber of a depth of 0.1 mm. and the cubic contents amounts to 0.1 X 0.1 = 0.01 cu. mm. The actual number of white corpuscles as contained in the solution — diluted 1:10 — will therefore amount to 10 X 100 = 1000 times the number as found in the circle. Example. — 8 white blood corpuscles found in the circle. 8 X 1000 = 8000 white corpuscles in 1 cu. mm., solution. 136 MEDICAL DIAGNOSIS In order to achieve a reliable average count, it is advisable to move the slide and count in various zones of the solution. The two factors: 100 X 1000 for red blood corpuscles are engraved in "red." 10 X 100 for white blood corpuscles are engraved in "white" on the counting slide. Advantages. — The counting plate is produced in a photographic way and can be focused sharply for every eye by means of the adjustable eye lens, and therefore, the ruling appears in sharp lines in the counting field. For the counting of red as well as white blood corpuscles, separate fields are used. These fields are, in their area, so adjusted that a unit for multi- plication is established. This factor allows quick counting. The apparatus is adjusted for an optical equipment of objective No. 6 (4 mm. focal length) and ocular No. 11 (5 X), as these are the lenses mostly used for blood-counting work. Small variations, as far as lenses of other makes are concerned, can be overcome through the adjustment of the tube length. On the bottom of the slide, a square is drawn and the proper I optical relation is established when this square covers the large square of the counting plate. (The author has had no experience with the instrument and has been unable to secure one for test purposes.) Oliver's Hemocytometer. — This ingenious instrument is shown in Fig. 49, and save in the severer types of anemia and in leukemia where the excess of leucocytes vitiates any optical method, is fairly accurate in skilled hands. Method. — A small amount of Hayem's solution is placed in the glass tube and into it is stirred the blood taken up by the capillary pipette. In a dark room it is then diluted gradually with the Hayem's mixture until a bright horizontal line becomes visible as the observer looks through the mixture at a candle flame beyond. Each point on the scale represents 50,000 red cells. Precautions. — (a) One looks at the edge of the tube, not its flat face, (b) The pipette should be thoroughly clean before using, (c) The tube should be inverted to secure proper admixture each time that the diluent is added, (d) An imperfect marginal line forecasts the appearance of the complete transverse line and warns one . to go slowly with the dilution, (e) A small Christmas candle should be used in a dark room. (/) The tube should be close to the eye and the observer fully 10 feet from the candle. The procedure is seldom employed at the present time. It has too limited a range and the personal equation is too great a factor. The Hematocrit (Hedin-D aland). — This consists of a graduated capillary tube, each degree of which represents 100,000 erythrocytes. The tube is filled with blood and placed (with a similar tube opposite) in the centrifuge which should be revolved at high speed for at least two minutes when the Fig. 49. — Method of holding Oliver's hemocytometer. THE EXAMINATION OF THE BLOOD 137 Volume index. red column will represent the erythrocytes present as indicated by the scale. The tube when filled by suction is dried and closed at its other end by the vaseline coated finger which is kept in place while the rubber suction tube is withdrawn. The results obtained are rapid but only approximate when used in the severer types of anemia. As pointed out by Capps, it affords a means of obtaining information relating to cell volume. It is a simple matter to calculate the normal height of the red blood cell column in the hematocrit tube as compared with the height of the total blood column. This is usually 50 on the scale tube and this figure is reckoned as 100 per cent, normal. The figure so obtained is divided by the figure representing, in percentage, the number of red cells per cubic millimeter counted in the blood of the same individual, as compared with the normal, 5,000,000 cells per cubic millimeter The quotient is the red cell "volume index" and parallels in a considerable degree the "color index" heretofore described, both as regards its variations and their clinical significance. The normal red cell "volume index" is 1. In primary pernicious anemia it is high; in secondary anemias, reduced; in chlorosis, distinctly low. These variations, if marked, are usually obvious to the trained observer in an examination of the simple well-made blood smear. The method may find its wider usefulness in the detection and measure- ment of blood changes other than those of anemia. LEUCOCYTOSIS AND LYMPHOCYTOSIS.— Assuming that the term leucocytosis covers an increase of the polymorphonuclear neutrophilic cells, both relative and absolute, it is evident that one must know first what con- stitutes a normal leucocyte count; second, what conditions other than disease may increase the number. The Normal Average. — This varies from 6,500 to 10,000 to the cubic millimeter of peripheral blood, the average being 7500. Physiologic Leucocytosis. — The most important is the so-called digestive leucocytosis which represents on the average an increase over normal of about one-third. The variation is greater after a heavy proteid meal than on a vegetable diet and reaches its maximum usually within from two to four hours after a meal. The increase itself may be purely polymorphonuclear or, more rarely, is common to all normal forms. It may be delayed in cases of subacid dyspepsia and is very marked in nursing infants and diabetics. The so-called preagonal leucocytosis may be observed immediately before death, the counts occasionally reaching 20,000 or even 30,000 cells. Cabot states that in pernicious anemia this may take the form of so decided a lymphocyte increase as to simulate lymphatic leukemia; nevertheless, as a rule, it is a polymorphonuclear increase due probably to the stasis of a failing circulation and a prof ound toxemia such as that which may be employed in the experimental production of a leucocytosis. In such instances the primary increase is lymphocytic, the polymorphonuclear increase following later on. It is important to remember that both in the later months of pregnancy in primiparae and during the first week following delivery a Pregnancy. Digestion leucocytosis. Misleading. 138 MEDICAL DIAGNOSIS New-born babes. Crucial point. Various associated conditions. Sepsis. Basis. Highly important. moderate leucocytosis is the rule. So also in new-born babes the count usually ranges from 18,000 to 20,000 during the first two days of life and after the second week and during the first year it remains at 10,000 to 15,000 per cubic millimeter. The type of physiologic leucocytosis is almost in- variably polymorphonuclear though there may be a coincident lymphocyte increase in the new-born, in malignant disease, or in hemorrhage. See "lymphocytosis" on following page. Differentiation of Leucocytosis from Leukemia. — The number of white cells present does not suffice to differentiate the one, a mere transitory symptom, from the other, a peculiarly intractable and fatal chronic disease. 77 is rather the type of white cell which dominates the clinical picture, or the blood findings as a wliole combined with other signs and symptoms of known character and association that sets leukemia apart so clearly and definitely as to leave little opportunity or excuse for error. With rare exceptions leucocy- tosis means a polymorphonuclear increase alone or, more rarely, a mere gener- al increase of leucocytes of the normal types. The Leucocytosis of Disease. — So many diseases are associated with a more or less marked leucocytosis that it is only necessary to enumerate some of the more striking instances, and more useful to remember the exceptions, or, more particidarly, the diseases in which a diminution (leucopenia) occurs. Practically all inflammations, particularly of serous membrane, and any suppurative process attended by toxemia, would ordinarily produce leucocytosis, yet we may have these, lacking such a phenomenon (a) because the infiammatioji or toxemia may be too slight to excite a reactive change; (b) because the toxin overwhelms the organism, thus preventing leucocytic reaction; (c) because the organism is primarily too feeble to respond. In illustration one may cite lobar pneumonia as representing a disease in which leucocytosis is ordinarily marked, and typhoid fever in which a leucopenia is ordinarily found. These diseases stand at opposite poles, one being sthenic and the other asthenic; one of brief duration, the other prolonged and tedious; one showing early and profound toxemia, the other allowing most of its victims to escape by resolution before the system is overwhelmed by toxins. The case of lobar pneumonia which slwws a leucopenia is practically hope- less. The case of genuine typhoid fever carrying a leucocytosis is one with complications. Acute appendicitis offers another illustration. In this disease one may have an inflammation and toxemia so slight as to produce no leucocytosis; an overwhelming toxemia with the same result; or, as it is the rule, a well- defined leucocytic reaction representing a good defensive mechanism opposed to sharp infection. It is useless to attempt to name or even tabulate all the conditions giving rise to leucocytosis. In abscess it is practically constant, but in malignant disease a high count may be found only in rapidly growing tumors of the kidney, lungs or liver, and in the author's experience especially in metastatic hepatic invasion from gastric carcinoma. In ptomain poisoning, uremia, cholemia, THE EXAMINATION OF THE BLOOD 139 and gas poisoning the leucocytosis may be marked. So also in cases of acute delirium, convulsions, after surgical operations or indeed after general anesthesia. A polymorphonuclear percentage above 85 strongly suggests the presence of actual suppuration or gangrene. The blood findings of the various diseases are discussed under the individual headings.* Leucopenia. — This covers any leucocyte count running below 5000 cells, excluding, of course, tJiose cases of reduction associated with profound anemia. As might be expected, this condition may be present as a result of mal- nutrition or starvation, but its chief importance is its occurrence in certain diseases of the infectious and toxemic type. Among these are typhoid, paratyphoid, malaria, Malta fever, influenza, measles and rotheln, tuberculosis {in the absence of septic symptoms), leprosy, trypanosomiasis, and less commonly in chlorosis, chronic infantile gastro- enteritis, and, following the use of agaricin, atropin, camphoric acid, ergot, picrotoxin, sulphonal and tannic acid. Lymphocytosis. — This may be either relative or absolute, the former without any necessary increase in the total white cell count, the latter covering both an increase in percentage and in the total lymphocytes. The latter is almost always a lymphatic leukemia. It should be remembered in this connection that in infancy the lympho- cytes and transitional cells may constitute 55 or 60 per cent, of the total white cells, gradually dropping to the normal figure at the age of four or five with a corresponding increase in the polymorphonuclear forms. There- fore, the increased percentage has little significance at early ages. Either the large, small or transitional mononuclear forms may predominate in any case, and the condition is invariably pathologic when occurring in older children or in adults. It is usually associated with profound malnutrition, and especially marked in the terminal stages of diseases of that type as well as in marked anemia and in several of the acute and chronic infections characterized by leucopenia, notably malaria, typhoid, Malta fever, scarlet fever, diphtheria, measles, tuberculosis and trypanosomiasis. So also we find the condition marked in ailments involving the lymphatic glands or spleen or the invasion of lymph channels by malignant growths. As regards drugs, it is said to follow the administration of thyroid, quinin and pilocarpin. Its occurrence in syphilis in which it is combined with eosinophilia is of some diagnostic importance. Eosinophilia. — The determination of this condition is made by a differ- ential count establishing their proportion, associated with a formal count of the total leucocytes, the latter multiplied by the former giving the total number of eosinophiles in a cubic millimeter. 77 is of lessened importance as a clinical sign because of its presence in a great number of diseases, but its constancy in trichiniasis , hydatid disease and in the victims of the more important intestinal parasites is of considerable value. * It is affirmed by some authorities that the percentage increase of polymorphonuclears (relative preponderance) represents the degree of toxic absorption and the total numerical increase of leucocytes measures the resisting power of the organism. Confusing factors. List of diseases. Normal in infancy. Abnormal. Syphilis. Value. 140 MEDICAL DIAGNOSIS Diseases yielding reactions. A double process. Use erythrocyte counter. Caution. Appearance of platelets. Normal count. Rationale. The attempt made by some of the foreign hematologists to create a group of which eosinophilia should be diagnostic has not proven successful. 77 is, as stated, of some clinical value in syphilis when combined with lympho- cytosis and its constant presence in spasmodic asthma is of interest. In scarlet fever there is at first a low white count but after a few days a marked leucocytosis and decided eosinophilia are present. Both are said to be absent in measles. Counting the Blood Plates. — Indirect Method. — This requires a diluting fluid* through a drop of which placed upon the finger the puncture is made. After mixing, a differential count is made to determine the ratio of plaques to erythrocytes. It is then only necessary to count the erythrocytes by means of a counting chamber to know the number of plaques present in the given specimen. Direct Method. — The direct method of Wright and Kinnicutt is prefer- able. One employs as diluting fluid solutions of brilliant cresyl blue (1:300, aqueous) and potassium cyanide (1:1400, aqueous). The solutions are mixed just before use in the proportion of two parts of the former to three parts of the latter. The original solutions must be freshly prepared, or, refrigerated if kept as stock solutions. v The blood platelets appear clearly defined as oval, round, or somewhat elongated bodies stained lilac and sharply contrasted with the leucocytes, which show a deep blue nucleus and light blue protoplasm. The red cells are decolorized. The size of the platelets is variable, being larger when few are present, smaller when occurring in increased numbers, but they average about 3 microns in diameter. Normally, their numbers vary from 150,000 to 300,000 per c.mm., and the count is made exactly as in the case of the erythrocytes. Determination of Hemolytic Resistance. — If blood is added to water it immediately "lakes," i. e., gives up the hemoglobin of its erythrocytes to the liquid. If the osmotic pressure is equalized by the addition of some suitable substance such as sodium chloride (0.9 per cent.) the solution becomes iso- tonic and no "laking" occurs. By using properly graduated solutions of sodium chloride or other sub- stances the resistance of any given blood to hemolysis may be determined. The same process is applied in determining the proper donor of blood for transfusion for both donor and patient must belong to the same group with respect to cell resistance whether to iso-hemolysins or iso-agglutinins. Total Blood Volume. — It is wholly probable that the ingenious and rela- tively simple procedure of Keith, Rowntree and Geraghty, will supplant the methods of Haldane and Smith, Morawitz, Zuntz and Plesch, Abderhalden and Smith, and von Behring. The principal feature of this latest procedure is the introduction into the blood of a rapidly diffusible, slowly absorbable dye, known as " vital red" * Aqueous solution of sodium chloride 1 per cent, and potassium bichromate 5 per cent. (Determann). Till: IX VMIXATION OF T1IK Hl.ooi) 141 (disodium-disulphonaphthol-azotetramethyl triphenyl methane), and colori- metric comparison with a properly standardized mixture of the dye and the unstained plasma of the patient. Its slow absorption and elimination and relative non-toxicity (3 c.c. per kilo of body weight being wholly without poisonous effects) insures the possibility of sufficient time retention to insure thorough mixing with the plasma, without appreciable loss of the dye, un- less to some slight extent through fixation by the tissues. The results obtained agree more closely with the older ideas than with the modern views as to the relation of total blood volume to body weight. Normal Keith and his co-workers find that the average blood volume is 85 c.c. per ; average - kilo of body weight, equal to one-eleventh of the body weight, and varying between that figure and one-thirteenth. As regards the partition of the blood components 57 per cent, was found Normal ra to represent plasma, and 43 per cent, erythrocytes and leucocytes. The plasma content as determined by the hematocrit varies from 42 to 56 c.c. per kilo of body weight. One of the interesting results reported bears upon blood volume in arterial hypertension, or hypotension. In the chronic hypertension of renal cases, it was found normal or even decidedly reduced. In obesity the blood (and plasma) volume is reduced, in anemia often increased as to total plasma. The actual technic while relatively simple is too extended to receive detailed description in a work of this type and too time con- Time suming and exacting in its demands to make it of general c availability to the practitioner in the comparatively infre- quent instances in which its employment might be of especial (clinical interest.* Coagulation Time. — It is sometimes important to estimate the coagulation period in hemophilia, purpura and in "ob-, struction of the biliary tract with or without jaundice" (Cabot), as in these conditions clot formation may be greatly retarded. For accurate work the method and instrument of Russell and Brodie as modified by Boggs may be used; or for rough determinations, in the absence of better appliances, the simple method represented by Fig. 50. In the former coagulation should occur within from three to six minutes; by the simpler method, in from two and one-half to five minutes. The latter p merely involves the placing of several drops of the suspected blood upon slightly warmed microscope slides which are tilted upward at varying inter- vals until they appear as in B of the plate, the elapsed time representing the coagulation period. Another rough but useful method consists in placing the drop of blood upon a perfectly clean glass slide and passing a needle through it every twenty or thirty seconds until the needle drags the clot. The Boggs coagulometer consists of : (a) a round glass-bottomed " moist * Reference to the extended original article is necessary. Keith, Rowntree and Ger- aghty, Archiv. Int. Med., Oct. 15, 1915, Vol. 16, No. 4, pp. 547-576. Often important. A B Fig. 50.— Delayed co- agulation of blood, a sim- ple test. (After Da- Costa.) Normal 142 MEDICAL DIAGNOSIS Courtesy of A. H. Thomas Co. chamber"; (b) a cover fitting into and closing the chamber and carrying in the center a cone of glass the truncate apex of which lies within the " moist chamber"; (c) a capillary tube opening into the side of the chamber through which a jet of air can be pumped with a hand bulb so as to impinge upon the drop of blood taken upon the tip of the glass cone for examination; (d) a small opening in the upper surface of the cover of the chamber, which serves as an air outlet. Procedure. — The lobe of the ear is punctured and the time of appearance of the blood accurately noted. The tip of the glass cone receives a blood drop, the cell is at once covered, the chamber is placed upon the stage of a microscope, and at intervals of 30 seconds a soft current of air is played upon the blood drop. Three essential FlG 5I> _ The Brodie-Ri^eU co^d^teT « stages of movement are seen to en- modified by Boggs. sue as affecting the blood corpus- cles: (1) Independent. (2) Clumped. (3) Mere "radial" mass response to the air current, denoting complete coagulation.* Wassermann Test. — The discovery of the spirochceta pallida was closely followed by this reaction for syphilis which combines the phenomenon of hemolysis with that of complement fixation (Bordet-Gengou). The test departs from the strict and definite "fixation of complement" reaction in permitting the use of antigen derived from certain normal tissues (Noguchi) as a substitute for the specific antigen hitherto deemed necessary to such tests. (See "Wassermann Test".) The reader is referred to the works devoted to serology for a full discussion of the test which is so delicate and so beset by confusing factors as to be of little value in the hands of anyone save the trained and up-to-date serologist. The value of positive reactions is undoubted, when these represent the work of the specially trained expert. Negative reports should not greatly influence the question of test treatment or be permitted to greatly influence an opinion based upon a strongly suggestive history or clinically significant symptom-group. The Determination of Alkalinity. — Personal experience with this method has convinced the author that it does not merit attention as a clinical procedure. Exudates and Transudates. — In general a transudate does not coagulate spontaneously unless there be much blood admixed, the specific gravity is 1015 or less and it contains not more than 2.5 per cent, albumin. An exudate coagulates promptly, contains 4 per cent, or more of albumin, and shows a specific gravity of 1018+. * The mass is fixed and recovers its outline when the gentle air current ceases, much as an indented rubber ball recovers its outline after indentation. Just preceding this terminal stage the clot has become so far fixed as to promptly correct the slight dis- location produced by the air current. THK EXAMINATION OF THE BLOOJ 143 CYTODIAGNOSIS.— Widal has given this name to the differential study of the leucocyte content of pleural, peritoneal and cerebro-spinal fluids as they are obtained in operative or diagnostic aspiration. It is a valuable procedure within narrow limits. The fluid must be centrifugalized, and if immediate attention cannot be given it, any clot may be broken up by shaking in a flask with small glass beads or the fluid may be drawn into a syringe or aspirator flask half full of a solution consisting of calcium oxalate (2 parts) and normal saline solution (1000 parts, Sahli). From 10 to 20 c.c. should be obtained if possible. The centrifuge must be run from five to ten minutes according to the speed obtain- able and the fluid kept on ice and examined within twenty-four hours. Exami- nations are best made by staining smear preparations as in the case of the blood. The triacid stain is satisfactory, or Wright's stain, plus one-third its volume of pure methyl alcohol, may be used, to save heating the specimens, though its methylene blue may overstain in the sharply alkaline serum. Under the microscope we consider erythrocytes, endothelium and tumor cells as well as leucocytes, and the following reasonably dependable conclu- sions may be drawn: (a) The presence of large amounts of blood suggests carcinoma, tuberculosis, and the hemorrhagic diseases, but may be present in cardiac, scorbutic, and nephritic cases, though usually accidental. (b) In general the predominance of polymorphonuclear forms indicates marked and relatively recent infection. (c) A large number of mononuclear cells indicates a less acute process, its later or chronic stages, or the chronic stage of a non-specific exudate. A combina- tion of a considerable quantity of red blood cells and an excess of lymphocytes strongly suggests tuberculosis. (d) A large number of endothelial cells unassociated with any considerable number of leucocytes speaks for a transudate. (e) Specific tumor cells may, if typically grouped, prove the presence of a malignant growth, but ordinarily can with no certainty be distinguished from endothelial cells. The combination of an excess of endothelial cells and red blood cells strongly suggests tuberculosis. Primary Tuberculosis is indicated by a predominance of lymphocytes after a week or ten days; acute infection, by polymorphonuclear preponderance. Predominance of endothelial cells in tesselate arrangement indicates a transu- date. Secondary tuberculous pleurisies may show polymorphonuclear pre- dominance or a sediment of necrotic cells and debris. An exudate showing bacteria and 90 per cent or more of polymorphonuclears means that empyema is imminent (Musgrave).* INOSCOPY. — Jossuet's method of predigesting the coagulum of sus- pected exudates as preliminary to the examination for tubercle bacilli has * Musgrave highly recommends Wright's stain, 3 parts, methyl alcohol, 1 part. Stain twenty to forty-five minutes, treat with 8 or 10 drops of water, let it stand two or three minutes and wash gently by flooding with water several times, allowing it to stand a few seconds with each washing. 144 MEDICAL DIAGNOSIS Hemoglobin- erythrocyte ratios. proven of much value in pleuritic cases but is now largely superseded by the "antiformin method." Its findings have less accuracy, however, than animal inoculation and possibly than cytodiagnosis, so that it is the positive factor that should be considered, the failure of the test being no adequate proof of the absence of tuberculosis. Technic. — The fluid is collected in sterilized flasks and the clot, when formed, thoroughly washed on sterile gauze spread over the mouth of a funnel or other receptacle. The clot is then placed in a flask or flasks in each of which is poured from 20 to 30 c.c. of the solution (pepsin 2 grams, glycerin and strong HC1 of each 10 c.c, sodium fluoride 3 grams, distilled water 2000). Digestion will be complete in about two or three hours at body temperature. Centrifugation of the mixture for ten minutes is followed by decantation and the staining of cover-slip preparations to which a bit of egg albumin may be added. Gabbett's method and stain should be used, but the preparation must not be as vigorously decolorized as is usual in sputum mounts, thirty to forty-five seconds being sufficient. THE ANEMIAS TYPES OF ANEMIA. — There are three principal clinical types of anemia : (1) simple anemia or chlorosis; (2) secondary anemia, which as its name implies is that which follows or is associated with other diseases; (3) pernicious anemia. Sim. Anemia. Chlorosis. Hemoglobin low. Cells rela- tively high. (Low index.) Secondary Anemia. More or less uniform reduc- tion in cells and hemoglobin. Hemoglobin relatively high Cells low. High index. Pernicious Anemia. Fig. 52. Chlorosis is characterized by a predominant hemoglobin loss and a rela- tively slight diminution in the number of red cells present. That is to say, the individual cell is poor in hemoglobin. Secondary anemia shows, as a rule, a more even reduction in both elements. IHE AN KM IAS 145 Pernicious anemia is the exact reverse of simple anemia in that the cell decrease predominates and, therefore, the hemoglobin value of the individual cell is high. GENERAL CONSIDERATIONS.— Color.— In the anemias pallor as M.sieading. affecting the skin and mucous membranes is the rule, but is subject to fre- quent exceptions. Perso)i$ may be pale, yet not anemic, or ruddy and profoundly anemic. The author recalls many cases of advanced leukemia in which the color was most deceptive. The student and the indoor worker is often pallid, yet not anemic. The outward signs of anemia should be sought in the face, the conjunctiva, the lips, the mucous membrane, the lobes of the ear, the finger nails, tongue and pharynx. Wide Variations.— In chlorosis there is usually marked pallor and the skin is likely to show a greenish-yellow tint. In pernicious anemia there is ordinarily very marked pallor and the skin is of a lemon-yellow tint. In secondary anemia aside from pallor one meets with many variations in color. In Bright J s disease with anemia the skin may be pasty white; or show the peculiar sallowness, brown or fawn color, more or less characteristic of the advanced chronic parenchymatous or "mixed" type of the disease. Interstitial nephritis, even when well established, often yields no such evidence, being found in men of normal complexion or in those who have the ruddy countenance of the high liver. Syphilis. — Certain cases of congenital and tertiary syphilis with secondary anemia show a peculiar sallowness impossible to describe, but easily recog- nized by those who have been shown it. Malignant disease, especially advanced carcinoma of the stomach, is sometimes associated with a somewhat characteristic earthy pallor and in some instances the anemia may be extreme and closely resemble that of the pernicious type. In diseases of the mitral valve one frequently finds an anemia masked by high color due to chronic congestion. Muscular Weakness. — In all pronounced anemias one meets with lassi- tude and muscular weakness, varying, as a rule, with the severity of the disease. It is least marked in mild anemias of the secondary type and most evident in pernicious anemia. Temperature. — Three-fourths of all cases of pernicious anemia are ac- companied by fever, usually of the intermittent type, with an evening exacerbation. It is by no means an infrequent symptom in severe cases of chlorosis* or secondary anemia. Gastrointestinal Disturbances. — Symptoms referable to disturbed di- gestion, gastric or intestinal, are encountered chiefly in the chlorotic and per- * It nevertheless should always suggest an active or smouldering tuberculosis in these latter cases and hence a thorough examination of the lungs. 10 146 MEDICAL DIAGNOSIS " Bruit de diable." Pseudo- "Corrigan pulse." Capillary pulse. Misleading headache. nicious forms of anemia and in the leukemias. Anorexia, bulimia, nausea, vomiting, constipation and diarrhea are the common symptoms. Established and advanced pernicious anemia is usually associated with exhausting at- tacks of diarrhea and intercurrent vomiting. Paroxysmal abdominal pain occurs in about 50 per cent, of the cases. Respiratory System. — Exertion dyspnea is more or less pronounced in all severe anemias, but particularly so in marked chlorosis and pernicious anemia. Circulatory System. — Palpitation, syncope and precordial oppression are common. Edema of the extremeties is not infrequent in chlorosis and is invariably present in advanced leukemia and pernicious anemia. The pulse is of low tension (60 to 80 mm. systolic pressure is not uncommon in pernicious anemia) ; a curious humming may be heard in the vessels of the neck, and various murmurs are audible over the heart and the great vessels. Myocardial weakness is likely to be pronounced and the heart is often dilated or markedly dilatable if the anemia is decided. Anemic Murmurs. — The general characteristics of the murmurs associated with anemia are: (a) Their systolic time, (b) Softness of quality, (c) Predilection for the pulmonary area, (d) Absence of marked and sequential cardiac outline changes, (e) Tendency to disappear as anemia is improved by treatment. These murmurs may be heard over any of the valvular areas, but are most frequent by far in the pulmonary and mitral regions. A systolic murmur in the subclavian and carotid is a very common feature in extreme instances. In certain cases combining anemia and chronic congenital asthenia, and in hyperthyroidism, one may find outward symptoms suggesting aortic regurgita- tion, viz.: throbbing peripheral vessels, water-hammer pulse, and even a capillary pulse. This condition need not mislead one in the absence of a diastolic murmur* and modified aortic second sound. The flow of blood is remarkably accelerated in severe anemia and this fact together with the lowered specific gravity of the blood and the weakened myocardium would seem adequate causes for the associated murmurs. Nervous System. — The symptoms under this head are many and various, being chiefly those in varying degree common to all conditions characterized by impairment or perversion of the blood supply of the tissues. Insomnia, drowsiness, vertigo, mental dulness and apathy, extreme irri- tability, perverted sensation, neuralgia, psychasthenia, hysteria, headache, and even delirium may be encountered, though delirium is not often seen save in pernicious anemia or the last stage of leukemia. Headache may be found in all degrees of severity in simple cases of chlorosis, and one form is peculiarly interesting by reason of its close resemblance to the headache of meningitis.^ Such headaches are so severe as to require most * The author has reported one (terminal stage) case of pernicious anemia in which all these symptoms, together with a loud diastolic aortic bruit were present without aortic valve changes adequate to explain the murmur, and a few other such clinical curiosities are to be found in the literature. t Two cases have come under the author's notice in which a mistaken diagnosis of cere- bral meningitis had resulted from this curious condition. THE ANEMIAS 147 radical measures for their relief, and often tend to recur until the general therapeutic indication, namely, the administration of iron, is fulfilled. General Nutrition. — In simple anemia the fat is usually well preserved, giving the patient a plump appearance. In secondary anemia the state of nutrition is dependent upon the primary lesion. In pernicious anemia, even in its later stage, there is often a wholly misleading appearance of fairly good nutritipn, due to the presence of overlying fat, but the skin in these cases has a peculiar velvety feel, and the muscles are sometimes of the consistency of jelly to the touch. The Eye. — Muscular insufficiencies are common, retinal hemorrhage fre- quently occurs in pernicious anemia and in all severe forms the ophthalmo- scope shows a pale fundus. GENERAL ETIOLOGIC FACTORS.— Age.— Secondary and pernicious anemias occur for the most part in those at or above middle age. Chlorosis is essentially a disease of the earlier years, most often commencing at or about the age of puberty. Sex. — Ninety per cent, of all cases of chlorosis (simple anemia) occur in young women. Pernicious anemia is more frequent in the male, secondary anemia follows the laws of incidence of the primary lesion. Specific Causes of Anemia. — Little is positively known of the specific pathogenesis of the anemias and the scope and purpose of this volume for- bids a discussion of the theories. General Causes. — In connection with simple anemia one is likely to find defects in food, environment, habits and general sanitation. Boarding- school girls and working girls may suffer alike from insufficient or improperly prepared food or from lack of variety, no less than from poor ventilation, over- work, or lack of fresh air or sunshine. Depressing emotions, such as grief, homesickness or disappointment in love often play their part, and the effect of nearly all of these general factors is shown in Arctic explorers who have in many instances suffered from severe forms of anemia during the Arctic night, when nostalgia, darkness, fatigue, poor ventilation and improper diet all were present. Secondary Anemia. — This may be associated with the following condi- tions: (a) Repeated hemorrhages (hemorrhoids, nose-bleed, uterine hemor- rhage, gastric ulcer, hepatic cirrhosis), (b) Malignant disease, especially carcinoma of the stomach, (c) Syphilis, leprosy and tuberculosis, (d) Mineral poisoning, arsenic and lead especially, (e) Malaria. (/) Bright' s disease in its various forms, (g) Intestinal parasites, (h) Auto-intoxication, (i) Any acute infectious disease, acute rheumatism being the chief. The foregoing statements as to general symptomatology are applicable to all forms of anemia in varying degree. Considered as arbitrary types, chlorosis stands at one pole, pernicious anemia at the opposite, while secondary anemias of exceptional severity are ordinarily overshadowed and dominated by the symptoms of the causal lesion and may assume varying and at times misleading forms. Varies with type of anemia. Pale disc. Bad hygiene. Lovesickness and nostalgia. 148 MEDICAL DIAGNOSIS A Cause of Chief Importance. — Many cases of chlorotic and secondary anemia lacking any easily demonstrable primary cause results from hidden foci of chronic intermittent or remittent infection such as are fully discussed elsewhere in this volume. CHLOROSIS Cause unknown. Lessened incidence. Developmental period. Recurrent cases. Type chiefly arected. Peculiar vulnerability. Leading char- acteristics. Characteristic Feature. — Hemoglobin deficit first reported by Johann Duncan in 1867 (Osier). Etiology. — Although known and recognized before the days of Hippo- crates, the specific etiology is unknown. Its onset is associated with the period of sexual development in the female and it would seem that some fault of function in the glands of internal secretion is the chief factor in causation. Its incidence in our own country has decreased strikingly dur- ing the past twenty years — a period characterized by greatly improved living conditions, a better understanding of concealed septic foci, and the free exhibition of Blaud's mass in the department stores. Age and Sex. — It occurs rarely in young males but is almost exclusively limited to the female sex. Of primary attacks, 99 per cent, occur between the ages of 14 and 25, and chiefly between the 14th and 18th years. Obviously, this latter period corresponds suggestively to that immediately preceding, accompanying, or following the establishment of menstruation. It repre- sents also the age of maximal susceptibility to focal infections. Inasmuch as the disease shows a peculiar tendency to chronicity and recurrence under the usual casual and unsystematic management on the part of patient and physician alike, one encounters frequently cases of chronic or recurrent anemia of the chlorotic type at later ages and occasionally even in middle age. The Congenital Asthenic. — According to the author's experience nearly all of the cases of pronounced chlorosis occur in individuals of the con- genitally asthenic (universally visceroptotic) type. The characteristics of this peculiar type of constitutional inadequacy or inferiority are such as would favor or predispose to the development of chlorosis, whether this be considered as fundamentally the result of disturbance of endocrine func- tion, nutritional deficit, or the result of infections. In such individuals there is a peculiar nutritional instability and an unfortunate dependence upon nutritional reserve for the maintenance of health and normal function. The larger number of cases of endocrine dis- turbance, of gastric neurosis, of cardiovascular abnormalities of the func- tional type, are associated with the presence of the "drop heart," abdominal visceroptosis, flabby abdominal muscles, a narrow costal angle and the slender bony and muscular structure characteristic of this type. They may be fat or lean. In these congenital asthenics, particularly, one finds with especial fre- quency not only focal infections of the usual type but radiographic evidence of larval or obsolete tuberculosis of pulmonary site. It has long been known that this is true also of cases of chlorosis. The readiness with which disturbance of function occurs in connection THE ANEM1 \S 149 with this constitutional state makes it easy to understand that deficient bone-marrow activity might occur readily in connection with it and indeed both the symptomatology and the etiologic indications accord with the assumption that in the greater number of instances one is dealing with this peculiarly vulnerable and unstable type. Older Theories of Causation. — Among the numerous and diverse theories which have been advanced in the past, one may note the following: Love-sickness is given as a cause. Of course, this may be and often is encountered in a disease affecting almost exclusively young girls and young women of the age which peculiarly predisposes to this state of mind and body. (b) Hypoplasia of the generative organs has also been advanced as a cause and is present no doubt in a certain proportion of the chlorotic cases. However, it would be improper in the light of present knowledge to consider this in itself a direct cause or a constant associated etiologic factor. (c) Tuberculosis, cardiovascular defects, heredity, psychoneurasthenic states, constipation and autointoxication, for the most part represent effects rather than causes and defects peculiarly likely to be encountered in connec- tion with the congenitally asthenic type. (d) Over-work, bad food, unhygienic environment, worry and mental depression, and even certain specific occupations have been advanced as casuative factors. Doubtless each and every one may be considered a potential contributory element, but certainly no one of them can be put down as a specific factor in etiology. (e) Much stress has been laid by certain writers upon the potency of homesickness as a factor in chlorosis and it is quite true that one encounters a large number of chlorotics amongst the recently arrived immigrants, especially such as come from northern countries as those of Scandinavia. Usually, however, it is unlikely that homesickness plays a part more import- ant in itself than any other state of mental depression and worry; and furthermore, in the class of individuals just mentioned, many other factors favorable to the development of the chlorotic state are present. The larger number of these young female immigrants have come from the farms, from an open country life with coarse wholesome food and abundance of out-door work, and have exchanged these favorable conditions of environ- ment for city living, domestic service, work in public laundries, and other occupations of a relatively unfavorable nature. (/) There can be little doubt that chronic concealed septic foci may play a part in the production and more especially in the persistance and recurrence of chlorosis, yet the greater number of anemias for which chronic infections of the tonsils, teeth, and other organs are responsible are of the secondary type to be described later and not of the chlorotic type. Unfavorable Environment. — The betterment of conditions of living and working has undoubtedly resulted in a marked diminution in the incidence of cases of chlorosis as might be expected when one considers the large number of contributory factors in etiology involved in bad housing, whether related Bone-marro\ deficiency. Dubious etiologic factors. Potential contributory factors. Nostalgia. Focal infections. 150 MEDICAL DIAGNOSIS Occupation. Low color index. Erythrocytes. Achromia marked. "Blasts." to dwellings or shops, insufficient and improperly prepared food, excessively long working hours with resulting tendency to extreme fatigue, and depriva- tion of fresh air and sunshine for the indoor dweller or worker. Each and every one of these factors is of vital importance to health in general and especially to the maintenance of good health on the part of those of the congenitally asthenic type of constitution. Cardinal Symptoms. — The most striking symptoms are lassitude, breath- lessness, the characteristic color, and a blood picture characterized by a low color index and the predominance of the small erythrocyte. Color. — Simple pallor or less frequently a peculiar " greenish-yellow " skin are usually, though not always, prominent signs. Indeed the term "chlorosis," "green sickness," is a misnomer. The patients appear, as a rule, relatively plump and well nourished, though pale, and their occupation is likely to be that of laundress, shopgirl, factory worker or school girl. The developmental period is the one of commonest incidence. The heart is often dilated moderately and edema of the ankles is a common symptom in severe cases. Vasomotor instability is marked and flushing may be associated with cold extremities, numbness and other symptoms of a like sort. A great many of the severe cases show the "drop heart" fully described elsewhere. Nearly all chlorotics are congenital asthenics. The lungs are sluggish and the breathing is superficial. Systolic murmurs are commonly encountered over the left base, at the apex or even in the aortic area. Both cardiac murmurs and dilatation respond promptly to effective treatment. A venous hum {"bruit de diable") is often heard over the jugular and a similar sound may at times be heard at the occiput or over the eyeball. Preservation of fat is the rule, high color not uncommon ("chlorosis rubra"), puffiness of the face may be decided and the eyes may be peculiarly brilliant and show a bluish sclera. The general symptoms are those described in the preceding pages but are usually moderate in degree. The therapeutic test for chlorosis is found in the prompt response of its symptoms to the proper administration of iron and relapses are common if pa- tients are not kept under observation for long periods. Blood Findings. — The blood macroscopically appears pale and thity and the color index is low. The hemoglobin percentage varies widely in the different cases (12 to 75 per cent.), its average being about 45 per cent. Total blood is increased and a certain grade of hydremia is present. The red cells are not proportionately decreased, the average being 4,000,000 per cubic millimeter. A count under 2,000,000 is rare, and the average size of the cell is less than normal. Stained specimens show marked achromia and old cases may show polychromasia and marked variation in the size of the cells (aniso- cytosis). Marked cell deformity (poikilocytosis) , is rare but in some recurrent cases extreme. Nucleated red cells are seldom found and when present are normoblasts. THE ANEMIAS <5' The leucocytes may be normal, slightly or markedly decreased* or increased and relative lymphocytosis is not uncommon. Myelocytes are rarely found, the eosinophils are decreased and the "coagulation time" is shortened. Blood platelets are slightly markedly increased. THE ADDISONIAN PERNICIOUS ANEMIA. ("Plastic Pernicious Anemia") Age. — It occurs usually in middle age and is excessively rare in childhood and in old age. Sex. — In the United States and England males are oftenest attacked. In Germany females are chiefly affected. The world owes to Addison of England its first knowledge of this remarkable and mysterious disease.! Etiology. — The actual causes of pernicious anemia are unknown, but its dominant and invariable characteristic is an excessive, intractable, and ulti- mately fatal hemolysis due doubtless to an unknown toxin. The blood picture is suggestively like that of the bothrioceph- alus and pyridin anemias in which known hemolysins are causative. It follows, oftentimes, shock, mental strain, prolonged exposure and fatigue, syphilis, malaria, alcoholism, and in women repeated and excessive child- bearing, but any or all of these factors seem to be only- contributory. The present view would seem to be that certain toxins acting in small but potent doses over long periods abnormally stimulate the hemolytic activities of the bone marrow, spleen and lymph glands. As a result of the continued overstimulation and the persistent hemolysis the erythrogenetic centers themselves become overactive and enlarged and cause that ultimate dominance of the large immature vulnerable erythrocytes and erythroblasts which dominate the blood picture of the disease. Grawitz lays especial stress upon the well-known shortage of free HC1 in the stomach contents of these cases as favoring excessive albuminous putre- faction and diminishing the defenses against bacterial activity. It would seem possible that the ultimate cause may be found in the selective activity of peculiarly virulent hemolytic streptococci. The disease is peculiarly insidious in onset and in public clinics the great majority of cases show an erythrocyte count under 2,000,000 at the first examination. Symptoms. — These are as described under "General Symptomatology" of the anemias, but patients present as special features or striking signs a more or less characteristic lemon-yellow color, together with insidious and slowly developed failure of strength, attaining gradually a most extreme type of muscular weakness in the established case. * Osier reports a series with an average white count of 8,467 per cu. mm., and Gulland and Goodall a series with average under 5000. f Addison's first report appeared in the London Med. Gazette, March, 1849. Biermer wrote of the same ailment in 1868, and in Germany it is termed quite wrongly "die Biermer- sche anaemie." Coagulation time. A mystery. Insidious onset. 152 MEDICAL DIAGNOSIS Striking symptoms Macroscopic "Coagulation time." High color ii dex, and low erythrocyte count. Hemoglobin. Poikilocytosis. Anisocytosis. Predominance of megaloblasts. Polychromasia. Impaired nutrition, intermittent gastrointestinal disturbance often of great severity and persistence, vertigo, submucous and subcutaneous hemor- rhages, extreme pallor of mucous membranes, retinal hemorrhage, severe headaches, tinnitus aurium, dyspnea, optical disturbances, fainting attacks, and slight edema of the extremities are among the prominent manifestations of this obscure ailment, as usually encountered. The asthenia is strikingly progressive in untreated cases, yet temporary recovery is common and may endure for several years, though the ultimate progno- sis is fatal. Heart. — The heart is weak and dilatable, the pulse rapid 'and labile in action and anemic murmurs are pronounced. Fever of the hectic type is a feature of the advanced cases or of the terminal stage. Hemorrhages in the spinal cord and meninges are not uncommon and mis- leading pictures may be produced through "patchy" involvement of the posterior or lateral column's singly or combined. Blood Findings. — The blood is pale, thin, slips quickly off the ear or finger following puncture, and if dropped on a piece of white bibulous paper the red is surrounded by a ring at first almost colorless but later showing a faint gray tint. The ''coagulation time" is increased and bleeding from the puncture of the ear may continue sluggishly for a considerable period, but is seldom or never excessive. The " total blood volume" -is diminished in these cases, the " volume index" is high, the specific gravity decreased. Blood plates and fibrin alike are strik- ingly diminished. The color index is high, the red cells are reduced on the average to 1,500,000 per cubic millimeter and 1,000,000 is a common finding. Nageli has reported a count of 138,000 and Zeigler one of 110,000 per cubic millimeter in a case of the ''aplastic" type, described further on as a separate form. The lowest observed by the author was 348,000. The hemoglobin usually is reduced greatly and may be as low as, or even below, 15 per cent., but in most instances is relatively in excess. The average diameter of the red cell usually is increased, poikilocytosis (cell deformity) is marked and the "pear-shaped" and " anvil " forms are pecu- liarly plentiful. The red cells show great variation in size (anisocytosis) and giant non-nucleated and nucleated red cells are invariably present, though often found only after careful search and only rarely in great numbers, save in the so-called "blood crises." In this so-called "plastic" form, the megaloblasts must be found to out- number he normoblasts or a positive diagnosis is not then justified. A relative excess of microblasts or of normoblasts usually indicates a severe secondary anemia. Polychromato philia . i.e., irregularity in staining and consequent lack of uniform color in certain of the stained cells in a blood smear is a marked characteristic of this disease though not peculiar to it. nil'. ANEMIAS 153 'Die leucocytes are diminished in three-fourths of all cases and this leuco- penia may be extreme, the average being less than one-half the normal count.* Myelocytes and erythrocytes showing basophile granules with Wright's stain are nearly always present, though in small numbers. It is usually possible to make an accurate diagnosis of pernicious anemia by the blood findings alone, but now and then cases occur in which the clinical history and physical signs must be invoked. BotJiriocephalus infection and nitro-benzol poisoning present a blood picture almost identical with pernicious anemia or actually indistinguishable from it. Advanced cases of malignant disease of the stomach may present quite as extreme an anemia, but in this the small cell type usually predominates, both as to nucleated and non-nucleated red cells, the polymorphonuclear leucocytes are normal in number or increased and the lymphocytes relatively or actually dimin- ished in number. The urine in advanced pernicious anemia is usually dark and shows a con- j siderable increase of urobilin. The frequency with which pyorrhea alveolaris , dental abscesses and the chronic tonsillar and sinus infections occur in certain intractable anemias may prove ultimately of the first importance in establishing the identity of the specific causa- tive agent. Autopsy Findings in Addisonian Pernicious Anemia. — The autopsy findings throw little light upon the cause of the disease but disclose certain striking pathologic changes more or less peculiar to it. Fatty degeneration is the dominant process in the parenchymatous viscera and is especially marked in the liver, heart and kidneys. The heart is usually dilated and flabby and contains little or no blood. Its color is a pale yellow. The red bone marrow is strikingly deepened in color and the yellow marrow of the long bones appears to be transformed into a deep red gelatinous sub- stance often likened to currant jelly. This appearance is usually more striking than that seen in even the severest forms of secondary anemia. An extraordinarily large deposit of iron in the liver and to a lesser degree in the spleen and kidneys attends the continued destruction of red cells. A section of the liver thoroughly treated with a weak solution of ferro- cyanide of iron and then washed in a weak aqueous solution of hydrochloric acid assumes a strikingly beautiful blue color. The entire general picture presented by the victim on post-mortem sec- tion is one of extreme anemia and deficient blood volume. Even the imper- fectly formed blood clots show a pallid red. * This leucopenia usually affects chiefly the polymorphonuclears both neutrophile and eosinophile and to a lesser degree the large lymphocytes. A relative lymphocyte increase is, therefore, usually present. Leucopenia. Myelocytes and basophiles. Its simulators. A confusing secondary form. Urobilin increase. Focal infections. 154 MEDICAL DIAGNOSIS Sex predominance. Cause unknown. Progressive and resistant. Low erythro- cyte count. Low or normal index. Absence of poikilocytosis. Only a syndrome. APLASTIC PERNICIOUS ANEMIA Definition. — This term is applied to a relatively uncommon pernicious form of anemia, occurring usually, but by no means exclusively, in females between the ages of twenty and forty, in which the blood findings suggest a failure of hyperplastic response on the part of the bone marrow. Etiology. — The cause of the disease is wholly unknown. It is held, with- out much substantial justification, that in some instances it represents a termi- nal transformation of the hyperplastic Addisonian anemia. It may be treated properly as a distinct type, however, for bone-marrow insufficiency and aplasia are the dominating features in its pathogenesis. The disease is usually progressively fatal, lacks the clinical signs of excessive hemolysis, is resistant to all therapeutic measures, and is distinctly more hemor- rhagic in type than the ordinary form. Blood. — The erythrocyte count is seldom much above 2,000,000 and one count as low as 110,000 is reported. The color index is usually low or about normal. All forms of nucleated reds are absent or extremely scant. Poikilocytosis and anisocytosis are slight or wholly absent and polychromatophilia is not marked. Leucopenia and relative lymphocytosis are present as in true pernicious anemia but of higher grade. The blood platelets are decreased markedly. The skin seldom shows the pale lemon tint so common in advanced Addi- sonian anemia. The urine is relatively fight in color and free from urobilin. The liver, spleen and lymphatic glands are not markedly enlarged and even though nucleated cells are originally present they tend to disappear as the disease advances. Autopsy reveals an entire absence of hyperplastic changes in the bone marrow and a greater or less degree of actual aplasia, the bone marrow in some instances consisting of yellowish fat. SPLENIC ANEMIA Not a Clinical Entity. — This condition has not yet made itself a place in medicine as a clinical entity and its features do not seem to be sufficiently characteristic to constitute a separate disease but rather to stimulate us to seek a more accurate terminology. Anemia with splenic enlargement would seem to be the more correct term. So far as the actual blood picture is concerned, any form of anemia may be simulated, the marked secondary type being that commonly shown. We must regard the condition for the present as an interesting symptom- complex, lacking the glandular enlargement of Hodgkin's disease or the peculiar blood changes of leukemia, and adding to the ordinary symptoms of anemia that of splenic hypertrophy, commonly associated with hepatic enlargement. A large number of cases of this general description prove to be due to syphilis or to malignant growth. Three syndromes under this general heading are worthy of discussion. THE ANEMIAS 155 SPLENOMEGALY WITH HEPATIC CIRRHOSIS AND ANEMIA.— This symptom-complex unites anemia, hepatic cirrhosis and splenomegaly. This disease was long ago known by the reasonably accurate and descrip- tive name "splenomegaly with hepatic cirrhosis." We owe to Banti an ex- cellent and orderly description of the condition. First Stage. — At any age, but most frequently between thirty and fifty a painless splenic tumor develops and gradually increases in size, until in form, area, and consistence it may closely resemble the spleen of a myelogenous leukemia. Coincidently there develops an anemia of the simple chlorotic or mild secondary type with low "color index" and more or less enlargement and induration of the liver. Second Stage. — Icterus appears and dyspeptic symptoms may become prominent. Third Stage. — After a few months the icterus and anemia become inten- sified but show no decided departure from the picture of severe chlorosis or of a secondary anemia of the ordinary type; epistaxis, hematemesis, purpura or other hemorrhages may appear, cachexia is marked and, later, ascites is evident. A fatal issue may result from progressive inanition or from gastric or intestinal hemorrhage. Nearly all of the cases observed by the author, whether at home or abroad, have proven ultimately to be either syphilitic or due to malignant growth, and those proven luetic have presented, for the -greater part, the typical picture as drawn by Banti. SPLENOMEGALY OF THE GAUCHER TYPE.— This extremely chronic and excessively rare disease of infancy and early childhood combines in itself the peculiar pigmentation of Addison's disease with splenomegaly, subsequent enlargement of the liver, and anemia. It is familial but probably not hereditary, occurring usually in several members of the same generation (females are chiefly affected), and is char- acterized anatomically by the presence of masses of peculiar hyaline cells of large size and probable endothelial or reticular origin, (40/z) in the spleen, liver, bone marrow and lymph glands. The blood picture is neither characteristic nor consistent. It may be that of mild chlorotic anemia (the usual form) with leucopenia, or present the blood findings of mild secondary anemia or those of a severe but atypical pernicious form with megaloblasts and myelocytes. A tendency to hemorrhages may be present. By some authorities it is stated that leucopenia is constant throughout and a chlorotic blood picture invariably present. The course of the disease is extremely protracted, the general health is but very gradually affected and death occurs after several or many years through some intercurrent disease. Though a disease of childhood and early youth, it often escapes diagnosis for many years. CONGENITAL HEMOLYTIC JAUNDICE.— This is an extremely chronic, strikingly hereditary, familial disease, of great interest and rarity, So-called "Banti's disease." Primary stage. Splenomegaly. "Transition stage." "Ascitic stage." Peculiar pigmentation. Familial. Bastard blood picture. Familial. i56 MEDICAL DIAGNOSIS characterized by extraordinary vulnerability of the red blood cells, decided anemia, splenomegaly, moderate hepatic enlargement, pronounced icterus and urobilinurea. All symptoms of an actual obstructive jaundice are lack- ing in the stools and urine. Hemolysis. The destruction of red corpuscles is extraordinary in many cases, the blood picture being in the rarer instances that of a pernicious anemia. Their re- sistance to hypotonic sodium chloride solution is so greatly diminished as to constitute an important factor in diagnosis. An interesting case was reported recently from the author's former clinic by Richards and Johnston.* LEUKEMIA ("White Blood") Historic Note. — Until 1841 this disease was regarded as a purulent inflam- mation of the blood. John Hughes Bennett gave the first account of the disease in the year 1845. Pathogenesis. — The latest investigations strengthen the theory that we shall find ultimately that an infection plays the chief role. Leukemia is undoubtedly a primary affection of the bone marrow and the lymphoid structures, the essential change being one of excessive and wholly unregulated myelocytic or lymphocytic hyperplasia, leading ultimately to the dominance in the blood picture of types of white cells which normally are wholly absent or appear only in small numbers in the blood stream. We know practically nothing of the early stages of the disease. Varieties. — There are two forms of leukemia, the myeloid and the lymphatic. In the first form the blood assumes the so-called myeloid type, in the second, the lymphoid. Although several cases of acute myelogenous leukemia have been reported, we may for the present regard it as essentially a chronic disease. Lymphatic leukemia, on the other hand, may be either acute, subacute or chronic. Transmutation may occur in rare instances. Important Distinction. — It should be clearly understood that the existence or non-existence of leukemia is not determined merely by the number of white cells present in the given blood. A count of 90,000 leucocytes may be but a leucocytosis and a count of 25,000 might represent a leukemia. The difference between the two is dis- tinctly qualitative, not quantitative. It is true nevertheless that in most cases of leukemia the leucocyte count is very high at the time of first recognition. * Cases showing an apparently clearly denned blood picture of pernicious anemia, but showing decided splenic enlargement and slight jaundice, should always be specially in- vestigated as to familial tendency and the osmotic resistance of the red cells should be tested. THE ANEMIAS 1 57 MYELOID LEUKEMIA Definition. — . 1 chronic, progressive and fatal disease characterized by a combination of profound anemia of the pernicious type with an extraordinary increase of leucocytes of both the common and the unusual types, which findings, together with splenomegaly, dominate the clinical picture. Etiology. — Age. — It may occur at any period, but for the most part is encountered in middle age. — Males are chiefly affected, predominantly so, in the author's experience. Other etiologic factors are not well understood. Certain rare cases of streptococcic sepsis have presented a picture suggestively similar but there remains no definite etiologic factor up to the present time. SYMPTOMS. — The general symptoms are those of severe anemia as already described at the beginning of this section. The disease is not likely to be detected until well advanced,* and the general symptoms are then those insidious in of a profound anemia with an especial tendency to hemorrhage and serous effusions. Dyspnea is marked; ultimate loss of flesh usually extreme, and both liver and spleen are enlarged, the latter to an enormous degree in certain cases, Enormous and always to a marked degree. f It is astonishing that so great an enlarge- ment frequently may be unattended by serious discomfort. In certain cases there is pain and tenderness over the long bones and disorders of sight and hearing are not uncommon. Blood Findings. — The red cell count is markedly reduced and the white striking picture. cells are greatly increased in number, the average count being 400,000 in estab- lished and well-advanced cases, the maximum sometimes exceeding 1,000,000 cells. The characteristically important white cell of leukemia is the myelocyte characteristic - e e , myelocytic and from 20 to 50 per cent, of the leucocytes present are of the myelocytic dominance, type. The eosinophiles are also present in unusual numbers, showing both an actual and relative increase. Both the lymphocytes and polymorpho- nuclear cells, though absolutely increased, are relatively diminished. Megaloblasts, normoblasts and microblasts are present in quantity and their nuclei frequently show mitotic changes. One of the most striking though not invariable symptoms of the later stages of the disease is the tendency to hemorrhage from mucous membranes. Hemorrhagic These are often large, persistently recurrent, and demand that every patient should be duly warned and instructed concerning measures for their relief or control. They often prove a terminal event, or death may result from asthenia or from either gradual or sudden cardiac failure, often associ- ated with general dropsy. Severe recurrent unexplained hemorrhages demand an examination of the blood. * Not only may strength be well preserved over long periods, but the outward appear- ance of health as well. Even a gigantic spleen may be wholly unnoticed by the victim. t In one case shown by the author to the Minnesota State Medical Society in 1903, the splenic margin actually rested against the anterior-superior spine of the right side. tendency. i58 MEDICAL DIAGNOSIS Lymphocytosis absolute. LYMPHATIC LEUKEMIA Essential Features. — The essential features of lymphatic leukemia are two in number: (a) Enlargement of the lymphatic glands, (b) An absolute monocytosis in which either the large or small cell type may predominate. The cause is unknown; chronic cases endure for years, but acute cases may terminate in a month or six weeks. SYMPTOMS. — Any or all groups of lymphatic glands may be enlarged. The tumors are, as a rule, separate and movable, free from active inflammatory changes and show little or no tendency to suppuration. They vary greatly in size but seldom exceed the dimensions of an egg. Usually all accessible glands are affected in some degree. Lymphomata. Predominant localization. Consistent picture. A terrible complication. Fig. 53.— Lower section shows a lymphatic leukemia. Upper section normal blood showing leucocytosis. These types of cells should be carefully noted. The cervical chains are ordinarily most prominent, but predominance of enlargement may be found in the axillary or inguinal groups and nodes normally inconspicuous may form large masses. In the rarer cases the glandular chains affected are not accessible, yet decided involvement of the retroperitoneal or bronchial groups may exist. The spleen is moderately or decidedly enlarged, but the glandular symptoms dominate the picture. Fever is present in variable degree in all acute cases and the later stages of the chronic form. Pressure symptoms may be marked and in three of the author's cases death occurred horribly from actual slow suffocation due to the pressure of mediastinal growths. THE ANEMIAS 159 Insidious Onset. — In this form of leukemia, as in the myeloid form, the condition is usually well advanced before the patient seeks his physician, complaining of progressive weakness, easily induced fatigue and, perhaps, of glandular swellings. Some pallor is usually manifest and these patients often carry a peculiarly harassed expression. The spleen is usually easily palpable but seldom descends more than one or two finger-breadths below the costal margin. The liver may be greatly enlarged and markedly indurated but usually the increase in size is moderate. Fever. — A moderate daily rise of temperature is not uncommon even in the chronic cases. BLOOD FINDINGS. — The blood picture contrasts strikingly with that of myeloid leukemia in the comparative lack of diversity of form and type in the blood cells. Save in the rarest instances, the lymphocyte absolutely dominates the leucocytic field. Nucleated red cells are rare as compared with the myelogenous leukemias, though in the acute type of the disease they may be present in considerable numbers and the same is true of certain of the leukemias of children. If nucleated reds are present, the normoblast predominates in most instances. Very rarely an extreme degree of anemia proper co-exists with the leukemia and the blood picture more nearly approaches that of pernicious anemia so far as the erythrocytes are concerned. The leucocyte increase, while striking, is seldom as large as in leukemia of the myelogenous type. The average lies between 200,000 and 250,000 cells, the maximum being about 1,000,000, but in a case observed by the author the count reached a remarkable 77 . J case. 2,133,000 for the single examination possible and w r as probably a preagonal increase, as it occurred but twenty-four hours before death. As before stated, the remarkable predominance of the lymphocytic type (average 90 per cent.) is striking and the cells show many atypical forms. The myelocytes are relatively rare, eosinophiles are diminished and neither the mast cell nor the basophile are common. ACUTE LYMPHATIC LEUKEMIA.— This rare ailment is sufficiently definite in its clinical characteristics to merit a special description. As in the case of the chronic form, post-mortem section reveals general proliferation of lymphoid tissues of somewhat less extent and degree, as w r ould be expected in a lymphatic leukemia of short duration. Suggests An Acute Infection. — The onset is usually abrupt and well- defined, rarely insidious. A chill may or may not initiate the febrile stage. Very often an antecedent or existing severe stomatitis, tonsillitis, or pharyn- gitis occurs and may prove most misleading, though in the future we may find the fact helpful in determining the true etiology of the leukemic states. A Misleading Occurrence. — When, as occasionally happens, there is no Onset usually abrupt. Suggestive coincidences. i6o MEDICAL DIAGNOSIS Depends upon blood - findings. Relatively common. change from the normal in the blood count for a period of several days error is very likely to occur. Fever is persistent and may assume a distinctly septic type late in the course of the disease. Indeed a definite streptococcic infection may occur in certain cases. This has been regarded as secondary but recent work with the hemolytic streptococci would suggest that such a conclusion may be erroneous. Hemorrhage from the nose or gums may initiate the attack and con- stitutes an important complication of the disease. It may be most persistent and intractable and even prove the terminal event. The condition of the mouth and teeth may closely simulate scurvy. Enlargement of accessible glands may be wholly lacking or very decided. Splenic enlargement is present but only of slight degree in cases of short duration and symptoms of profound anemia rapidly develop with progressive cardiac weakness. The blood picture is identical with that of the chronic form, the small lymphocyte usually, but by no means always, predominating. Early counts may prove negative. It is asserted that many of the cases termed acute lymphatic leukemia are actually instances of acute myeloid leukemia, the mononuclears representing NaegeWs myeloblasts. The differentiation of these cells from the lymphocyte offers great diffi- culties, even to the expert hematologist, and is of slight clinical importance. Prognosis. — The disease is invariably fatal and may terminate within a few days or be prolonged for two or three months. DIFFERENTIAL DIAGNOSIS OF THE ANEMIAS.— The enormous value of blood examinations is evident if one considers the insuperable difficulties surrounding the purely clinical differentiation of the conditions described, as compared with the ease with which each disease may be identified, usually, by hematologic methods. As regards anemia in any of its three chief forms, no confusion is possible save in rare instances, and the two chief varieties of chronic leuke- mia are quite as sharply contrasted. The glandular enlargements of Hodgkin's disease, tuberculosis and syphilis seldom offer the slightest difficulty if the blood findings are invoked, nor can the various enlargements of the spleen be confused with the splenomegaly of mye- logenous or lymphatic leukemia. Sources of Confusion. — Certain cases of profound secondary anemia, particularly those associated with carcinoma of the stomach or primary atrophy of the gastric tubules {not merely the simple achylia gastrica) may at times present a picture almost indistinguishable from that of per- nicious anemia though the small red cell, both nucleated and non-nucleated, is the predominant form in almost every instance. To this may be added bothriocephalus anemias, which symptomatically, and in the blood changes, may be identical with pernicious anemia proper, and separable only through THE ANEMIAS 161 the discovery of the true etiologic factor. A careful examination of the stools is indicated in all anemias. It is probable that in the anemias of true gastric atrophy of the type mentioned, the blood findings are always those of the profound secondary type. Subdivisions and Transition Forms. — It is quite possible that further subdivisions of leukemia may be made in the future, and indeed many cases of variation in the relative predominance of cell types and apparent transi- tion are constantly being placed on record.* Von Jaksch has reported a " multiple periostitis with splenomegaly and myelocytic anemia, multiple arthritis, profuse sweats and a like and even greater tendency to the hemorrhages such as so frequently complicate the later stages of myelogenous leukemia." CHLOROMA. — In this rare disease the blood findings may be indistinguish- able from those of lymphatic leukemia, but the clinical symptoms are strikingly different save that its course closely parallels lymphatic leukemia of the acute type. Tumors. — The curious greenish tumors of chloroma are strikingly unlike anything occurring in connection with lymphatic leukemia. At autopsy they are found widely disseminated throughout the body, but their tendency to appear at points of prominence on its surface makes the diagnosis simple if the existence of such a rare disease is recalled to memory. Indeed they are especially numerous over the bones of the skull and face. This curious ailment is invariably fatal and attacks, almost exclusively, male children and adolescents. STILL'S SYNDROME. — Still has reported a syndrome, the main feature of which is an anemia associated with infantile arthritis with enlargement of the lymph glands and spleen, but lacking the blood -findings of leukemia and presenting usually the history of rachitis. MYELOMA. — In this rare and obscure ailment a period of neuralgia-like bone pain may be followed by painful metastatic swellings usually affecting chiefly the ribs or bones of the cranium and sometimes producing spontaneous fractures. Diagnosis depends upon the presence of the Bence- Jones proteid in the urine and the result of roentgenographic studies. LEUKANEMIA. — This term has been widely and loosely used to cover a clinical picture in which the symptoms of leukemia and of pernicious anemia are confusingly blended. It has been wrongly used also to cover cases which were undoubtedly myeloid leukemias or clearly pernicious anemias in which unimportant departures from the type had occurred.! * The author has observed a case of apparently typical Hodgkin's disease become in all respects lymphatic leukemia and many reports of myeloid leukemias under X-ray treat- ment have shown an apparent transition to the lymphatic type. t As Cabot says, "most reported cases are clearly leukemic and nearly all of the re- mainder are pernicious anemias." ll "Green cancer." A useless term. l62 MEDICAL DIAGNOSIS Not uncommon. High altitudes. Multiple causes. Stasis polycythemia. If the term is to be retained it should be confined to cases of the type originally reported under it by Leube and Arneth. The original case pur- sued the course and had all the attributes of a rapidly progressive and fatal acute injection. The blood picture was that of a pernicious anemia of the Addisonian type to which was added a large increase of leucocytes with many neutrophile myelocytes. PROGNOSIS IN THE ANEMIAS.— In anemia of the chlorotic type the prognosis is always good unless it be a part of the clinical picture of gastric ulcer or incipient tuberculosis, or attributable to recurrent septic infection arising from obscure foci. Secondary anemias are wholly dependent as to cure upon the possibility of removing the primary cause. Pernicious anemia is almost invariably fatal, though long periods of apparent recovery may be noted in cases of the plastic type.* Leukemia offers a bad prognosis, though of late apparent cures have been common. It is probable that these cases will also prove fatal after a period of apparent arrest. THE POLYCYTHEMIAS POLYCYTHEMIA. — (Erythrocytosis) . — A more or less marked increase of erythrocytes above the normal count is observed in a great variety of conditions, some important, others trivial, and, curiously enough the perma- nency of such a condition still remains unproven. It usually represents nothing more than blood concentration or stasis, and in high altitudes is perfectly accounted for by the assumption that nature meets an actual need associated with the rare air and the dyspnea first pro- duced in a non-habituated person. f This assumption is borne out by the secondary partial reduction noticed in those who take up permanent residence. A similar slight increase may follow baths, hot or cold, massage, violent exercise and the administration of certain drugs or may be associated with the process of digestion, blood regeneration, vomiting, profuse sweating, the removal of exudates, profuse diarrheas and, it is said, with myxedema and acute yellow atrophy. Its presence in connection with circulatory stasis, such as may occur in organic heart disease, emphysema, stenotic dyspnea and similar conditions affecting the circulation is readily understood and in extreme cases the count may reach 7,000,000 per cubic millimeter. In congenital heart disease * The longest duration of such a period of false cure personally observed was five years, a second period of about one year followed a second stay in the hospital, succeeded by a rapidly fatal relapse. One case of complete cure has occured in the author's practice. The blood being wholly normal ten years after apparent recovery. t An immediate primary apparent increase such as occured in the military observers and fighters of the aviation corps during the "Great War" is caused probably by car- diovascular embarrassment and irregularities of distribution, violent and abrupt transi- tions from sea level to 14,000 ft. altitude being common events of the day's work. THE POLYCYTHEMIAS i6j Polycythemia rubra. A recent discovery. of extreme cyanotic types the erythrocyte count may exceed 9,000,000 per cubic millimeter of blood and hyperplasia of the red marrow is found in such eases. In the dyspneic states due to acquired heart disease there is probably no excessive formation of red cells, but rather an irregular distribution through- out the circulation. ERYTHROCYTOSIS MEGALOSPLENICA.— (Erythremia).— This pe- culiar disease or syndrome of unknown etiology comprises: {a) Marked increase of the red cells, (b) A pecidiar l( red cyanosis." (c) Enlargement of the spleen, (d) Frequently, hepatic enlargement, (e) Commonly, albumi- nuria, (f) Hyperviscosity of the blood, (g) Rapid coagulation, (h) Great increase in the total blood volume. The disease was first noted by Vaquez in 1892, again reported by Saundby and Russell* and by McKeenf in 1901, and in 1903 Osier's report of cases and masterly description brought the condition into prominence. It is rare, but not to the extent formerly assumed. The author has encountered four cases in his private consulting practice during the past few years. Hemoglobin values of 165, and even 220 (by Palmer's method), have been reported, but in one of Cabot's cases it was but 85 with a count of 8,484,000 reds and 15,000 whites, and in another 105 w T ith a count of 11,352,- 000 reds. Moderate or absent leucocytosis is the rule. The highest erythro- cyte count reported is 14,800,000 per cubic millimeter. The color index is low, the coagulation time variable, and the behavior of the erythrocytes to salt solution is normal. The specific gravity of the blood is high; that of the serum, normal; and the freezing point shows no abnormal variation. Symptoms. — The diagnosis can be made at sight with reasonable accuracy by one who has carefully observed a typical case previously. The face and ears exhibit a peculiar dusky redness seen in no other disease. Dusky red 77 is furthermore quite distinct from ordinary cyanosis, however intensive, in that the red dominates the color field as far as the face is concerned. The extremities are markedly cyanotic and its depth and degree is greatly intensified by exposure to cold and the dependent position. Decided enlargement of the spleen is present almost invariably and may attain large proportions. It is smooth, indurated and seldom or never fixed by adhesions. { All of the author's cases showed marked enlargement. The liver is usually decidedly enlarged. Albumin and casts have been present in four of the six cases occurring in the author's practice and in all the blood pressure was distinctly high. In all cardiac hypertrophy and dilatation were manifest. * Lancet, 1901, Vol. 1. t Boston Medical and Surgical Journal, June 20, 1901. % In a case hereafter referred to as under observation for eight years past the primarily gigantic spleen is greatly shrunken and the liver has assumed almost a normal outline. The last blood count showed 'over eight million erythrocytes. Sight diagnosis. Splenomegaly. Arterial hypertension common. 164 MEDICAL DIAGNOSIS Many cases are reported which have lacked circulatory disturbances of this nature; and, doubtless, a large number of the cases on record are unworthy of inclusion. It is certain, however, that the typical cyanosis with splenomegaly and erythrocytosis may exist without high blood pressure. Internal hemorrhages and thromboses are common terminal events. Prognosis. — No well-authenticated cases of cure have been placed upon record. But one of the four cases of the author is living after eight years of observation and his improvement has been maintained only by repeated free phlebotomy and the use of benzol:* In reporting cases the chief clinical factors must be demanded inasmuch as a polycythemia of marked degree may co-exist with cyanosis under other conditions. The peculiar cyanosis with its accompanying brick-red, mottled facial color is most striking. CERTAIN OBSCURE DISEASES ASSOCIATED WITH ANEMIA HODGKIN'S DISEASE. — ("Pseudo-leukemia" "lymphomatosis granulo- matosa," ' ' lympho-sarcomatosis" "lymphadenosis" "anemia lymphatica," " adenie," u lymphadenie ," "malignant granuloma" "infectious granuloma") Definition.- — An infectious granulomatous process of uncertain etiology, chronic, progressive and fatal, chiefly affecting male adults under forty years of age; characterized by peculiar histologic changes in and marked enlargement of the lymph glands; associated with splenic enlargement and anemia of varying degree, but lacking the blood changes of lymphatic leukemia. The number of names given above indicate the dubious nature of the ailment and the diverse pathologic processes with which it has been confused. Historic Note. — The disease was first reported by Malpighi in 1669, who did not recognize it as a distinct disease. Craigie, in 1828, differentiated the anatomical character of the glands from those of carcinoma and tubercu- losis, but to Dr. Hodgkin (1832) we owe our first definite description of the disease as a clinical entity. It did not, however, attain general recognition until the sixth decade of the last century. Etiology.— C. H. Bunting has recently isolated and cultivated a Gram-posi- tive diphtheroid bacillus, corynebacierium granulomaiis maligni, which, when grown in pure culture and injected into apes, produces an enlargement' of glands and histologic changes similar to, if not identical with, those of Hodgkin's disease in man. Fraenkel and Much have reported Gram-positive granular non-acid-fast bacilli, and some observers have considered these as degenerated tubercle bacilli, but on the whole, little evidence has been adduced to support the older supposition of Sternburg that the disease is of tuberculous origin. The etiology therefore remains unknown. Glandular Enlargement. — Dorothy M. Reed reports the following his- tologic picture as characteristic of Hodgkin's disease: '(a) Swollen endothelial * No knowledge of the actual duration of this disease is available for the reason that none have been seen in the early stages and watched throughout the course of the disease. HODGKIN S UISKASE 165 cells lying upon the fibrils of the reticulum; (b) Large epithelioid giant cells lymphocytes and eosinophiles occupying interstices of the stroma. The essential clinical change is one of enlargement of the lymph glands involving primarily limited areas, but tending to extend widely. The cervical and in- Fig. 54. — Hodgkin's disease, enlarged glands filling the mediastinum. (Dr. Frank S. Bisscll.) guinal glands are usually the first affected, the former giving to the disease its most marked characteristic. The tissues of the neck may entirely lose their normal contour, and the glands there and elsewhere tend to steadily enlarge without marked tenderness or symptoms of inflammatory change. They tend to maintain their individual outline until late in the disease, i66 MEDICAL DIAGNOSIS A source of error. Debated point. Important data. The Hodgkin's Collar. and the skin usually remains unaffected and unattached to the subjacent tumors. When periadenitis occurs in the later stages lobulate tumors are formed which may lose the firmness characteristic of the earlier period, become softened and, rarely, may undergo ulceration. The deep glands above the trachea, those of the larger bronchi, of the mediastinum and retroperitoneal area become involved and in some instances form large tumors and greatly complicate the case. The spleen is enlarged in 75 per cent, of the cases. In some cases the internal lymphadenoid tissues alone are involved, rendering positive diagnosis extremely difficult. The Blood. — There are no changes in the blood peculiar to this disease, the picture being one of secondary or of chlorotic anemia. The blood index is in fact usually low as in the chlorotic type and the number of red cells seldom falls far below 2,000,000 per cubic millimeter. In cases which de- velop marked mediastinal involvement and cyanosis a stasis-polycythemia may obscure the blood picture. In most cases a moderate or decided leuco- cyte increase is observed, especially during periods of increased fever when it may reach a high figure (50,000 or more). A more or less decided eosinophilic, is usually demonstrable. Pseudopodia-like elements representing megalokaryocytic protoplasmic masses are also reported by Bunting as appearing in the blood. In certain profoundly cachectic and asthenic cases the polymorphonu- clears are decreased and a relative lymphocytosis results. Whether an actual lymphocytosis is at all common is a contested point. Morawitz asserts its frequency and its value as a differential point in the separation of true Hodgkin's from the other granulomata. It is probable that such an increase is usually only apparent and is actual 1 y relative. Bunting believes that an increase in blood plates and transitional leucocytes constitutes a constant feature and it is true certainly that these features are encountered with sufficient regularity to make them diagnostically suggestive. Acute Hodgkin's Disease. — Certain cases develop so rapidly as to be properly called acute, and may run their course to a fatal termination in a few weeks. The symptoms are, however, not different from those of the chronic type, save that there is a certain concentration of all clinical phenomena. Symptoms of the Ordinary Form. — The onset is insidious, save in acute cases, and the enlarged glands, usually in the cervical region, but sometimes in the groin and axilla, may first attract attention. The glandular enlargement may primarily be either unilateral or bilateral, but extends and tends to become general. The changes in the neck and the peculiar outline produced have given rise to the descriptive term, "the Hodgkin's collar." As the disease progresses, though often only after several months, a considerable or high degree of secondary anemia and more or less progres- sive emaciation appear. If, as is not infrequent, the mediastinal glands take on a rapid growth, the pressure symptoms may be extreme and will precisely resemble those seen HODGKIX'S D1S1 VS1 167 in any other mediastinal tumors, pain, cough and dyspnea, paroxysmal or continuous, being the chief symptoms. Fever is present in the advanced cases and shows a decided tendency to the relapsing form. Indeed its behaviour may constitute a point of differential value. Splenic enlargement is readily made out in three-fourths of all cases and occasionally becomes excessive. The liver is less frequently affected* Differential Diagnosis. — From tuberculous adenitis it is usually readily differentiated by the age of the patient (which is generally above thirty and almost invariably above twenty); by the absence of decided inflammatory symptoms in and around the glands during the earlier periods; by the absence of a history of tuberculosis past or present; by the excision, if necessary, of a small gland and its examination; together with the fact that tuberculosis is more generally localized and unilateral, and that its tumors never attain a large size without marked evidence of inflammation and caseation. From leukemia it is absolutely differentiated in most instances by the blood examination. Aleukemic lymphadenosis lacks the blood picture of Hodgkin's disease. Syphilis must be differentiated by the history, the presence or absence of scars, the result of a Wassermann or luetin test, and the difference in the character and extent of the glandular swelling, which in this disease, though more or less general, does not often attain the large size found in Hodgkin's disease. Tentative antiluetic treatment is often advisable in clinically atypical cases. Lymphosarcomatosis spreads rapidly to all other glands in the area affected but does not invade the other adjacent organs. True sarcoma tends to spread to other tissues. Simple lymphoma is localized and lacks the predominating symptoms of Hodgkin's disease. In all the conditions named the blood picture described above is lacking. It must be admitted that certain of the generalized granulomata of tuberculous or syphilitic origin cannot always be differentiated clinically from Hodgkin's disease. Unusual Symptoms. — An enormous number of symptoms might be named in connection with the development of glandular masses in the abdomen, among these being bronzing which results probably from pressure upon the solar plexus. One has only to bear in mind that in this disease large tumors may develop in remote regions producing exactly the same effects as would any other tumors in the same location. Prognosis. — The disease is almost invariably fatal, its course occupying usually one or two years. Misleading periods of improvement followed by relapse are extremely common and this applies to both the general and local manifestations of the disease. * Marked splenic enlargement is due usually to secondary growths: that of the liver to the same cause or to fatty degeneration. Bronzing possible. Progressively fatal. i68 MEDICAL DIAGNOSIS Significance "Hysterical' purpura. PURPURA Definition. — A morbid state characterized in its graver forms by a low blood-platelet count, prolonged bleeding time, deficient contractility of the blood clot, usually without delayed coagulation time, by hemorrhages, subcutaneous, submucous, or, in rare instances, an outpouring of blood into the serous cavities, with or without fever and other constitutional symptoms. Deficiency of blood platelets, and the consequent deficiency or lack of platelet thrombi, may account for the persistent or unduly prolonged bleeding noted, in the severer forms of purpura, following slight wounds. The cause of the platelet deficiency is wholly unknown, nor can we determine whether in any given case the unknown etiologic factor operates to destroy them when formed, inhibit their production from the megacaryo- cytes or destroy the parent cell in the bone marrow. The platelet count has a practical value in this ailment inasmuch as a count below 60,000 per cmm. predisposes to or initiates hemorrhage (Minot) and with a decided rise in the count the danger of hemorrhage disappears. In severe purpura the platelets may almost wholly disappear (5000 or less per cmm. of blood). Comment. — So little understood is this disease that an arbitrary classi- fication serves the purpose of clinical convenience and little more. It seems to bear a close resemblance to certain forms of urticaria, to scurvy and to hemo- philia, and possesses but two constant and invariable symptoms, viz.: subcutan- eous hemorrhages, and imperfect thrombus formation. Cases may be grouped under four general heads. 1. Complicating purpuras, viz., those occurring in connection with (a) acute infections, (b) chronic diseases associated with cachexia. When purpura occurs in association with acute infection it ordinarily indicates aii exceptionally severe type of the primary disease. One may encounter it in typhoid fever, smallpox, malignant endocarditis, septicemia, pyemia, whooping cough and measles as well as in the more virulent of the tropical diseases. In cerebro-spinal meningitis and typhus fever it re- presents the usual exanthem. In the chronic diseases it is seen most frequently in connection with scurvy, pernicious anemia, idiopathic plastic anemia and leukemia, not infrequently in tuberculosis, Bright's disease, Hodgkin's disease, syphilis, and various cardiac lesions, particularly those associated with marked degeneration of the myocardium. In epilepsy it is not uncommon and sometimes points the way to a correct diagnosis in cases of an obscure nocturnal type. In such instances it is usually slight and transient, often showing only on the face as an indistinct capillary streaking which may last for a few hours or a few days. In hysteria, the same form may be present, or the rarer forms, among which the most curious is the cruciform purpura in which, it is said, the hem- THE PURPURAS 169 Cruciform purpura. Differentia- tion possible. orrhages appear at points corresponding to the wounds of the Saviour on the Cross. 77 may be seen at once that in epilepsy and whooping cough mechanical strain plays a great part. True purpura would seem to be a more or less direct expression of an i infection and might better be considered wholly apart from the conditions mentioned in the paragraph preceding. 2. Arthritic Purpuras. — In the three forms of purpura coming under this class there is a joint involvement distinctly rheumatic in type. Under this we have: (a) Simple purpura, (b) Peliosis rheumatica (Schonlein's disease). (c) Henoch's purpura. This classification need not be confusing if the fol- lowing points are borne in mind. In all, the essential lesion is hemorrhage; all are accompanied by fever and by joint lesions. Simple purpura is of a mild type and short duration. Peliosis. rheumatica is much more severe, with higher fever, more marked joint involvement, sore throat usually at the onset and not only marked purpura, but frequently, pemphigoid spots, purpuric edema and marked urticarial mani- festations of either the ordinary or giant variety. The distinctive feature, how- ever, is the involvement of joints to a marked degree. Henoch's purpura differs from the two already named, primarily, in the fact that gastrointestinal symptoms, such as nausea, vomiting, diarrhea, and hemorrhage from mucous membranes, are the predominating features, while the arthritis is usually slight. In all other respects it may closely resemble the other forms. 3. Purpura Hemorrhagica {Morbus Werlhofii). — This terrible disease may be rapidly fatal, and is characterized by severe and often intractable hemor- rhage from any or all mucous membranes, associated with high fever. It will be seen from the foregoing description that though the basic symptom is the same in each and every variety, the differences presented are such as to permit of clinical differentiation in most instances. One cannot but feel that an infection must lie at the root of purpura, but nothing of a specific nature has so far been discovered. 4. Purpura Fulminans. — In this form the disease runs a rapidly fatal course and may terminate without the appearance of joint lesions, those of the skin being the only striking indications of the nature of the ailment. HEMOPHILIA Definition. — A morbid state, hereditary and characterized by an extraordi- nary tendency to spontaneous or induced hemorrhage, and an especial familial tendency to attack the young males and spare the females who, however, are the chief sources of its transmission to succeeding generations. Etiology. — The actual cause is unknown, but deficiency of fibrin ferment (thrombin) or of one of its necessary constituents (thrombokinase, or perhaps, prothrombin), is proven. A peculiar thinness and fragility of the vessel walls, a neuropathic tendency and abnormal alkalinity of the blood, together with many other, presumably baseless, assumptions, have been advanced as factors in causation. 170 MEDICAL DIAGNOSIS Atavism. Extraordinary features. Beware of "bleeders." "Spontaneous' hemorrhage. Extraordinary delay. Age and Sex. — It affects chiefly male children under ten years of age, first appearing in early childhood,* cases being rare in the later years of life, and usually less severe in their nature. In those affected who live to maturity the tendency seems to diminish gradually. The oft-repeated claims that women of hemophilic stock may themselves be bleeders seem to be unsupported by substantial evidence. The claim for occasional conduction through the male seems still less valid. Heredity. — Although cases occur in which this element apparently is lacking, the disease furnishes one of the most interesting known examples of atavism in relation to disease. It affects male children through maternal heredity, the mother or the girls of a family seldom showing any hemophilic tendencies, yet passing it on to their male children. In one family in Switzer- land the disease can be traced back over 300 years. It may even skip a generation or two only to return later on. Symptoms. — Intractable nose-bleed is most common, but hemorrhage may occur from the lips, gums, throat, stomach, urethra, lungs, bowels or, in the female, from the uterine mucous membrane, though, strangely enough, menstrual flow is not always excessive nor is labor extraordinarily perilous, in those rare in- stances of hemophilia in the female ordinarily showing extraordinary hemorrhage in response to slight wounds, abrasions or even pressure. It is fortunate that the disease is relatively rare, as information upon the subject is sometimes withheld by members of these foredoomed families, and slight wounds or bruises, even the puncture of the ear or finger for blood examination, the drawing of a tooth, the application of a leech or a vaccina- tion, may bring about a fatal hemorrhage. More extraordinary still is the fact that the slightest traumatism or even light and unconscious pressure or friction may excite what apparently may be spontaneous hemorrhage from mucous membranes or even the free skin (lobe of ear, tip ■ of finger) . Coagulation Time. — This is greatly prolonged, a firm clot never forming under an hour if blood from a vein, unmixed with the tissue juices, is used. Blood from a mere skin wound or puncture gives unreliable and misleading results because of the unavoidable admixture of such tissue juices which contain cephalin. The mortality is extremely heavy, and pseudo-rheumatic affections are common, as are ecchymoses and hematomata, these showing its close resem- blance to purpura and scorbutus. Prognosis. — A majority of male children of affected families die under ten years of age, though light cases occur in which, after the age of puberty, the tendency is largely or wholly lost. * Infants are usually free from its manifestations even though they may be profoundly affected later. Nevertheless Nacke of Kirchheim, the physician of the famous Mampe family which has been under medical observation since 1827, states that he could tell from the hemorrhage following the cutting and tying of the cord whether or not that child would prove a " bleeder." SCORBUTUS I 7 I SCORBUTUS ("Scurvy") Definition. A morbid state peculiarly dependent in most instances upon the diet* (vitamin deficiency), characterized by profound weakness, anemia, apathy, and a marked tendency to sponginess of, hemorrhage from, and severe inflammation and ulceration of, the gums. Etiology. — The actual cause is unknown, but the conditions of its develop- ment are well understood. They are: (1) A diet from which fresh vegetables, fruits and meats arc excluded. (2) Bad air, overcrowding, overwork, deficient light. Its occasional presence in children even in our own country must not be forgotten. Up to within the last century scurvy was the scourge of seamen and armies. During the Crimean war there were 23,000 cases in the French army alone. Military and naval expeditions had sometimes to be abandoned on account of outbreaks of the disease and East Indian ships frequently lost half of their crews in one voyage. In one of the early Arctic expeditions 50 per cent, of the members died of the disease. In a recent Antarctic expedi- tion the effects of the factors mentioned above were clearly shown, though a better food supply prevented a general epidemic. A considerable number of cases occurred in the Russian troops during their war with Japan; it was present to some extent in the Allied Armies during the last great war, and exists at the present writing in famine stricken Russia and doubtless in some of the lesser Balkan States. Essentially, however, scurvy belongs to generations past.f Symptoms. — The leading symptoms are spongy, bleeding, and often ulcer- ating gums, purpuric symptoms, areas of brawny induration especially in the lower extremities, progressive circulatory weakness often with right heart dilata- tion, and subperiosteal hemorrhages especially in children. In children the swelling is commonly over the outer aspect of the femur; and in every marked case is hard, tense, and exquisitely tender (see " Barlow's Disease," following). Epiphyseal suppuration may occur and hemorrhages into the joints and retina are not uncommon. Retinal hemorrhages are not uncommon. Physical weakness is extreme and there is pronounced and progressive mental depression and usually edema of the ankles. BARLOW'S DISEASE. — Occurring in infants, scurvy is known as Barlow's disease, having been described by Dr. Thomas Barlow in 18784 Up to that time it had been regarded wrongly as "acute rachitis" and was so * In an absolutely typical and remarkably complete adult case recently observed by the author absolutely no connection with diet could be traced nor could the man's condition be materially improved by the usual therapeutic measures. It may have represented one of the rare examples of atypical purpura exactly simulating scorbutus. Many cases of purpura strongly resemble scurvy and the latter sometimes lacks the most striking features of the disease. t The theories asserted as causative factors: (a) sodium excess, (b) potassium deficit, (c) ptomain activity, (d) acidosis, (e) deficient phosphorus compounds, and (/) specific infection, have one and all failed to stand. X Dr. Cheadle, a colleague, had previously suggested that scurvy played a part. An avitamjnosis. Known factors. Once a scourge. Peculiar syndrome. 172 MEDICAL DIAGNOSIS Age incidence. The gums. Posture. Misleading appearance named by Moeller in 1857. As before stated, the most aggressive symptom in children is the subperiosteal extravasation. The child lies motionless, shrinks from the touch, and presents what is really a characteristic swelling, the author having seen, as a student, in Dr. Barlow's and Mr. Edmund Owen's wards an immediate diagnosis on sight and touch in many instances. The disease is rarely seen in breast-fed children and occurs usually from the sixth to the sixteenth month. It. derives its general interest from the fact that the other symptoms of scurvy as seen in the adult may be entirely lacking. In children possessing teeth, mild scorbutic changes in the gums may be manifest but in very young babes these are wholly absent. The usual symptoms of the hemorrhagic diathesis may be marked and in a considerable proportion hematuria may be an early symptom. Suggestive Symptoms. — Unwillingness to move the legs though the reflexes are wholly normal and the attitude of the babe, which lies with the thighs drawn up, cries out if handled and, manifestly, is comfortable only when in this position. It may be shown usually that the lower end of the femur is exquisitely tender or this may be absent primarily and extreme pain on movement at the hip or knee be the chief symptom. This is followed by a firm, tense, ex- tremely tender swelling which becomes bilateral and involves primarily and chiefly the upper and lower portions of the femur and upper third of the tibia but does not extend to the epiphyseal junctions. Other bones may be affected and even actual epiphyseal separation may result. Similar subperiosteal blood extravasations may affect the ribs anteriorly and cause what appears to be a marked recession of the sternum and costal cartilages. The diagnosis should be possible before such extreme symptoms appear. DISEASES OF THE GLANDS OF INTERNAL SECRETION I 7 J DISEASES OF THE GLANDS OF INTERNAL SECRETION ADDISON'S DISEASE ("Morbus Addisonii") Historic Note. — This was first reported by Dr. Addison, of Guy's Hospital, in 1855, and in his monograph he attributed the ailment to a disease of the suprarenal capsules. Definition. — A disease characterized by progressive weakness and apathy, marked gastrointestinal disorders in the later stages, and a peculiar pigmentation of the skin and mucous membrane. Etiology. — The exact nature of the primary causative factors remains as yet undetermined. An antecedent tuberculosis seems the most important. Various diseases may precede it, but their direct connection in causation is unproven. Poor food, insanitation, and excessive mental or physical labor, are often associated factors, but may be only coincident. Congenital Eypoadrenia. — Of late the impression that in cases of Addison's disease the chromaffin system is both anatomically and functionally inade- quate from birth, has been strengthened. It would appear probable that in such cases the glands are peculiarly vulnerable to certain infections and especially to tuberculosis. Males are affected much more frequently than females (60 to 70 per cent.). It is most common in middle age, yet cases have been reported in infants. Nearly 90 per cent, of these cases show demonstrable lesions of the suprarenal cap side, and in 80 per cent, of these instances the lesion is said to be clearly Etioiogic , . paradox. tuberculous. In a relatively small percentage a-4esion of the capsule is not evident, and, furthermore, the suprarenals may be removed by operation or be congenitally absent without of necessity producing the disease* Morbid Anatomy and Pathology. — Any one of several conditions may be found at autopsy. These are, atrophy, simple or due to chronic interstitial inflammation, malignant disease of the capsule, extravasation of blood, inflammation or pressure affecting the semilunar ganglia and in a vast majority of cases tuberculous infection of the suprarenal itself. 77 seems impaired probable that Addison's original theory, that the disease was due to a loss or function impairment of adrenal function , is correct. The involvement of the semilunar ganglia may materially affect the secre- tions of these glands and contribute to the symptom-complex. This view seems on the whole much more rational than that advanced by some observers, which holds the nervous system entirely responsible for the disease. The Chromaffin System. — In the medullary substance of the suprarenals nests of cells occur which stain brown with chromic acid. These, the chromaffin cells, may be found in the solar plexus, in the ganglia of the sympa- thetic trunks and along the sympathetic nerves. Furthermore, such cells exist at the hilus of the kidney itself, at the point of origin of the left coronary artery, at the root of the mesenteric artery and in the left stellate ganglion. * It is true, nevertheless, that experimental epinephrectomy in animals produces some of the most important symptoms of Addison's disease. 174 MEDICAL DIAGNOSIS Blood. Pigment distribution. Mucous membranes. In the suprarenal gland the chromaffin cells constitute physiologically a em largely independent of its "inter-renal" fellow — a distinction which nphasized in certain lower animals by an entire and permanent anatomic separation. Adrenalin is the active constituent secretion of chromaffin tissue and it is probable that impaired function of the chromaffin system may account for at least many of the symptoms of Addison's disr Among the:- xplainable are low blood pressure, subnormal body- temperature, progressive muscular weakness, the tendency to lymphocytic predominance in the blood picture, the lowered sugar content of the blood and the pigmentation itself, though the cortical system may play a part in the production of the cardinal symptom last named.* SYMPTOMS. — The disease is characteristically insidious in its approach and is rarely suspected until pigmentation ; ±- ell-marked. The gastro- intestinal disturbance as well as the loss of strength tends to increase and may assume the form of crises, yet there are cases showing long periods of lot-: and relative immunity from vomiting, nausea and diarrhea. A slight secondary anemia is usually present, but is not an important factor. LympJtocyiosis is now held to be an almost constant rinding and the polymorphonuclear neutrophil leucocytes are both relatively and absolutely diminished. The total leucocyte count, however, does not often exceed normal res. An eosinophilic increase may often be demonstrated but is not constant. The body-temperature is subnormal and the blood pressure is invariably low, dropping in some :;-ses bo 50 mm. v systolic). As the disease progresses, atfacks of syncope, vertigo and palpitation may be troublesome and sight and hearing may be impaired. Vomiting may become persistent, and indeed uncontrollable, sometimes ending fatally, but usually subsiding after several days. A history of active tuberculosis, past or pres in some other part of the body is often obtainable. The pigmentation of the skin :'; :cr\ ::?:::'■: .::. . the typical case showing a deep bronze color that is quite unmistakable, though tlie early pigmentation may be little more than a brownish-yellow or definite brown, and, rardy 1 the vase may :>. before this deepens to the typical shade. It sr:c-us rtain interesting 2nd important characteristics as regards dis- tribution, in that it is most marked in the portions of the body exposed to light, such as the face and I md to (hoi :: pressure or friction from clothing, being emphasized in the axilla, groin, under the breasts, or at the waist line and knees. Areas oi pigment atrophy often appear, making a sharp contrast and the mucous membranes of the lip and buccal surfaces especially are likely to show patchy pigmentation. The heart invariably shows atrophy at autopsy. * The interested reader should refer to Falta's masterly description :: Addison's disease for an adequate description. •"The Ductiess Glandular Diseases.'' BIakis:on, 1915. An extended discussion of hyper- and hypo-adrenia is to be found in Tice's "' Practice of Medicine."' vol. viii. 1921. p. 131. and Oxford Medicine, vol iii. p. -$3. DISEASES OF THE GLANDS OF INTERNAL SECRETI<»\ 175 Misleading variations. "Vagabond's disease." Diagnosis.— The diagnosis is ordinarily easy in view of the grouping of low blood pressure, progressive loss of strength, marked gastrointestinal disorders and the peculiar pigmentation as above described. In those rare cases in which all characteristic skin discoloration is lacking, the autopsy alone suffices to positively confirm a tentative diagnosis. Differential Diagnosis. — Verminous bronzing is rarely seen except in the clinics of the great medical centers, being due to the constant presence of vermin, attended by scratching, which results in a more or less profuse pig- mentation; in most instances the attending signs would be lacking as would certainly be the patchy mucous membrane pigmentation.* Cirrhosis of the Liver. — In a few instances hepatic cirrhosis in its last stages may produce a very dark pigmentation, but in such instances there is j almost always abundant evidence that the color is due to an actual jaundice. In no such case in the author's experience has any doubt arisen. Argyria (chronic silver poisoning) is excessively rare at the present day, and the color is quite different from the pigmentation of Addison's disease, being more distinctly gray, and when excessive, showing a distinct bluish- black tint; moreover, it is ordinarily limited to the face and hands, and the associated symptoms of the latter disease are absent. Parry's disease^ and many other conditions are accompanied by pigmenta- tion and peculiar patchy discoloration of the skin, i.e., malignant disease involving the abdominal organs, certain cases of tuberculosis, of chronic nephritis, etc., but it does not seem that the difficulties in diagnosis are so great as to permit us to accept the dictum of Leube, to the effect that one "should forego any diagnosis of affections of the adrenal bodies." The tuberculin reactions whether positive or negative are of slight value in view of the deceptive frequency of the former and the uncertainty of response in any such profound cachexia as is characteristic of the disease. The strongest emphasis should be placed upon the absence of patchy pig- mentation of the mucous membranes in the many simulators of Addison's disease. Status Lymphaticus. — Certain evidences of this condition are not in- frequently encountered and thymus hypertrophy has been reported. Prognosis. — The disease is almost invariably fatal, usually within one or two years, and the last case observed by the author died after an illness of only a few months' duration. In rare instances life is prolonged for more than a decade and a few cures have been reported in cases where syphilis was possibly the primary factor. STATUS THYMICOLYMPHATICUS, ^Lymphatism" a Status Lymph- aticus,'' ; ' Constitutio Lymphatic -a") . Definition. — A morbid state characterized by coincident hyperplasia of the lymph nodes, spleen, thymus, red bone marrow and, in certain instances, hypo- plasia of the heart and arteries. A decided tendency to sudden death exists in this condition. * In such cases as have been observed by the author, the likeness was only sufficient to draw a passing reference, t Exophthalmic goitre. Tuberculin test. Variable. 176 MEDICAL DIAGNOSIS Probable cause. Important complex. Disease of youth. "Thymus death." Historical Note. — The discussion of this curious condition is really a revival of ancient knowledge. Nearly three centuries ago the association of an enlarged thymus with sudden death is said to have been noticed by Plater, and thymic asthma was described by Kopp in 1830. This he regarded as a pressure asthma. Later discussions occurred, but the subject was again dropped to be renewed during the past few years. Etiology. — Little is known of the etiological factorsj but the disease is one of youth and early childhood. It is probably associated with functional inadequacy of the chromaffin system and this belief receives clinical support in its not infrequent appearance in cases of Addison's disease and the fact that the blood picture is practically identical in these two conditions. As to the functions of the thymus itself little of importance is known although many theories have been advanced and much conflicting testimony adduced. Symptoms. — The symptoms upon which, as a whole or in part, a diag- nosis must be based are essentially the following: a pale, pasty, rachitic or tuberculous aspect, enlargement of the spleen and of the superficial glands, usually associated with tonsillar hypertrophy, adenoids and dulness over the upper sternum. The thyroid may be slightly enlarged, and there may be evidence of in- volvement of the mesenteric glands. The chief clinical importance of the disease lies in its relationship to early and sudden deaths in the young or even the adult, both as occurring without apparent cause and in connection with operative or therapeutic pro- cedures, the so-called "thymus death." This assumes considerable importance to both the physician and surgeon, cases having been reported as following adenoid operations, anesthesia, adminis- tration of antitoxin, convalescence from various infections, and croup. Paltauf ascribes to this condition many of the cases of otherwise inex- plicable sudden death in children. The condition merits further study and observation, and its symptomatology should be kept clearly in mind. Attacks of causeless suffocative dyspnea and cyanosis occurring in babes or young children shoidd always suggest the condition as a possibility and demand a most careful investigation including roentgenography and careful percussion. A dull area over the manubrium whose lower border rises with extension of the head and falls with flexion is particularly suggestive and any dyspnea in- duced by throwing the head back may be regarded as a suspicious symptom. 'Athyrea. Sporadic or endemic. MYXEDEMA AND CRETINISM ^Definition. — A chronic depressive disorder of cellular metabolism associated with more or less marked functional insufficiency affecting alike vegetative, psychic, circidatory and trophic spheres, associated with and resulting from structural changes and impaired function on the part of the thyroid gland. Cretinism is the term applied to athyrea in the immature organism and may be either sporadic or endemic, the latter form appearing chiefly in regions where goiter is prevalent. DISEASES OF THE GLANDS OF INTERNAL SECRETION 1 77 Signs of the disease usually appear at or about the fifth or sixth month Age but may develop earlier or much later. Some authorities attempt to dis- tinguish two forms, the "infantile" and "juvenile." Classification.— Although lacking in fundamental differences, three clinical groups may be distinguished: First. — Cretinism or myxedematous changes in the infant or young child. Second. — Myxedema adultorum, i.e., as it appears in the adult. Third. — Operative myxedema, which covers the changes attending the complete removal of the thyroid gland. Etiology. — That the loss of function which is usually but not invariably Gland atrophy associated with atrophy of the thyroid gland is directly responsible for myxe- dematous changes has been well established by both clinical and experimental observations. The disease attacks women five times more often than men, is peculiarly Heredity - . . . , ,. , . , ... marked. frequent in certain countries and districts, and in the case 01 cretinism seems to be markedly hereditary; the offspring of people who have removed from regions where cretinism is endemic showing a marked tendency to the disease whatever the nature of their new environment. Congenital syphilis, a tubercular taint and rachitis seem to favor the Predisposing development of the disease in children and infants. In these the disease is ordinarD y directly due to congenital atrophy or deficient function, but does not make its appearance for several months after birth, as a rule, and some- times not for many years. SYMPTOMS OF SPORADIC CRETINISM.— The appearance of the The cretin, affected child is characteristic and unmistakable. The face is senile, coarse and stupid, the lips and eyelids thickened and Characteristic overgrown, the tongue is large and thick and often protrudes from the mouth, the root of the broad, flattened nose is depressed, the head is large, clumsy and rests upon a thick, short neck. The stature is dwarfed, and a child of fourteen or fifteen appears often to Arrested . t tl .{ ' J J JJ rr J development. be two or three years old. The legs are bowed, the abdomen prominent, the joints thick and clumsy, the gait awkward, dragging, laborious, and marked lordosis is often present. The skin is sallow, the hair often thin and brittle, the skin usually dry, though it Depressed may be greasy, and signs of arrested mental development are as striking as the physical appearance. The fontanels remain open and muscular weakness is usually marked. open In infants the dentition is markedly delayed and, in all children affected, there is likely to be a great delay in the epiphyseal closure. Delayed t . . ., . ,. «.«.,., i* • • dentition. It is impossible to discuss fully in this volume a condition concerning which so little is positively known or to deal with the many conditions which may or may not represent mere variants. Certain cases seem to represent a form of infantilism. The head enlarges but the growth of the facial bones is retarded, and myxedematous changes in the skin are usually marked. physiognomy. 1 7 8 MEDICAL DIAGNOSIS Sexual organs. Test medication. Striking when typical. Acute myxedema. Sexual development is distinctly retarded and imperfect, and the sexual instinct is almost wholly lacking in the female and but slight in the male. Respiration is slowed, the temperature lowered and such patients do not sweat under the usual test doses of pilocarpin or show glycosuria following the administration of adrenalin. ENDEMIC CRETINISM.— This form of athyrea or hypothyrea occurs chiefly in regions where goiter is prevalent among the adults of the population and differs materially from sporadic cretinism not only in the frequent ab- sence of some of the extreme features (half-cretins) but also in its less marked and constant response to thyroid medi- cation. Typical Symptoms of Myxedema in the Adult. — The skin is dry, harsh and pasty, the hair lusterless and brittle, the face peculiarly moon-shaped and lacking in expression. The features are clumsy and coarse, the nostrils broad, the lips thickened and the tongue enlarged. Thought, motion and speech are slow and clumsy. The whole body is increased in bulk, and the superfi- cial tissues have an appearance like edema, yet show no pitting on pressure. Large pads of firm inelastic tissue usually appear above the clavicles and on the extensor surface of the forearm and wrist, and the hands and feet are "pudgy" and clumsy. Headache may or may not be present. Irritability is usually marked and actual delirium, hallucination and even true in- sanity may develop. A bluish red color in the lips, nose and cheeks may be present and the palpebral fissures are often narrowed. Low blood pressure, readily excited exertion-dyspnea, low body temperature with more or less persistent or easily induced chilliness, are usually manifest. Duration. — The course of the disease may extend over a period of from ten to twenty years, the patient dying of intercurrent disease. Osier reports what is apparently a case of acute myxedema and in some instances it seems to have been associated with the development of exophthalmic goiter. The author has reported in 1905 a case in which very decided symptoms of myxedema coexisted with those of acromegaly.* * See Transactions of the Association of American Physicians, 1905 (see also reference under "Acromegaly"). Fig. 55. — Cretinism. {Courtesy of Dr. Henry Jackson.) DISEASES OF THE GLANDS OF INTERNAL SECRETI<>\ i; Operative myxedema does not differ materially from that described above. This condition is rare because it necessitates for its development the complete or almost complete removal of the thyroid gland. Diagnosis of Myxedema. — /;/ the adult this must depend upon the peculiar physiognomy, the dry skin, marked edematous aspect of the body, and the failure of the bulky pads of tissue to pit on pressure, combined with the speech and mental state of the patient. Carbohydrate tolerance is greatly increased, although, in general, metabolism is distinctly depressed; 250-300 grams of glucose producing no alimentary gly- cosuria, a fact of considerable importance in certain doubtful, illy-developed cases. The improvement of all symptoms under the administration of thyroid gland Therapeutic offers conclusive proof of the nature of the disease, but loss of bulk alone is not sufficient evidence. Masked Myxedema. — Where one case of myxedema is recognized, a hundred cases of thyroid insufficiency escape our notice and it should be clearly under- Extremely stood that fragmentary clinical pictures fully justify and indeed demand test doses of the specific remedy. Some of the ?nost striking cases of improvement observed by the author have represented patients whose obscure symptoms barely suggested dysthyroidism as a possibility. It is impossible to formulate any clean-cut group of symptoms which would lead us to a correct diagnosis in these cases of masked hypothyroid- ism. In many, one's suspicion is excited by the occurrence of a fragmentary myxedema picture made up of any one or several of the following symptoms: dryness of the skin, the presence of the so-called myxedema pads particularly at the back of the wrists or in the supraclavicular region, inactivity of the sweat glands, a slowing up of the mental processes, and the like. Osier properly warns the clinician against laying undue stress upon the supraclavicular pads alone. As a matter of fact, this condition is very insufficient commonly seen in any stout person otherwise in perfect health and may be absent in decided thyroid insufficiencies. But in many instances the therapeutic test, namely, the administration of thyroid gland, is productive of the happiest results even when no clinical picture is discernible. If the administration of this remedy is carefully and intelligently handled one need not fear the results, but every patient should be carefully watched least some larval hyperthyroidism be roused into activity. HYPERTHYROIDISM (" Exophthalmic Goiter " "Parry's Disease" Definition. — A disease which, when fully and typically developed, is char- acterized by abnormally increased metabolism, prominence of the eyeballs, rapid pulse, enlargement of the thyroid gland and fine tremor associated with marked nenous manifestations. ' i8o MEDICAL DIAGNOSIS Neither Basedow's nor Graves' disease. Hyperthyrea. Ndt a "nervous disease." Types of extreme importance. Atypical Forms. — 77 may be, and often is, but imperfectly developed as a clinical picture, even when assuming an extreme and rapidly fatal form and may present an acute, subacute, chronic, or larval type, the last two being the forms oftenest encountered. The names of Basedow and Graves have apparently been improperly used in connection with this disease, and it should be called Parry's disease, as he described it quite fully in 1825, indeed having made notes of a case as early as. 1786, half a century before the description of the two former appeared (Osier). ETIOLOGY. — The disease is due chiefly to hyper thy rosis (increased thy- roid activity), the exact cause of which is unknown. It is the exact opposite of myxedema with respect to the vegetative functions, which are exalted to a marked degree. It is probable, as suggested by Falta, that the symptomatic expressions of hyperthyrosis vary with and are dependent upon the participation and response of other sources of internal secretions in the individual case. Age and Sex. — It is rare in men, quite common in women, and appears usually between the ages of twenty and forty, though rarely under the age of fifteen. Emotional Crises. — It seems to be well established that violent or depress- ing emotion, even though transient, may produce it and in some instances it has seemed to the author that there was a marked sexual element. It can no longer be regarded as a disease of the nervous system. SYMPTOMS.— Acute cases occur which, with or without marked exoph- thalmos or excessive or even marked tremor, may terminate fatally after a few days of violent and intractable gastrointestinal crises and profound and progressive cardiac weakness, i.e., precisely the same phenomena that -may bring a chronic case to a fatal end* Curious abortive or incomplete transient acute attacks also occur with or without the complete, classical, clinical picture. Ordinarily, the onset of the disease is gradual and its progress slow, its tendency being toward increase in the severity of all symptoms, but with marked periods of improvement if under observation and treatment. Thyroid Enlargement. — It usually involves both lobes, but not equally, and may be unilateral or, at first, almost wholly absent. Venous bruit and loud systolic or double murmurs are commonly heard, there is usually a palpable thrill and often a visible expansile pulsation. Exophthalmos. — This protrusion of the eyeballs varies greatly in degree, and it is said may become so great as to actually dislocate the eye.f The change is almost invariably bilateral, the vision is seldom affected, but * A rapidly fatal case of this type seen recently by the author showed a relatively slight unilateral enlargement of the thyroid of sudden onset, following by several days an accident which resulted in a broken thigh. Tachycardia was marked, vasomotor relaxation extreme, intractable vomiting domin- ated the clinical picture and the heart rapidly weakened, dilated enormously, and yielded no response to stimulation. f No such extreme cases have ever been observed by the author. DISEASES OF THE GLANDS OF INTERNAL SECRETION 181 much stress has been laid upon three so-called signs in connection with exophthalmos. These are: (i) The failure of the lid to follow promptly the downward movement of the eyeball ("Graefe's sign"). (2) Great lengthening of the time intervals of involuntary winking. These ordinarily represent but fifteen or twenty seconds but in this disease may be minutes apart if exophthalmos is marked ( %i Stelwags sign"). (3) Deficient convergence of the eyes ("Moebius's sign"). {4) A tremor of the lids may be noted when the eyes are slowly and softly closed which has been dignified of late by the name of Rosenbach's phe- nomenon, but is neither limited to exophthalmic goiter nor new to medicine. (5) A lifting of the upper lids when the patient's gaze is fixed intently upon some object ("Kocher's sign"). All are somewhat superfluous clinically. The characteristic associated appearances, in any considerable grade of exophthalmos, are the peculiar stare and the rim of white which appears between the corneal margin and both lower and upper lids ("Dalrymple's sign"), but these are not necessarily due to either palpebral spasm or lid retraction. Tests of Importance. — Of late several tests have been proposed for the detection of larval hyperthyroidism. It is well known that the basal metabo- lism is greatly increased, but the special apparatus needed and the time necessary for the completion of the tests and the special delicacy of the technic employed, render it quite unavailable for the average practitioner. Hence, simpler tests are greatly to be desired. Of these, several have appeared during the last few years, the most readily applied being those of Goetsch and Loewi. It must be remembered that neither of these have proven infallible, yet both may be considered useful, justifiable, and of considerable value. Goetsch's Tests. — Goetsch has devised two tests; one, a skin reaction; the other, a general one. The Skin Test. — Goetsch states that if 1 minim of a 1:4000 solution of adrenalin is injected intradermically "the central large area of blanching" results, this being "surrounded by a peripheral zone of reddening due to neighboring secondary vasodilation. In the blanched area a characteristic 'goose flesh' is often seen due to the contraction of the 'erector pili ' muscles, which are of the smooth variety and under sympathetic control. The reaction lasts for one and one-half to two and one-quarter hours as compared with one-half to three-quarters of an hour in a normal individual, in whom, furthermore, the area of blanching is much less definite and the peripheral zone of red is usually entirely absent." In practically all cases of hyperthyroidism, Goetsch states that the reac- tion is more marked and of longer duration than in a normal individual. It should be added that of late much stress is laid on the behavior of the color of the areola produced in this test, which, in victims of hyperthyroidism, though fading to a lavender color remains for nearly or quite four hours after the time of the original injection. The Hypodermic Test (Goetsch). — Seven and one-half minims (0.5 c.c.) Over-rated signs. lS2 MEDICAL DIAGNOSIS May for a time exist alone. Cardiac dilata- tion common. of a 1:1000 solution of adrenalin chloride is injected hypodermically in the deltoid region. If hyperthyroidism is present there is an " early rise of blood pressure, and pulse variation of from 10 to 50, and normally proportional to the degree of toxicity present." Among the associated symptoms produced are " asthenia, tremor, throbbing, vasomotor changes, apprehension and nervousness." Note. — It is obvious that the second of these tests should be used with some discretion and that both must contain possibilities of error. With respect to the hypodermic test, it would appear that the condi- tions under which it is performed should be controlled carefully, this being especially true if we are to draw fnimtinr i mmmum any conclusions of importance from the rise in blood pressure of the lesser grades. Every practis- ing physician knows how readily decided increases in systolic pressure occur and there would seem to be a considerable oppor- tunity for error with respect to this manifestation. Loewi's Test.— This consists in the instillation of a 1:1000 solution of adrenalin into the eye; dilatation of the pupil following if hyperthyroidism is present. Rapid Pulse. — This is often the first symptom to attract attention frequency is greatly affected by exertion and psychic excitation alike (labile pulse); regularity or irregularity may be present and the frequency may vary from 90 to an uncountable rate, as is frequently seen in fatal cases. Peripheral pulsation is marked, the abdominal aorta may throb violently and a capillary pulse or even a venous pulse is often present. High " pulse pressure" is common in well-marked cases. Bruits. — All sorts of bruits may be heard at the base and over the gland or the vessels of the neck, usually associated with palpable thrill in well- marked cases, together with visible pulsation of the gland itself. A systolic murmur is seldom lacking in the mitral area and the heart is not only readily dilatable, but often dilated.* * Some of the most rapid and extreme dilatations observed by the author have been associated with acute hyperthyroidism and several have been post-operative complications. Residual' post-operative dilatation of a decided degree is common and, too often, disre- garded and far more rapid and satisfactory post-operative results would be obtained if the cases showing marked cardiac involvement were treated medically for a short period before surgery is attempted. At present, even in successfully operated cases, a period of several months (6-12) is usually necessary to the development of maximal improvement follow- ing surgical procedure. Such cases usually are perfectly responsive to rest and digitalis, though in some, but not all, of the extremely acute forms the drug seems impotent. Fig. 56. — Tachycardia as frequently seen in exophthalmic goiter. Upper tracing,, jugular; lower, radial. Pulse rate 132. Time 3^ sec. Note respiratory curve in jugular tracing, and resemblance of pulse to that of aortic regurgi- tation. (Tracing by Dr. R. E. Morris, made with his modification of Mackenzie's ink- polygraph.) Pulse DISEASES OF THE GLANDS OF INTERNAL SECRETION I S3 "Formes frustes" important. Nervous symptoms marked. Goiter heart may sometimes be due to pressure on the vagus, ("Rose's dyspneic form"). The glandular bruits are sometimes auto-audible, or to be heard at a distance. The subjective sensation of throbbing is often most harassing. The heart action may be violent, often tumultuous, and its area of visible pulsation greatly extended. Tremor. — A fine involuntary tremor usually attacks the head and extremities, rarely the eyelids, lips or tongue, and is of great importance, as constituting one of the earliest and most constant symptoms of the disease. Tremor and rapid heart action may be present, separately or in combination, without exophthalmos or demonstrable goiter. Decided exophthalmos is absent in at least 60 per cent, of the cases. Blood Picture. — Aside from a decided tendency to a relative lymphocytosis or, more correctly, a mononucleosis the blood shows nothing of interest. This is increased during exacerbations and may be experimentally produced by thyroid feeding. Subsidiary and Complicating Symptoms. — A vast number of symptoms may be encountered in connection with the course of the disease. Ordinarily extreme nervousness, insomnia, subjective sensations of throbbing, flashes of heat, excessive perspiration, general or local, excessive flow of saliva or, more rarely, dryness of the mouth, cardiac distress and mental irritability are those most marked. Less common are the marked gastrointestinal disturbances, complicating myxedemas, angio-neurotic edema, pigmentation or leukoderma of the skin. Serious mental depression may occur or instability in the psychic sphere may manifest itself in ways most diverse and capricious. Irritability or actual choler may rapidly alternate with gaiety and exaltation. * Melancholia has been the common form observed, -though acute mania sometimes occurs. Emaciation is often extreme in advanced cases; yet on the other hand, one frequently meets with those of the well-nourished type. The disease is ordinarily chronic, lasting for several years; it is, moreover, frequently curable under medical treatment or may disappear and reappear The author has thrice seen an acute firm enlargement of the thyroid gland associated with marked nervous symptoms, tremor and tachycardia, which lasted but three or four days.f Mere swelling of the thyroid gland, whether inflammatory or non-inflam- May be trivial, matory, suppurative or non-suppurative, is not unusual, and moderate en- largement of the thyroid is so common in young girls at the age of puberty and in young women at the time of their first pregnancy as hardly to deserve notice. The surgical conditions of the thyroid cannot be considered here. Mental disturbances. Usually unimportant. * In one case coming under the author's observation an insanity developed temporarily, in an ancient virgin, with delusions of so unfortunate a nature as to involve wholly innocent parties in a serious scandal, the later development of the case making all clear. f The last case two weeks. 184 MEDICAL DIAGNOSIS Pituitary gland affected. ACROMEGALY ("Acromegalia, Marie's Disease") Definition. — A chronic nutritional disease, supposedly attributable to overactivity of the anterior lobe (glandular) of the hypophysis, and charac- terized by progressive enlargement or overgrowth of certain portions of the body, chiefly and primarily affecting the bones of the hands, feet and face, essentially chronic and progressive in its course and tending to a fatal issue after the lapse of many years. Historical Note. — It was first described by Marie in 1886, having existed for thousands * of years without recognition as a clinical entity, though presenting one of the most striking pictures known to medicine. Etiology. — The cause of the disease is unknown, though the fact that in nearly every case that has come to autopsy the pituitary gland has shown definite changes, usually adenomatous or adeno-- carcinomatous, points to that curious structure as the prob- able source of the disease. The pituitary gland is a secreting organ as regards its anterior portion, whereas its posterior lobe has evidently a nervous func- tion. As its duct has become atrophied in the process of structural de- velopment, the secretion has become an internal one taken up by lymphatic absorption. But little is definitely known with respect to its functions despite the excellent work of many workers during the past few years. There is much to support the belief that it is the main center for body growth and that it bears some curious but little understood relation to the thyroid and suprarenal glands. A relation between gigantism and acromegaly has been suggested and is probable. It would seem possible that as suggested by Brissaud and Meige, if the hyperpituitarism occurs in childhood, gigantism results, but if delayed until ossification of the epiphysis is complete, acromegalic changes occur.* The disease occurs more frequently in women than in men, usually begins in early adult life, almost never after the age of forty, and no recognized preexisting disease has been definitely connected with it. * This is denied by Falta and others who insist that hyperpituitarism alone does not produce gigantism and that acromegaly may occur while the epiphyseal junctures are still open. Fig. 57. — Acromegaly showing enlarged and clumsy bones (case of L. G.). DISEASES OF THE GLANDS OF INTERNAL SECRETION ■l«5 SYMPTOMS. — If well- developed, it is essentially a case for street- car diagnosis, being easily recognized by its outward signs. The face is elliptical in form, the superciliary ridges being prominent, the head often large and massive, the lower jaw prognathic, the features enlarged and coarse also by reason of the marked thickening of the greasy integument, in which appear deep creases, especially marked across the forehead. In many cases even the lids are thick and coarse, the hands and feet are enormously enlarged, the ringers are spatu- late and clumsy, and upon ex- amination the increase is found to depend upon the bony overgrowth, a rinding easily verified by the X-ray. This growth may extend for a considerable distance upward along the bones of the fore- arm and leg, and sooner or later tends to involve the clavicles, scapulae, ribs and spinal column, at which time the patient is likely to assume a peculiar stoop, due to kyphosis of the spine. The X-ray may reveal an enlarge- ment of the sella turcica. There are no constant symptoms, as far as the in- ternal organs are concerned, and decided subjective symp- toms, such as headache, mental irritability, malaise, joint pains, disturbance of vision or drowsiness, may be absent until the later periods of the disease. The tendency is toward a fatal termination after a long term of years, in some cases covering two decades, and the symptoms are subject to many variations and exceptions. In one case which, fortunately, has been under the author's close ob- servation for nearly twenty years, most interesting variations have been observed.* In this case the predominant facial hypertrophy in the bones of the face appeared in the upper jaw; the bones of the feet were but slightly hypertrophied as compared with those of the hand, yet after a * Transactions of the Association of American Physicians, 1905. Fig. 58 Acromegaly. — Showing predominant hypertrophy of great toe (case of L.G.) Street-car diagnosis. Striking symptoms. Sella turcica. Prognosis. An unusual case l86 MEDICAL DIAGNOSIS term of years marked localized overgrowth appeared in both great toes. Another, then rare, phenomenon was a very marked co-existing myxedema, which promptly vanished each time that a course of thyroid medication was applied, finally disappearing altogether at a time when a previously existing marked enlargement of the thyroid gland slowly subsided. In this case also there was from the beginning a chronic synovitis of the knee- joints, persisting and so weakening the ligaments as to permit displacement of the patella and render the patient liable to dangerous falls. At the present writing this individual still lives, but grows gradually weaker and is subject to attacks of vertigo and occasional syncope. Differential Diagnosis.— The difficulties attending the diagnosis of acromegaly relate almost wholly to its early or relatively early recognition, and this must usually depend upon the testimony of the patient, or those in daily contact with him, relative to changes in physiognomy, often best revealed by a comparison of photo- graphs taken at different ages, and to a definite enlargement of the head, hands or feet necessitating changes in the size of the hat, gloves or shoes, respectively. The marked enlargement of the sella turcica, readily demonstrated in _^, n . . 7 J . Fig. 59. — Hand. Case of pulmonary most of the advanced and decided cases osteoarthropathy. with actual tumor, may be lacking in certain cases. Acromegaly, it is said, may be mistaken for myxedema, leontiasis ossea, osteitis deformans, arthritis deformans, and pulmonary hypertrophic osteoarthropathy. There is hardly a shadow of an excuse for any error along these lines. Osteitis deformans is rather a matter of deformity than overgrowth, and in it the cranial bones are chiefly affected rather than the facial bones as in acromegaly. Furthermore, the shape of the head in osteitis deformans is characteristic, its broadened cranial portions contrasted with the narrower maxillary region, a condition usually reversed in acromegaly. Leontiasis ossea shows merely bony prominences on the skull and face, and lacks every characteristic of acromegaly. In pulmonary hypertrophic osteoarthropathy enlargement of the hands and feet exists, but is confined chiefly to the^articulations. The face is not affected, and chronic pulmonary disturbance of some sort, primary or secondary, is an invariable accompaniment. Syringomyelia causes enlargement of the extremities but is readily differ- entiated by the associated symptoms. Arthritis deformans certainly could not be mistaken for acromegaly under any conditions. The demonstration of an enlarged sella turcica by the X-ray, a procedure already mentioned, is a valuable and sometimes crucial test. DISEASES OF THE GLANDS OF INTERNAL SECRETION l8 7 Gigantism. — There are two chief divisions of giants, viz., the acromegalic and the eunuchoid. In the latter the genitals are distinctly of the infantile type and the bones long and slender. It is assumed to be the result of hyperpituitarism existing prior to uniting of the epiphyses. Hypopituitarism. — The evidences of this condition vary with the age period at which the pituitary insufficiency occurs. Its chief effects express themselves in the retardation or actual limita- tion of growth, underdevelopment and, in adults, impairment of sexual function, obesity and in the female amenorrhea. Dwarfism in some forms is probably an expression of the condition and in young children a syndrome embodying adiposity and arrested sexual development may be associated with pituitary tremor. INFANTILISM. — Closely related to myxedema and cretinism is the curious condition termed infantilism of the Lorain type or those described by Gilford as ateliosis and progeria. The former type (Lorain) represents merely man or woman in miniature. In the latter (Gilford) there is an asexual type representing delayed develop- ment and a sexual form represented by the ordinary traveling showman's dwarf, the delayed development in this case yielding along sexual lines at puberty. Progeria covers cases of infantilism associated with premature senility, outward and structural. „ PANCREATIC INFANTILISM.— This condition, characterized by a marked amelioration under the administration of pancreatic extract, is described by Byrom Bramwell. * In this case the developmental arrest was complete for seven or eight years, but in the course of nine months' treat- ment there was a gain of 8% pounds in weight, and nearly 2 inches in growth. The patient was eighteen years of age, his developmental arrest occurring at eleven or twelve. The various classifications of infantilism are unsatisfactory and probably do not rest as yet upon a very substantial basis. EXOGENOUS OBESITY.— Obesity may be general or local, and its cause may be excessive food consumption, or defective employment of normal oxidation or elimination. In view of the discomfort caused by the excessive accumulation of fat, its tendency to limit proper exercise and cause impairment of the functions of vital organs, such as the heart, one may fairly consider the condition as a morbid state tending directly to shorten life. The general conformation of the body should be given consideration, and large bones, unusual muscular development and a relatively small waist measurement are factors that materially modify the estimation of individual longevity. This means that excessive fat is the condition most feared. There are two distinct types of the obese, namely, the anemic and the plethoric, with little to choose between them, so far as life expectancy is * Clinical Studies, Vol. 1, part 2, Jan., 1903. . Shortens life. Lines to be drawn. i88 MEDICAL DIAGNOSIS concerned. The excessively obese are peculiarly liable to disturbances of the secretory organs, heart disease, asthma, diabetes, gall-stones, gout, apoplexy. Furthermore, they succumb readily to severe acute infections, and are bad subjects for major operations. ENDOGENOUS OBESITY.— In certain cases of obesity the combustive capacity of the individual is subnormal. General Comment. — As is well known, certain races or tribes deliberately cultivate obesity in their women, making the pudgy outlines of the Hottentot Venus their ideal of feminine beauty. In all races 90 per cent, of the cases of excessive obesity occur in women; furthermore, the condition is often congenital. Cases are reported in which a baby thirteen months old weighed 75 pounds, a child four years old weighed 256 pounds. In some of these less pronounced cases the excessive fat of childhood disappeared largely in adult years. Cases of excessive weight have been reported that tax one's credulity to the utmost. Daniel Lambert is said to have weighed 730 pounds. A case was reported in Baltimore in which the weight was 850 pounds, and one from North California is said to have reached 1000 pounds. These cases are ordinarily short-lived, and the fact that few excessively fat people attain advanced age cannot fail to strike even the lay observer. In a rare and curious disease known as "adiposis dolorosa," more likely to affect women than men and falling almost wholly between the age periods of forty-five and sixty, the excessive accumulation of fat is associated with asthenia, headache, pain, tenderness of tissues, and mental disturbances. The accumulation of fat in this disease ordinarily occurs in the form of bunches or nodules, though later becoming widely distributed in most in- stances. Its cause is possibly a disturbance of internal secretion but nothing certain is known.. Degeneration of the ultimate nerve filaments has been reported and inthe absence of the typical findings with respect to fat deposit its differentiation from an alcoholic polyneuritis may be difficult or impossible. It is wholly probable that "adiposis dolorosa" as an entity will disappear soon from medical literature. CERTAIN DISEASES OF UNKNOWN CAUSATION OSTEITIS DEFORMANS. ("Paget's Disease").— Definition.— A rare disease characterized by kyphosis of the upper spine, a broad-based thorax, lozenge-shaped abdomen, marked enlargement of the cranial portion of the head and enlargement and deformity of the long bones, due to a rarefying osteitis. The disease is extremely rare and of unknown etiology and needs no further description. LEONTIASIS OSSEA. — A disease characterized by hyperostosis of the bones of the cranium, rarely those of the face, in some instances com- bined with localized hypertrophy of the soft tissues. MICROMEGALY. — This disease is the opposite of acromegaly, is ex- cessively rare, and of unknown causation. THE EXAMINATION OF THE URINE 189 PULMONARY HYPERTROPHIC OSTEOARTHROPATHY.— {Bam- berger's Disease). — This ailment, associated almost invariably with chronic pulmonary disease, is characterized by an enlargement of the hands and feet, the distal portions of the long bones, joints, and terminal phalanges chiefly being affected. The finger-nails become brittle and show longitudinal striation. Achondroplasia.— Victims of this curious developmental abnormality are seen frequently on our streets active, intelligent, wearing a facial aspect reasonably well suited to their actual age, but seldom exceeding in height that of a well developed child of ten, and almost invariably wearing a "pug" nose as evidence of precocious ossification. The genitals develop normally to full adult proportions. The skull is so enlarged as to suggest hydrocephalus, the four fingers of the hand are of nearly equal length, and if, as happens often, the mid- and ring- fingers stand apart, the two pairs of fingers with the thumb form the "trident hand." The trunk is nearly or quite of adult proportions but the arms and legs are extremely short. These cases are readily distinguishable from the cretinic dwarfs on the one hand and' those of pituitary disease (Frohlich's syndrome), with their obesity and infantilism, on the other. A great variety of cases of excessive fat accumulation may be placed under this head, but their exact classification is unsatisfactory and the condition may arise from various disturbances of the internal secretions. Among these, the obesity of hypothyroidism is especially important, as is that fol- lowing castration and the menopause. URINALYSIS AND DISEASES OF THE KIDNEY General Considerations. — The normal activity of the kidney depends upon a proper performance of function on the part of the other related organs, as well as upon the structural and functional integrity of the kidney itself. Its remarkable intrinsic nervous mechanism makes it difficult to apply rigid rules governing its activity, tut it may be said that the quantity of urine and inorganic salts depends upon osmotic glomerular filtration as affected by blood pressure and volume, whereas the output of urea and its congeners is determined by the peculiar selective action of the cells of the convoluted tubules. Therefore, anything affecting the renal structure or circulation, directly or indirectly, must alter the amount and constitution of the urine. Value of Urinary Examination. — No other secretion or excretion of the body furnishes greater or more varied information. Any substances which are taken into the blood stream are excreted ultimately in large measure by the kidneys, and through a critical chemic and microscopic examination of the urine we can measure variations in nutrition and waste, and obtain positive, suggestive or corroborative data with relation to many diseases, both local and general. Poisoning (coal-tar products, morphia, lead, mercury, chloral, etc.), Bright's disease, diabetes, spermatorrhea, cystitis, pyelitis, gonorrhea, Active and intelligent Pug-nosed dwarfs. Relationships marked. Filtration. Selective cell action. Wide scope. 190 MEDICAL DIAGNOSIS Obtain 24 hours' urine. Collection and preservation. Night vs. Day. Best. Worst. Diverse factors. Women and children. Transient and trivial. oxaluria, gout, the presence of fever, a failing heart, typhoid fever, pneumonia, septicemia, urinary and general tuberculosis, filaria sanguinis hominis. dyspepsia, chronic appendicitis, hysteria and partial or fully established obstructive jaundice may be mentioned as some of the conditions, either directly diagnosticated, or suggested, by urinary signs. The ordinary examination of the urine is largely qualitative, but certain necessary quantitative methods involve only a small amount of apparatus and a negligible loss of time, and all vital procedures may be carried out by simple methods whose margin of error is not so great as to vitiate clinical results. The First Step in the Urinary Examination. — The total urine for twenty- four hours best represents the functional activity of the kidney as affected by changes in its structure or diseases of related organs. It should be collected in clean bottles, the night urine separate from that of the day, and if it cannot be kept cool, a preservative should be added. Chloroform is the best agent readily available and is readily removed by heat. Camphor, thymol, chloral and formalin give rise to misleading reactions. Toluol is an admirable preservative and, as it floats upon the surface^ need not be removed, the urine needed for examination being withdrawn by a pipette as needed. Procedure. — The urine passed on the first morning is disregarded, all voided for the remainder of that day saved, thoroughly mixed, and kept in a cool place. That passed after retiring and that portion voided upon arising the following morning are separately collected.* In certain important renal diseases, notably in advanced interstitial nephritis and certain cases of cardiac insufficiency, the normal ratio of day to night excretion is greatly modified or reversed. Ordinarily, the day urine is three or four times greater in volume than that of the night, hence any marked departure in the direction of equalization or of reversal of preponderance is suggestive. Single Specimens. — Of the individual specimens, that passed late in the day, preferably after a full meal and exercise, is most likely to contain albumin or sugar, and, except in suppurative disease of the kidney or bladder, that least likely to show abnormalities is the early morning urine. Normal Variation. — The normal amount of urine varies from 750 to 2000 c.c, and this variation may be temporary or permanent, depending upon exercise, the amount of perspiration, the kind and amount of water ingested, or the nervous condition of the individual. The smaller amount represents usually either diminished ingestion or increased loss of fluid through other channels, such as free perspiration during hot weather, or a diarrhea. Women drink little water and usually show a small daily total, and children secrete relatively more though absolutely less than adults. POLYURIA.— Temporary vs. Persistent. — An increased flow may be temporary or permanent, purely functional (psychic, emotional), or, due to * This insures at least one fresh specimen should decomposition occur in either of the others, and a mixing of the three gives the twenty-four hours' total. THE EXAMINATION OF THE URINE IQI local or general organic disease. The ingestion of large quantities of water or such diuretic substances as beer or gin, the use of certain diuretic drugs, hysteria, migraine, and atmospheric humidity with low temperature, markedly, though temporarily, increase the amount. Persistent polyuria usually indicates actual disease, and is encountered in certain neuroses (urina spastica), as well as in chorea, pyelitis, amyloid kidney, interstitial nephritis, convalescence from acute nephritis, absorption of exudates, and diabetes mellitus or insipidus. Diabetes mellitus and certain rare cases of interstitial nephritis* violate the accepted rule that increased flow of urine results in or is associated with a lowered specific gravity. In diabetes insipidus the total urine shows increased total solids, though the individual voidings yield diametrically opposite findings. OLIGURIA. — Pathologic diminution is usually associated with severe acute congestion, various forms of acute nephritis, chronic parenchymatous nephritis in its active stage, or with circulatory diseases and conditions producing passive congestion. Among these are cardiac weakness from any source, cirrhosis of the liver, chronic emphysema, or pressure due to ab- dominal growths or a pregnant uterus. Relation of Oliguria to Color and Specific Gravity. — A marked oliguria accompanies acute infections associated with toxemia and high body tem- perature, profuse diarrheas or hemorrhages, shock or collapse. In nearly all instances a reduction in the total quantity of urine is associated with an increase in coloring matter and a heightened specific gravity of the individual specimen. . This last may be present from various causes in the individual voidings, even though the total excretion of solids is markedly diminished. ANURIA. — Complete suppression of urine may result from many causes and, though always serious, may or may not prove critical. It may occur in nephritis, renal tumor, phosphorus poisoning, shock or collapse, hysteria, ureteral calculus, cholera, and as a sequel to nephrectomy. If but one kidney is functionally potent, pressure upon the ureter of the other organ may produce complete anuria. It is sometimes directly obstructive and, in cases not due to actual renal dis- ease, has been known to exist for two weeks or more without producing uremic manifestations. Frequency of Micturition and Dysuria. — Increased frequency associated with pain usually indicates disturbance of the renal pelvis, bladder, prostate or urethra, rather than disease of the kidney itself. It maybe due to simple concentration and high acidity or, more frequently, urethritis or cystitis. Relatively or absolutely painless increased frequency may accompany any increased urinary flow, normal or abnormal, or certain stages of active disease, acute or chronic, of either the pelvis or the paren- chyma of the kidney. * Ogden reports such an instance — "The Clinical Examination of the Urine," 1903. The author has never encountered one though the relatively high specific gravity of the scant urine of terminal cardiac incompensation in such cases is a common finding. Usually important. Polyuria and specific gravity. Associated conditions. Etiologic factors. Unusual duration. Painful. Painless. 192 MEDICAL DIAGNOSIS An important sign. Specific gravity and reaction. Black. Green-black. Claret-color. Yellow foam. Yellowish- green, green- ish-brown, reddish- brown. Deep green. Of some diag- nostic value. Habitual rising at night to void urine may be due to urethral stricture, an enlarged or inflamed prostate, gravel, renal or cystic stone, diabetes mellitus or insipidus, malignant or tuberculous diseases of the genito-urinary tract, interstitial nephritis, insomnia, and, rarely, to mere habit. Nearly all patients exhibiting the polyuria of interstitial nephritis or the frequent night micturi- tion of prostatic disease believe the frequent voiding to be merely the result of "habit." THE COLOR. — Fresh normal urine varies from pale yellow to yellowish- red, and all urines may be classified as pale, normal, high-colored, or dark. Deep color is usually associated with relatively high specific gravity and marked acidity; pallor with low specific gravity and lessened acidity or alkalinity, diabetes mellitus furnishing an exception to the ride. Indeed, so striking is the heavy weight of diabetic urine in connection with its light color, that a provisional diagnosis is often suggested when lifting the tube or bottle. Fever urines are usually high-colored, scant and of high specific gravity, though fever may of course exist in exhausting and wasting diseases with a relatively pale color and low specific gravity. Brown, Black, Smoky, or Red Urines. — (a) Blood. — Color red, reddish brown, smoky, brown, or black. (b) Melanemia (Melanotic Sarcoma). — The urine becomes black on standing, but does not reduce Fehling's solution. (c) Alcaptonuria. — Urine becomes black on standing and reduces Fehling's solution. (d) Poisoning by Coal-tar Products. — The greenish-black color is due to hydroquinon and follows the excessive use of drugs like carbolic acid, naphthalin, guaiacol, resorcin, salol, creolin and lysol. (e) Hematoporphyrin. — Color of port wine or Bordeaux. (/) Bile. — Greenish, yellowish-green, greenish-brown or deep brown urines may contain bile pigment, in which event the foam produced by shaking the liquid is yellow. Urine containing bile may, when freshly passed, be reddish brown, but oxidation of the brown bilirubin converts it into biliverdin and produces the greenish tinge. A deep green urine results from the administra- tion of methylene blue. Blue urine usually indicates a great excess of indoxyl products, as in ileus, cholera and typhus, but is rare. Orange and reddish-brown urines suggest rhubarb, senna, or chrysophanic acid; yellow urines, santonin. INDICAN. — (Indoxyl-potassium-sulphate). — This normal urinary chro- mogen and tryptophan derivative results from albuminous putrefaction in the presence of bacteria; and, if found in the urine in excess, suggests intestinal stasis or obstruction, septic processes or the excessive ingestion of red meat. C. E. Simon reports an excess in hypochlorhydria, anachlorhydria and the hyperchlorhydria of certain gastric ulcers, and an excess is found in typhoid fever, appendicitis (chronic or acute), cancer of the stomach, peritonitis, chronic gastritis and similar conditions, reaching its maximum in stasis and ileus. THE EXAMINATION OF THE UK INK 193 Establish a rough standard. color solution. Obstruction in the lower colon or simple constipation does not materially increase it.* Test (Jafe-Stokvis). — (a) Take equal parts of the urine and strong hydro- chloric acid, (b) Add two or three drops of a saturated solution of sodium or calcium hypochlorite or of common saltpeter. Shake. Add 1 ex. of chloroform, shake thoroughly and repeatedly and set aside. The chloroform then shows a depth of color varying with the amount of indican present. Potassium iodide if present may yield an intense carmin, and codein a reddish-purple. The observer should establish a normal standard by repeated observa- tions using always the same quantities of urine and reagents. A more accurate test involves the use of a small amount (not an excess) of lead acetate sol. (20 per cent.) which removes the urinary pigments in the recipitate. Quantitative Tests (Strauss' s Method). — This involves the use of a standard color solution obtained by dissolving 1 mg. of C. P. indigotin in standardized 1000 c.c. of chloroform. This should be carefully sealed and kept in the rk. Take of urine 20 c.c, add 5 c.c. of lead acetate sol. (20 per cent.) which recipitates the urochrome, filter. Mix 10 c.c. of Obermayer's reagentf with 10 c.c. of filtrate (= 8 c.c. urine), add 5 c.c. of chloroform, cork, and shake gently for two minutes. Remove chloroform, add another 5 c.c. of same and so continue until no color is extracted. Of the chloroform used take 2 c.c. in test-tube, add chloroform guttatim until the color corresponds with that of the standard solution in a control tube of equal caliber, both being held against a white background. I The total number of cubic centimeters of chloroform used both in ex- traction and dilution represents the amount containing 1 mg. of indigotin. By multiplying the total amount of chloroform used for extraction by the amount used to dilute to a standard color and dividing by two which cor- responds to the amount subjected to this dilution we obtain the amount necessary for complete standardization of the total chloroform used. INDOL (Excreted as indoxyl potassium sulphate). — When found in substance in the urine this suggests recto-vesical fistula; otherwise, the same statements and tests apply as are given under "Indican." Test for Indol in Substance. — Cholera red reaction. Add to the urine a few drops of dilute sodium nitrite solution and gently pour it down the side of a tube containing sulphuric acid. Indol yields a purple color at the point of contact, a diffuse pink on shaking and blue-green on neutralization with sodium hydrate.% Recto-vesical fistula. * Winternitz considers the absence of an indican increase in ovarian disease of differential value in cases where doubt arises as between this disease and a chronic appendicitis, in the presence of symptoms equally explainable by either condition. t Obermayer's reagent. C. P. HC1 1000, ferric chloride 2. This forms a permanent fuming yellow mixture. Accurate quantitative determination is not essential. \ This is simple and sumcientiy delicate, but other tests, such as that of Ehrlich, will show 1 part of indol in 400,000 parts of urine. 13 194 MEDICAL DIAGNOSIS Diagnostic importance. Diagnostic value trivial. Of slight diag- nostic value. SKATOL (Excreted as skatol-carbonic-acid). — This substance is said to be especially abundant in cases of tuberculous ulceration of the intestines, gastric or intestinal carcinoma and pneumonia, and is not increased in the other diseases showing an excess of indoxyl (F. C. Wood). Rosenbach's Test. — Add nitric acid, guttatim, to boiling urine. A Burgundy-red color with a bluish-red foam on shaking indicates skatol. A reddish or brownish red is usually due to urobilin. UROERYTHRIN. — This normal urinary pigment is increased in febrile states, gout, in various dyspeptic conditions and after excesses in food or alcoholics. It gives an orange color to the urine and a rose tint to uratic sediments. Test. — Add C. P. sulphuric acid to the urine guttatim and a carmine- red color reaction appears, or some pink urates dried or filtered may yield a bright green color with a drop of sodium hydrate solution. MELANIN. — This substance produces a brownish-black urine or one darkening thus from above downward upon exposure to the air (melanogen) . This color is intensified by the addition of nitric acid, bromine water, chromic acid or ferric chloride. Significance. — It is the pigment of melanotic sarcoma and carcinoma (see also "Alcaptone" which also produces dark urines). UROBILIN. — This, or rather its chromogen, urobilinogen, in very small amounts is a normal constituent of urine, is derived from bilirubin by a process of reduction within the intestine and is probably the stercobilin of the feces. In excess it suggests an acute infection, such as sepsis, scarlatina, pneu- monia, acute rheumatism, malaria, typhoid or erysipelas, as well as lead colic, hepatic cirrhosis, hemolytic pernicious anemia, congenital hemolytic jaundice or internal hemorrhage. It may accompany passive Congestion, as in a weak heart, the ingestion of such substances as antipyrin and antifebrin, chloro- form inhalation or the injection of tuberculin (Wood). It may be also the forerunner of, or alternate with, jaundice, constituting the urobilin icterus, most frequent in atrophic cirrhosis, carcinoma and pneumonia. It will readily be seen that it assists but slightly in exact clinical diagnosis save in relation to hemolytic processes. Chemic Test. — To the reddish or reddish-brown urine, w T hich upon shaking usually shows a brownish or even yellow foam, one adds ammonia freely and follows with a few drops of a i per cent, solution of zinc chloride. Urobilin is indicated by a green. fluorescence. Spectroscopic Test. — Dilute urine if necessary, add a few drops of tinc- ture of iodine to each 10 c.c. of urine, and the spectroscope will show a broad absorption band between the green and blue if urobilin itself, not its. chromogen, be present. THE OXYACIDS. — These have the same significance as indoxyl and have no special clinical importance. ALCAPTONE. — This rare substance, a derivative of the amino-acids, has no clinical importance aside from the fact that it produces a urine which, like that containing melanin, slowly darkens on standing or, rapidly, following the addition of an alkali. It reduces Fehling's solution, though not affecting THE EXAMINATION OF THE URINE 195 the fermentation, phenyl-hydrazin or bismuth sugar tests, and yields a nega- tive polariscopic test. See also "Melanin" and "Hematoporphyrin," both of which produce dark urine. HYDROCHINON AND PYROCATECHIN.— Both of these substances produce a urine which darkens on standing, but are of no other clinical importance. UROCHROME AND HEMATOPORPHYRIN.— These constant normal urinary pigments are often associated with urobilin and uroerythrin. The first is the chief yellow or amber pigment, the second scant and red. (Uro- bilin yields a yellowish brown and uroerythrin a pink color to the urine.) Urochrome is readily precipitated by lead acetate solution, leaving a clear urine well adapted to spectroscopic examination. Urochromogen Test of Weiss. — This simple test consists in dividing a small amount of urine into two portions, reserving one for control, and add- ing to the test specimen a few (2 or 3) drops of potassium permanganate solutions, 1 : 1000. A canary-yellow color constitutes a positive reaction and is said to be of special importance in relation to prognosis in pulmonary tuberculosis.* Hematoporphyrin is an iron- and albumin-free derivative of hemoglobin and is often excreted in excess in chronic users of trional, sulphonal, tetronal, and the like, the urine being by transmitted light Burgundy red, and, by reflected light, dark brown or black. It is probably derived from hematin. Salkowski's Test. — Treat 30 c.c. of urine with a mixture consisting of equal parts of a solution of barium chloride (10 per cent.) and cold saturated solution of barium hydrate. Wash the resulting precipitate with water, again with absolute alcohol, and shake it up repeatedly with a warm solution representing 10 c.c. of alcohol and 6 to 8 drops of HC1. If the test be positive, a red- violet color results and the solution yields to the spectroscope the characteristic double bands of acid hematoporphyrin, viz. — a narrow dark band in the orange and a broader one between the yellow and the green in contact with a lighter band in the yellow. CREATININ. — This derivative of the ingested meats follows the same laws as urea as to the variation in excretion, both in health and disease. Test. — It is easily recognized by the intense red color produced by adding a little saturated solution of picric acid and a few drops of sodium hydrate (Jajfe's test) to the urine. Various other substances of no clinical importance but related to the foregoing organic compounds are omitted. * M. E Cowen has recently reported the results of testing 832 cases at the Cresson Sanatorium and believes that " only in the presence of an actual destructive process does the positive reaction appear. He would apply it, therefore, both in prognosis and in the man- agement of the individual case. The author has had no personal experience with the test, but if its name is truly descriptive it should have much the same incidence, significance and value in this disease as would positive diazo-reactions, i.e., according to the author's ex- perience it would indicate active mixed infections. A useful procedure. 196 MEDICAL DIAGNOSIS Chylurea, pyurea and lipurea. , The nubecula. Physiologic sediment. Persistent opacity. Fixed vs. volatile alkali. MILKY URINE. — Such an appearance is usually due to pus or chyle. Pus forms a sediment and its characteristic cells are easily detected by the proper chemical and microscopic tests. Free fat upon the surface is almost invariably from an unclean bottle, the local use of some unguent, or, rarely, to extreme fatty degeneration of the kidney. Fat cells are characteristically refractile under a shifting focus and stain black with osmic acid and red with Sudan III. It cannot be denied that a true lipurea occurs as a rare finding in many diseases or even in an alimentary form. Chyluria. — This rare condition is almost pathognomonic of the presence of Filaria sanguinis hominis. The urine appears usually like skim milk though often tinged with pink. The typical large fat globules are absent, blood and lymph cells present, and the fat cells appear under the microscope as fine mote-like particles. The urine resembles a fine emulsion. A " cream" layer may rise on standing and the parasite itself be found in the fluid. Tests for Fats. — The microscopic or macroscopic examination suffices in many cases. Chemic Test. — Add potassium hydrate and ether, shake, decant and evaporate the supernatant fluid. The fat is taken up, held in solution and remains after evaporation. Fibrinuria. — In rare instances, as in some cases of villous growth in the bladder, the urine jellies on standing, or, if less fibrin be present, a sticky sediment may adhere to the bottom of the glass. TRANSPARENCY. — Normal, undecomposed urine is usually perfectly clear save for a slight mucous nubecula floating in its upper portion. Even in freshly passed urine, however, earthy phosphates or the amor- phous urates sometimes cause a physiologic sediment, the phosphates being associated with feeble acidity or alkalinity;* the urates with concentration and acidity. Heating increases the precipitation of phosphates and redis solves urates. Persistent opacity or turbidity is pathologic in undecomposed urines and may be caused by pus, blood, fat or bacteria. ODOR. — The peculiar odor is intensified in sharply acid, concentrated urine and distinctly and characteristically modified in alkaline urine; the volatile alkali (ammonia) being easily detected if present, as are indol and skatol in recto-vesical fistulas, the odor of hydrogen sulphide in hydro thionurea, bitter almonds in nitro-benzol poisoning, etc. REACTION. — The reaction may be acid, alkaline or amphoteric, i.e., doubly reactive, f // alkaline, the physician should determine by repeated tests whether the condition is temporary or permanent and the alkali fixe d (potas- sium or sodium) , or volatile (ammonia) . Any ammoniacal urine to which a few * Many such urines are really neutral, as shown by a phenolphthalein solution, though turning red litmus-paper blue, possibly through the release of C0 2 from the bases (F. C. Wood). f Presumably because of the co-existence of the acid monosodium phosphate and the alkaline disodium phosphate. THE EXAMINATION OF THE URINE IQ7 drops of potassium or sodium hydrate solution has been added yields when boil- ing the odor of ammonia. So also, immersed red litmus-paper resumes its original color when dried in the air. The "Alkaline Tide." — A physiologic alkaline or neutral reaction often appears two or three hours after a meal especially in vegetarians, in which case the alkali is fixed, not volatile, and the condition unimportant. Persistent, non-dietetic alkalinity is abnormal, and urine ammoniacal when passed indicates usually some disease of the bladder or prostate with or without renal involvement. An exclusive meat diet tends to produce acidity; an exclusive vegetable diet, alkalinity; but quantitative determination of the acidity or alkalinity is clinically useless. Excessive Acidity. — This may be encountered in fevers, in acute rheu- matism to a marked degree and in gout, diabetes, leukemia, scurvy, and decided cardiac incompensation. As a rule high acidity and scanty urine go together. SPECIFIC GRAVITY.— For ordinary purposes a clinical urinometer of the usual type, properly graduated for definite temperature (usually i7.5°C.) is sufficient. In testing freshly passed urines, for every 3°C. above the standard temper- ature for the individual instrument one point should be added to the right-hand figure of the specific gravity. If more accurate results are de- sired or very small quantities of urine are to be dealt with, as in urethral catheterization, the hydrometer of Saxe, one of the pycnometers, or the Westphal balance may be readily obtained. Technic. — In ordinary clinical work the following precautions are necessary: (a) The urine must be allowed to cool or proper allowance made, (b) All air bubbles must be removed with filter-paper, (c) The urinometer must be perfectly dry and (d) intro- duced with a little spin to prevent it from adhering to the side of the receptacle, (e) The specific gravity should be read from the meniscus or true surface, the observer's eye being at that level; false readings result if one reads from above, because the fluid rises slightly along the urinometer stem, if) If the amount of urine is small, approximate results may be obtained by diluting sufficiently to float the instrument and multiplying the two right-hand figures of the specific gravity by 2, 3 or 4 according to the amount of distilled water used. Factors Determining Specific Gravity. — The normal figures vary from 1. 012 to 1.024, the average lying between 1.018 and 1.022. Hysteria and the use of diuretic fluids or drugs may reduce it to 1.002 and in disease it varies from j. 002 to 1.060. In general, high specific gravity points to large hemorrhages, profuse per- spiration, diarrhea, fever, and diabetes mellitus. i Fig. 60. — Urinometer, thermometer and specific- gravity tube on foot. Physiologic alkalinity. Volatile alkali. Effect of diet. When encountered. Instrument. Temperature. Details important. Wide variations. 198 MEDICAL DIAGNOSIS Exceptions to rule. Organic vs. inorganic. Rough methods. Urinary nitrogen. Variations. Low specific gravity suggests chronic Bright's disease (particularly inter- stitial nephritis), diabetes insipidus and hysteria. As a rule, a low specific gravity accompanies increased excretion, and a high specific gravity, diminished excretion, but there are many exceptions to this rule, many grave diseases being associated with scant urine and defi- cient elimination of solids, whereas diabetes mellitus may show an enormously increased excretion with the highest readings and diabetes insipidus an in- creased amount and low specific gravity with an actual excess of solids in the twenty-four hours' urine. URINARY SOLIDS Normal Constituents. — Normal urine in the healthy adult of average weight and on a mixed diet should contain about 60 grams of solids. Of these about 35 grams are organic and 25 grams inorganic. By multiplying the two right- hand figures of the specific gravity by 2.2337, one obtains roughly the total urinary solids in 1 liter (1000 ex.) of urine. [Example: Sp. Gr. 1020. 20 X 2.337 ~ 46.74 grams per 1000 c.c] Of this about one-half is urea, which should be separately estimated. The principal inorganic substances are: HC1 (9.35 grams), phosphoric acid (2.5), sulphuric acid (2.5), nitric acid (1.0), oxalic acid (0.0 1 to 0.02), sodium (8.0), potassium (3.0), ammonia (0.7), magnesia (0.5), lime (0.3), iron (0.001 to 0.002). The organic substances are, in grams^ urea (30.0), creatinin (r.o), uric acid (0.7), hippuric acid (0.7). Traces of a large number of organic sub- stances, including the purin bodies, make up the balance for the organic group. The pathologic substances are the albumins, blood, bile pigment, bile acids, indoxyl, acetone, diacetic acid, cystin, leucin, tyrosin, carbohydrates, phenol, creosol, skatol, urobilin, cholesterin, lecithin, diamins, melanin, fats, fatty acids, lactic acid, beta-oxybutyric acid. Of these, indoxyl, acetone, lactic acid, fatty acids, phenol, creosol, skatol, urobilin and even albuminous bodies may be present in clinically unrecognizable or negligible traces in normal urine. TOTAL NITROGEN.— A Direct Index of Protein Metabolism.— Before considering urea and uric acid the derivation and importance of the total nitrogen excretion should be considered. While the total nitrogenous output of the human body involves a consideration of that of the feces, lungs and skin as well as the urinary nitrogen, the fact that this last represents, in health and on a mixed diet, from 92 to 93 per cent, of the total makes the urinary examination the primary clinical consideration. Unfortunately the same ratio does not hold true in disease and in the case of special dietaries, for the reason that in pathologic states the total amount of nitrogen is divided among other nitrogen-containing compounds in vari- ous degrees. The healthy adult on a mixed diet secretes 0.2 gram of nitrogen per THE EXAMINATION OF THE URINE 199 kilo of body weight, viz., from 10 to 15 grams of nitrogen per day and under such conditions about 86 per cent, of the urinary nitrogen is urea nitrogen, though this ratio is not absolutely constant. Eight per cent, is derived from ammonia, creatinin, the purin bodies and the pigments, while 6 per cent, rep- resents hippuric acid and unknown substances. The total nitrogen excretion measures the variations, not merely of nitrog- en us intake, but of body waste and hence the metabolic processes. Nitrogen Retention. — Though excretion is increased by nitrogenous diet, an excess may nevertheless be retained in part for several days, a fact which has not yet been explained. Increased Excretion. — This occurs in acute infectious fevers (excepting acute yellow atrophy of the liver), malignant growths, chronic infections, pernicious anemia, exophthalmic goiter, scorbutus, the leukemias, resorp- tion of exudates, diabetes insipidus, phosphorus poisoning and, indeed, in practically all diseases associated with marked emaciation, malnutrition or excessive toxic metabolism. Diminished Excretion. — This occurs in nephritis, diseases of the liver and in convalescence from acute diseases, though in the first named, if associated with excessive albuminuria, the urine may show an apparent increase if the albumin is not removed. In nephritis especially, the stomach, intestines and skin may take on vicarious activity and the feces will show increased nitrogen content. For accurate work, careful measurements of the nitrogen intake and that of the feces as well as the urinary nitrogen is necessary, a time- consuming process illy-adapted to clinical work. (See "Index of Urea Excretion. ") Individual specimens of urine are no more than suggestive with respect to the nitrogen excretion. It must always be determined from the twenty- four hours' total urine. For a full description of all the elaborate chemical processes involved, the reader is referred to the special works dealing with physiological chemistry, but the most commonly used methocl of quantitative " urinary nitrogen" estimation is given briefly in the following paragraphs. ESTIMATION OF TOTAL NITROGEN (KjeldahVs Method).— This method depends upon: (a) The conversion of urinary nitrogen into ammonia. (b) The transformation of ammonia into ammonium sulphate, (c) The liberation of the ammonia by sodium hydrate, (d) Distillation into a deci- normal sulphuric acid solution, (e) Determination of the amount of com- bined ammonia by titration of the decinormal acid solution with a decinormal alkaline solution, using some such indicator as rosalic acid, alizarin red, or methyl orange. (/) Estimation of total nitrogen on basis of 0.001401 gram of nitrogen for each cubic centimeter of combined acid and ammonia as indi- cated by the preceding titration. Test. — First Step. — Using the apparatus shown in Fig. 61 and placing it under a proper fume-conduction hood, one measures into a Kjeldahl flask of 800 c.c. capacity, 5 c.c. of urine; 10 c.c. of concentrated sulphuric acid and 1 gram of copper sulphate. Ratio to body weight. Urea. Not practicable. Avoid fumes. 200 MEDICAL DIAGNOSIS Oxidation processes. Conversion into ammonium sulphate. Prevent "bumping." Liberate ammonia. Distil and recombine ammonia. Ammonia bound by acid. Titrate to measure amount combined. Second. — Heat over low flame until white fumes indicate the giving off of sulphuric acid. Third. — Add 5 grams of potassium sulphate and, shaking carefully from time to time, boil for from thirty to forty minutes or until the yellow color has entirely given place to bluish green. Fourth. — Set aside to cool. Fifth. — Add distilled water sufficient to make total quantity of liquid in flask about 250 c.c. Sixth. — Add a few bits of zinc, pumice stone or a little talcum powder to prevent "bumping" during the succeeding stages. Fig. 61. — Kjeldahl's nitrogen apparatus. {Webster, "Diagnostic Methods") Seventh. — Add 50 c.c. of 40 per cent, sodium hydrate, being careful to avoid having it touch neck of flask. Eighth. — Shake; connect by means of a Fresenius bulb with a Liebig condenser. Ninth. — Place in an Erlenmeyer flask 50 c.c. of a decinormal sulphuric acid solution and rapidly connect the outlet tube with the bulb and condenser. Tenth. — Heat slowly and carefully to boiling and maintain slow boil for twenty to thirty minutes or until about 150 c.c. of test mixture have passed over, or until outlet tube fails to color red litmus-paper blue, i.e., until distillation of ammonia is complete. Eleventh. — Disconnect distilling flask and rinse both connecting and outlet tubes into acid solution. Twelfth. — Titrate acid solution with decinormal sodium hydrate, using for an indicator rosalic acid, methyl orange, or alizarin red. The acid and alkaline solutions being standardized and of equal strength, THE EXAMINATION OF THE URINE 20I — * — 5 — va — U.QI — *02 003 the number of cubic centimeters of sodium hydrate solution required indi- cates the number of uncombined acid molecules, and by deducting this from 50 — the number of cubic centimeters of decinormal acid solution originally used — one finds the number representing combined ammonia, each cubic centimeter of which is equivalent to 0.001401 gram of nitrogen. Hence the difference between the number of cubic centimeters of deci- normal sodium hydrate solution used in the last titration and the number of cubic centimeters decinormal acid solutions originally used, multiplied by 0.001401 gram gives the amount of nitrogen in 5 c.c. of the urine, and multiplying by 20 one obtains the total nitrogen percentage and readily calculates it for the mixed twenty-four hours' output of which the original 5 c.c. must be a part.* UREA. — In the normal individual on a mixed diet the urea output varies from 20 to 35 grams in twenty-four hours. Under such conditions it follows in nearly every particular the laws of total nitrogen excretion already given. Women excrete less than men, and in vegeta- rians or poorly fed patients, or those on a milk diet, the amount may not exceed 15 grams a day. Urea nitrogen represents approximately 86 per cent, of the total nitrogenf (protein-free diet 60 per cent., vegetable diet 79 per cent., rich proteid diet 87 per cent.). Retention Periods. — There are periods of re- tention lasting several days, and these may be increased by certain drugs, such as salicylic acid, caffein, and quinin. Urea excretion is greatly increased in many conditions associated with marked tissue waste such as fevers, severe ad- vanced diabetes, pernicious anemia and leukemia. In diseases of the liver the urea excretion is more greatly diminished than is the total nitrogen, leucin and tyrosin being coinci- dently increased, or, in acute processes, an increased ammonia excretion replaces the leucin and tyrosin. In view of the recent work of Folin and others, one cannot consider the mere estimation of urea a substitute for total nitrogen determinations in questions of protein metabolism, but it still remains of value in relation to renal disease. Urea in Blight's Disease. — In Bright 's disease, save the early stage of parenchymatous nephritis, and especially in the interstitial form, urea excretion is usually diminished and also shows marked periodic or irregular variations. * Synopsis is taken from the full description contained in Webster's excellent book, "Diagnostic Methods." t And may reach 92 or 93 per cent. 62. — The Doremus ureometer. Periodic variations. 202 MEDICAL DIAGNOSIS Sudden drops. Early chronic nephritis. Nephritis sine albuminuria. Estimation important. Instrument. Test. It is supposed that retained urea in such instances is responsible for the periods of diuresis or diarrhea so commonly seen. A sudden drop in urea is often noted in nephritis of all kinds, and is a danger signal that cannot be disregarded. In many of the author's cases presenting intractable neuralgias the at- tacks coincided with periods of low urea excretion. In others indeterminate but troublesome gastric symptoms, marked psychasthenia and hypochondria and arterial hypertension were found to coincide with the same condition and all these cases were promptly relieved by treatment directed to secure the better elimination of urinary solids and proper dietetic restrictions. In eight such instances no structural disease of the kidney was then clinic- ally demonstrable, but all have since shown typical interstitial nephritis. The author would strongly differ from, and, indeed, hold the exact reverse of, the statement made by certain writers that in renal disease urea determinations are less important than the finding of casts and albumin. With relation to the functional activity of the kidney even the rough esti- mation of urea, under dietetic control, is one of the simplest and most important of all clinical tests, and the most convenient method of quantitative testing is that of Dor emus which is sufficiently accurate for ordinary clinical purposes * Description of the Doremus Ureometer. — The Doremus apparatus is much used and consists of a tube carrying a bulb below and so graduated that each division corresponds to o.ooi gram of the urea as represented by the volume of nitrogen evolved at 65°F. There is also a small, curved, nipple- capped pipette holding i c.c. of urine. The tube is filled with hypobromite solution f and the pipette, J filled with urine {freed from albumin or sugar) up to the cubic centimeter mark, is carefully introduced into the bend as far as it will go, while holding the measuring tube perpendicularly, and the contained urine slowly and com- pletely discharged. After the evolution of gas is complete the number of divisions is read off as milligrams per cubic centimeter or the result multi- plied by ioo to obtain the percentage. A Fascinating and Accurate Procedure. — The method of determination of renal function described below should be known to all students and practitioners of medicine and the author has felt constrained in this instance to give much space to a procedure both time-consuming and exacting. It will be noted with satisfaction that the simpler phenolsulphonephtha- lein test (see p. 245) has borne the comparison very well and that in renal disease the variations from normal are usually violent in the obscurer forms of * Of the more elaborate and accurate methods, that of E. K. Marshall is the most recent and most useful. It depends upon the use of the Soya bean ferment urease, for the hy- drolysis of urea to ammonium carbonate. Though relatively simple, as compared with the older methods, it requires special apparatus, and far more time than the practitioner can afford. f 100 c.c. of caustic soda dissolved in 250 c.c. of distilled water makes a permanent solution, to 50 c.c. of which 5 c.c. of bromine is added to make test solution when needed. X The instrument can now be obtained with an attached hollow arm with a thumb-screw to hold, measure, and release the amount of urine used. THE EXAMINATION OF THE URINE 203 nephritis. It must be borne in mind that a lack of absolute accuracy in the rough simple older form nice by no means wholly destroys their clinical value. This lies in their simplicity and availability, for this test of precision, however fascinating and valuable, is wholly unavailable for the greater num- ber of practitioners of medicine. Like the Wassermann test, it must remain in the hands of the expert and he will apply it chiefly to groups of patients accumulated over several days. The Index of Urea Excretion. — Most interesting and accurate results are being obtained at present by expert workers in the clinical laboratories, through the use of F. C. McLean's " index of urea excretion" which represents a marked improvement of Ambard's process based upon his two "laws," i.e., (1) when the concentration of the urinary urea is constant the amount excreted by the kidneys varies proportionately to the square of the blood- urea concentration; (2) when the blood-urea is constant, renal excretion varies inversely as the square root of the urinary urea concentration. On the basis of these two laws Ambard devised what he calls the u ureo-secretory- constant" obtained through a formula known as the "urea-coefficient." His formula (the urea coefficient) is the following: Ur K (constant) = — , — j== VDX7oVc_ P 25 Ur = urea per liter of blood. D = grams of urea in urine during 24 hours. P = weight of patient in kilos. C = grams of urea per liter of urine. It is asserted by him that the " urea-secretory-constant " ("K") varies only from 0.06 to 0.07 in normal individuals, whereas in cases of nephritis the value of "K" is enormously raised, by reason of concentration of urea in the blood as a result of diminished renal elimination. McLean and Selling greatly increased the accuracy of the process by replacing the hypobromite method of urea estimation used by Ambard, by the exact technic of Folin and of Marshall. The tedious recourse to logarithms they avoid by the use of a scale rule adapted to the formulas. With relation to the necessity for and value of such a method, and after briefly reviewing the various other tests of renal permeability and adequacy now in use (lactose, phenolsulphonephthalein, etc.) McLean says:* " In all these tests it has been the urine alone which has been examined, the assumption being made that alterations in the manner or time of elimination are due to kidney factors alone. But this assumption is open to serious objection. The time required for the ex- cretion of considerable amounts of nitrogen or salt, suddenly added to the diet, may, in- deed, give some indication of the degree of kidney insufficiency; but the failure to excrete these substances within a specified time is often due to other factors than the ability of the kidneys to carry on their excretory functions. Thus a patient with fever may retain enormous quantities of salt in the body, even though the kidneys are perfectly capable of *Journ. A. M. A., Vol. LXVI, No. 6, p. 415 (abstract). Italics are the author's. 204 MEDICAL DIAGNOSIS excreting it, and retention is due to the fact that the excess salt is removed from the blood by the tissues. That, under certain other conditions, a similar retention of nitrogen in the tissues occurs, independently of the ability of the kidneys to excrete nitrogenous sub- stances, is indicated by the recent studies of Foster and Davis. "Study of the daily nitrogen or salt balance between intake and output is of even less value than study of suddenly added nitrogen or salt. "It has, indeed, long been recognized that determination of the total nitrogen or urea output gives no indication as to the state of the function which provides for the excretion of nitrogen. An individual may excrete normal amounts of urea in the twenty-four hours, and remain in perfect nitrogen equilibrium for weeks or months, and yet be suffering from severe nephritis, with advanced functional changes. Except in the case of those patients with chronic parenchymatous nephritis, who are scarcely able to excrete any salt at all, comparison of the salt output with the intake gives little information. The same objection seems to hold with regard to the use of potassium iodid as a test of the ability of the kidney to excrete salts, since potassium iodid is influenced by the same extrarenal factors which influence sodium chlorid. "Studies such as these, of urine alone, can at best give only a general idea of the true renal condition, and can be in no sense a quantitative measurement of the renal activity. "Determination of the amount of urea nitrogen, or of total non-protein nitrogen in the blood, however, is not entirely dependable as a measure of excretory activity. The normal concentration of urea in the blood is not fixed, but varies within wide limits in response to variations in nitrogen and fluid intake. As a matter of fact, the larger proportion of indi- viduals with disturbed urea function have concentrations of urea in their blood which are below the upper limits in normal individuals, so that the line of demarcation between normal and abnormal subjects is not sharp. " Blood urea figures alone, therefore, may call attention only to the more serious instances of disturbed function. Furthermore, the concentration of urea in the blood even of nephritic individuals is not constant or fixed. On the contrary, Widal and Javal, in 1904, showed that the concentration of urea in the blood can be made to fluctuate at will in cases of nephritis, by varying the protein intake. "Either increased urea formation in the body, or disturbance of urea elimination through the kidney, requires a higher level of urea in the blood to provide for a sufficiently rapid rate of excretion to keep the organism in nitrogen equilibrium. "Changes in the rate of water excretion alter the rate of output of urea, which changes as the concentration of urea in the urine changes, though not directly in proportion to these changes. The rate of elimination also varies according to the weight of the individual, and is constant per kilogram of body weight, when the other conditions remain constant. I All of these factors have been considered by Ambard in formulating the laws published by him. "Data obtained by this method are direct quantitative measurements of one of the most important functions of the kidney, that is, the elimination of nitrogen in the form of urea. Performance of the test requires a shorter time than the use of any test diet, requires fewer analyses, is much more broadly applicable, and may be repeated indefinitely without harm or inconvenience to the patient. It requires no knowledge of the nitrogen or fluid intake, and is not interfered with by vomiting, refusal o f food, diarrhea, delirium or coma. The blood and urine required for the necessary analyses may be secured within the time of an ordinary consultation, and the analyses can be carried out in any well-equipped clinical laboratory. Also of the value of the results obtained, the method is to be preferred to the various modifications of the test diet. "The Index of Urea Excretion. — The index of urea excretion is based on an ideal normal Ambard's coefficient of 0.080. The extremes of variation of Ambard's coefficient in the normal are from about 0.050 to 0.085 or 0.090. Deficiency in urea function results in higher values. These higher values are. due to a change in the ratio which exists between the concentration of urea in the blood and the rate of its excretion. Such findings indicate deviation from the normal, but do not measure the extent of the functional change which THE EXAMINATION OF THE URINE 20 is responsible for such deviation. The significance of the abnormal ratio found in any pathologic case, therefore, can be understood only by reference to an arbitrary scale, de- termined by experience. "Since it is possible to utilize the laws of Ambard in another form to measure functional changes directly, we have thought it desirable to use a new formula. In the case of the formula as at present used, the ideal normal is determined arbitrarily, by experience, and deviations from the normal in the rate of urea excretion are measured directly in terms of the ideal normal. Ambard has shown experimentally that the rate of excretion of urea under otherwise constant conditions varies directly with the amount of functionating kidney tissue. In observations in human subjects it is not possible to keep conditions constant, but it is possible, by an application of Ambard's laws, to measure the influence of their variations on the rate of excretion of urea. The ideal normal rate of excretion, under the conditions found, at any time, is given a value of ioo. The index then expresses, in direct percentage, the rate of excretion found, in terms of the rate of excretion that a normal individual would develop under the same conditions as to concentration in the blood, con- centration in the urine, and body weight. "The index is therefore not a substitution of a new formula, with a new scale of arbitrary values, in place of the Ambard formula, but is a direct measure of an important excretory function. "Since, as we have shown, Ambard's coefficient is not in itself a direct indication of the state of the function which has to do with the excretion of urea, but is merely the ratio between the concentration of urea in the blood and the rate of its excretion, the index expresses facts which can be obtained from Ambard's coefficient only by further calculation. "Ambard's laws depend on the constant relationship of four variables: (i) the concen- tration of urea in the blood; (2) the concentration of urea in the urine; (3) the rate of urinary excretion, which together with (2) gives us the rate of urea excretion, and (4) the weight of the individual. We have indicated this constant relationship in our present formula as follows : Rate of urea excretion •%/ Concentration in urine X Constant Index of excretion Weight of individual X (Blood urea) 2 "In order to give the index a constant value of 100 for the ideal normal, and in order to determine the numerical value for the constant, certain arbitrary methods of expression of the various factors must be adopted. We have adopted the same methods as those used by Ambard, that is, the expression of rate of urea excretion as grams per twenty-four hours, the concentration in the blood and urine as grams per liter, and the weight of the individual in kilograms. Urea, and not urea nitrogen, is used throughout. It should be distinctly understood that other methods of expression of the various factors would not change their constant relationship, or the index, but would change merely the numerical value of the constant of the formula. When variables which give an Ambard's coefficient of 0.080, the figure chosen as the ideal normal, are substituted in the formula, the constant must have a value of 8.96 to give an index of 100. The mathematical derivation of the new formula js discussed in detail in our previous papers. It reads: T A t TT T7 f m D VCX 8.96 Index of Urea Excretion (I) = — „., w ., „ — Wt X Ur 2 D = grams urea excreted per 24 hours. C = grams urea per liter urine. Ur = grams urea per liter blood. , Wt = body weight of individual, in kilograms. "The rate of excretion is not actually determined for twenty-four hours, but for a shorter period, usually seventy-two minutes (one-twentieth of twenty-four hours), the calculation being made on a basis of grams per twenty-four hours. It is important to remember that it is not the actual twenty-four hour excretion of urea that is essential, but the rate of excretion at the time of observation. 206 MEDICAL DIAGNOSIS "Substitution in the foregoing formula of values obtained by observation in normal individuals should give values for the index approximating ioo. The actual variations in Ambard's laws in normal individuals are magnified by this formula, the variability appear- ing to be much greater than when the same results are expressed in the form of Ambard's coefficient. When observations are made under the proper conditions, values for the index of jess than 80, corresponding to an Ambard's coefficient of 0.090, should never be obtained in normal individuals, and no normal subject should be repeatedly below 100. Values above 100 are the rule, and values up to 180 and 200 may occur. Much higher values may be obtained under certain pathologic condi- tions, associated with an increase in the rate of urea excretion. It is perhaps unfortunate that such apparently wide divergence occurs among normal persons, and in the same normal individual. This is a result of expressing the laws in this form, and it does not affect the value of the index as a measure of abnormal variations. =:E° I I ri o Example : Grams urea excreted per 24 hours, D = 20.0 Grams urea per liter of urine, C = 11.0 Grams urea per liter of blood, Vr = 0.330 Body weight, in kilos, Wt = 55.0 _ D VCX 8.96 _ 20.0 VITo X 8.96 Index- mxUr2 ~ 55.0XC0.330) 2 1. 55.0 on Wt scale is set opposite 20.0 on D scale, first position. 2. Hair line on runner is moved to 11.0 on C scale, second position. 3. Slide is moved so that 3.30 on TJr scale is at hair line on runner, third position. Reading is now made at the arrow which points to scale I and is at 100. Therefore Index, / = 100. "Methods j or Observation. — Observations can be made at any time, without regard to diet, since application of the laws is inde- pendent of the nitrogen intake. It is preferable, though not essential, that the observation should not be made too close to the taking of food, since the most rapid changes in the various factors occur during the height of digestion and absorption. Since observations require neither the introduction of a foreign substance, nor the ingestion of weighed amounts of food, they may be made without regard to vomiting, coma or delirium, and interfere in no way with any plan of treatment that is being carried out. Fre- quent observations may thus be made without the necessity of interrupting a dietetic treatment with test meals. "The essential points in an observation are (1) the collection I of urine over a carefully timed period, (2) the collection of blood near the middle of that period, and (3) accurate determination of the urea content of the samples of blood and urine. "Our usual routine is as follows: The patient is given from 150 to 200 c.c. of water, in order to insure a free flow of urine. One-half hour later, in order to start with the bladder { empty, he voids. The patient is catheterized if necessary, as in urine retention or in the case of coma. The time of voiding is recorded to within one minute. About thirty-six minutes later, from 7 to 10 c.c. of blood are withdrawn from an arm vein into a dry tube containing a few milligrams of potassium oxalate or citrate to prevent clotting. At the end of seventy-two minutes from the first voiding the bladder is again emptied, and the urine carefully measured to within 1 c.c. and used for analysis. The patient takes no food or water during this period. Otherwise no restrictions are placed on him. THE EXAMINATION OF THE URINE 207 "The seventy-two minute period is merely for convenience, as being one twentieth of twenty-four hours. Any other period, preferably not too long, will serve. Ambard pre- ferred a period of thirty-six minutes, but the possibility of error in the collection of the speci- men is doubled when the time is halved. If it is desired to carry out a simultaneous phenol- sulphonephthalein test, the sixty minute or two hour phthalein period may be used, half of the urine being used for the phenolsulphonephthalein reading, and the other half for the analyses. "Analyses should be made by the most accurate, convenient and rapid method avail- able for determination of urea in the blood and urine. The method requires more than the usual degree of accuracy in clinical laboratories, as a relatively slight error in analysis may introduce a considerable error into the formula. The urease method, introduced by Mar- shall, fulfils all of the requirements. This method depends on the breaking down of urea into ammonia and carbon dioxid by the specific enzyme found in the soy bean, and the sub- sequent determination of the ammonia. We have used the permanent preparation of urease described by Van Slyke and Cullen,* and carry out the determinations in the manner which they prescribe. With careful technic and control of the reagents, this method gives consistently accurate results. It is very simple, very rapid, and requires the minimum of manipulation. Three analyses are necessary; blood urea, urine urea and urine ammonia. Urine ammonia is determined in order to correct the urea figure for preformed ammonia, which is also determined in the urea method. Duplicate determinations on blood are ad- visable, as a higher degree of accuracy is thus obtained. The determinations are run simultaneously in the same apparatus, and require little attention. Table I. — Illustration of Independence of Index and Nitrogen Intake! °™» nitrogen in 24 hr. S'SZS&t' Output c ! S3.S — ' « m ki 1 h ffl , "0 1-1 3\2 Date, Weigi Intak O ■»-> w "3 Nov. 5 65.0 19.2 16. 1 Nov. 12 ; 64.8 1 9.6 ; 7.92 Nov. 16 64.8 j 9.6 i 6.6 Nov. 30 65.4 4.8 3.48 3.15 1. 61 2.92 1-3/ 19.25 9-53 9-52 4.85 -0.05 +0.07 +0.08 -0.05 0.858 9-87 0.499 jio.68 0.41 1 7,06 0.211 4.37 37-5 | 22.0 12.8 23.2 1 1 . j 24.0 3-32| 21.4 1 "Calculation form in which t without clothing stituted in the f by the use of a s] is a modified 10- matical principle comes purely me culation is most < * Van Slyke, use in the Detei A. M. A., May Slyke and Culle with directions f t Case 1.— C stitial nephritis. % The rule, wi Fulton Street, N described in pre\ of the 1 bey are , shoul ormula serial c men sli( s invol chanica easily p D.D., •minati [6, 191; n by th or use. A. P., th dire ew Yor r ious pa Index — to be i be kc and t alculat le-rule, ved. A 1, and r erforme and Cu 3n of I I. P- 15 e Arlin man, a :tions f k. Th pers. -The re express own to ae inde ng dev one ne< Vith a equires d with lien, G. Jrea, J< 58. Ui gton CI tged 45 or use, e same suits fr »ed in t within x calcu ice, 'illi ids to r little p only a an ordi E.: A )ur. Bi ease is lemical Diag may be rule is om the he fori one ki ated. istratec ememb ractice few sec nary si Perma d1. Che prepar Compj nosis: £ obtain used f determii nula. T logram. Calculat in Fig. er neithe in readir xmds.t de-rule, nent Pre m., 1914 ed accor iny of Y( general ai ed from or calcul lations are cal le w r eight of t The four vari ion has been re 53. With this r the formula r g the scales, c Without this or by the aid paration of U , xix, 211; id. ding to the m mkers, NY., •teriosclerosis, Keuffel and ] ation of the cl culated to the he individual, ables are sub- ndered simple device, which or the mathe- alculation be- slide-rule, cal- of logarithms. rease and Its , The Journal ethod of Van and furnished chronic inter- ^sser Co., 127 ilorid formula 208 MEDICAL DIAGNOSIS "Application of the Index. — Numerous studies have been made, or are in progress, using the index as a measure of urea function. It is not the purpose of this paper to present cases or conclusions, but certain points regarding the applicability and value of the index are illustrated. "Table I illustrates the fact that the index is independent of nitrogen intake. It also shows clearly that the actual blood urea figure may be very misleading, if taken by itself, as an indication of the ability of the kidneys to excrete nitrogen. In the case illustrated, reduction of nitrogen intake was followed by a corresponding decrease in nitrogen elimina- tion, the patient coming rapidly to equilibrium. The balance between intake and output was maintained at a lower level of urea in the blood, the index remaining constant. Had the blood urea alone been determined at the lowest level, which is lower than the usual normal, one could not have said that there was evidence of impaired renal function. By application of the index, the actual ability of the kidney to excrete urea is seen to be the same at the lowest level in the blood as at the highest. "This case also throws light on the mechanism of so-called nitrogen retention. One can easily see that the increased level of urea in the blood on the higher nitrogen intake is purely compensatory, and is not due to a lack of ability on the part of the kidney to excrete the larger amounts of urea being formed in the body. The kidney actually does excrete the larger .amounts of urea just as well as the smaller amounts, but it requires a higher concen- tration of urea in the blood to bring this about. To speak of nitrogen retention on the basis of increased concentration of non-protein nitrogen in the blood is therefore apt to be mis- leading. Table II. — Illustration of the Comparison between the Urea Index and Percent- age of Phenolsulphonephthalein. Excreted in Two Hours Subject Diagnosis Blood urea, grams per liter Urea index Phenolsulpho- nephthalein, per cent, in two hours 2 3 4 5 4 4 6 4 7 8 7 7 8 4 9 io ii ii 12 4 4 13 14 ii Mitral stenosis Parenchymatous nephritis Mitral stenosis Acute nephritis (convalescent) , Heart block Acute nephritis (convalescent) . Acute nephritis (convalescent) . Chronic nephritis Acute nephritis (convalescent) . Chronic nephritis Chronic nephritis Chronic nephritis Chronic nephritis Chronic nephritis Acute nephritis (convalescent) . Mercuric chlorid poisoning Chronic nephritis Chronic nephritis Chronic nephritis Chronic nephritis Acute nephritis Acute nephritis Chronic nephritis Chronic nephritis Uremia „ 0.132 0.216 0.196 0-383 0.480 o-395 0.317 0.388 0.406 0.446 o.437 Q-454 0.546 o .400 0.634 0.610 0.488 0.977 1. 016 1.850 1.320 0.966 I. no 2.147 3-430 250.0 139.0 105.0 92.0 91.0 89:0 68.0 60.0 56.0 52.0 47 .0 44.0 39 -o 37-o 33-o 19.0 18.0 8.1 7.9 7-4 7.0 6.1 4.2 1.0 0.27 S3 66 65 46 58 5i 4i 45 34 41 38 33o 42.0 27.0 25 15 25 8 8 13 2-5 Trace 0.0 THE EXAMINATION OF THE URINE 209 "Relation to Phenol sul phone phthalein Output. — Numerous simultaneous observations on urea and phenolsulphonephthalein elimination make it appear that the mechanism is the same in the two instances. The curves of the percentage of phenolsulphonephthalein excreted in two hours, and of the urea index are parallel and are quite striking. No con- siderable divergence has been found in any case, with the exception of some patients suffering from heart failure. These subjects were not excreting enough water to carry off the urea formed in the body, but were able to eliminate phenolsulphonephthalein fairly well. In Table II are given figures comparing the results by the two methods. These observations were all in individuals who were excreting water at a rate sufficient to eliminate all the urea being formed in the body. They were either simultaneous observations on phenolsulphonephthalein and urea elimination, or the two observations were made within a short time of each other. "These figures are in close agreement with those of a similar study published by Widal, Weill and Vallery-Radot, their figures for urea excretion being recalculated in the form of the index of urea excretion. Both studies show a remarkably close parallelism between the index and the percentage of phenolsulphonephthalein excreted in two hours. In the cases with normal or increased excretion of both urea and phenolsulphonephthalein the figures for the index are naturally higher, since the ideal normal index is 100, and higher figures are attained in persons with increased excretion, while the normal phenolsulphonephthalein excretion is about 60 per cent, in two hours, and 100 per cent, can be approached by individ- uals with increased excretion, but not exceeded. In the lower figures the two tests show in practically every instance the same diminution in rate of excretion of urea and of phenol- sulphonephthalein. Both show the failure of the blood urea figure alone to indicate the degree of disturbance in urea elimination, since many cases show blood urea figures below the upper limits in normals, though both the index and phenolsulphonephthalein figures are low. "These findings confirm the value of the use of phenolsulphonephthalein as a clinical test of the ability of the kidneys to excrete substances belonging in the same class with urea. While a rational basis for the use of phenolsulphonephthalein is thus given, certain factors make the direct determination of urea function of still more value than the phenolsulpho- nephthalein. In the first place, it is a direct determination of a normal function, of which the phenolsulphonephthalein test is an indirect determination. Interpretation of possible discrepancies between the two methods must recognize this fact. For study of the effects of treatment in a given case, the index is certainly the more delicate indicator, and the line of demarcation between normal and abnormal cases is sharper than in the case of phenol- sulphonephthalein. The index has an added advantage in that, as it tends to approach zero, smaller differences are of greater import, and are more easily determined than in the case of phenolsulphonephthalein. Thus the difference between 3 and 6 per cent, phenol- sulphonephthalein excreted in two hours is difficult to determine colorimetrically, while it is a very considerable difference in the case of the index. From the standpoint of deter- mining whether the condition is stationary or progressive, the index is therefore much more delicate than determination of the small amounts of phenolsulphonephthalein excreted in cases with advanced impairment of function. "In addition to the index itself, the analyses necessary in determining it are of direct value. We have learned to attach a certain amount of import to the blood urea figure alone. The index, therefore, adds enormously to the value of an already recognized method, with the addition of practically no technical details. The determination of urea in the urine, the only laboratory work required in addition to the blood urea, demands only a moment's extra time. "Neither the phenolsulphonephthalein nor the index, in itself, furnishes positive information as to the cause of the impairment of function. Indirect information is, however, furnished by the determinations made in arriving at the index. A low index, associated with a diminished excretion of urine, with a high urea content, suggests passive congestion of the kidneys. The same index, occurring with the excretion of normal or increased amounts of urine, with a low urea content, may be characteristic of 14 2IO MEDICAL DIAGNOSIS certain forms of nephritis. Thus additional information is obtained in the determination of the index. "For the present we prefer to study cases of nephritis with both the index and the phenol- sulphonephthalein test. Each serves as a check on the other, and the maximum of informa- tion is obtained in the simplest way possible. u Practical Value of the Method. — Applicability of the method as a guide to diagnosis, prognosis and treatment will depend on further clinical reports, but certain facts have become evident: "An index below 80 is to be considered as abnormal, though not necessarily seriously so. In renal disease an index below 50 is indicative of a considerable degree of impairment of functional ability. The amount of damage to the kidneys, it is believed, is increasingly greater as the index is lower, and tends to approach zero. But a low index may be only temporary, as in the passive congestion of heart failure or in acute nephritis, and may return to normal on improvement of the condition which is responsible for impaired function. The actual figure obtained for the index should be of value in prognosis in renal disease, though renal function alone is often not the determining factor in prognosis. In our ex- perience a low index has at times been the first indication of a serious kidney involvement. When the condition is stationary, life may be maintained for some time with a low index. For example, we have seen patients with chronic nephritis survive for several months with an index of from 5 to 8, and we have seen recovery from acute nephritis after a number of weeks, during which time we have obtained the same figures. In another instance, the patient survived for about a month after the index was as low as 1.2. Such figures, in chronic disease, certainly determine a grave prognosis. But, unless the condition is known to be progressive, it is difficult to give a prognosis with regard to the duration of life. Other aspects of the disease must, of course, be considered in attempting a prognosis. "Progressive decrease in the index, usually associated with a corresponding increase in the concentration of urea in the blood, is of serious import. Two cases have recently been under observation in which such a fall in the index was followed by death within a short time. In one case the fall in the index was the first indication of impending uremia, al- though the first symptoms did not occur until ten days after the discovery of a change in the index. "Use of the index as a guide to dietetic or other treatment of nephritis must depend on further studies. It is doubtful whether the diminished urea content of the blood which follows a diminished nitrogen intake has any direct beneficial effect. Whether a long- continued rest of the urea function will improve that function remains to be demonstrated. On general principles, an impaired function should not be overtaxed, and a restricted protein intake should be advised in cases with a markedly lowered index of excretion. But brutal restriction of nitrogen intake to below the nitrogen requirement of the body does not seem to be indicated in cases capable of excreting normal amounts of urea, though the blood nitrogen may be high and the index low. "The influence of diuretic drugs also requires further study. Here the findings will depend on the type of case studied, and it is necessary to have a satisfactory method for grouping them. Study of diuretic drugs, involving also their effect on chlorid function, is in progress. 11 Application of the index is seriously interfered with when water excretion is greatly diminished, as in passive congestion or in some forms of nephritis. The laws of urea excretion depend on a sufficiently rapid rate of urine excretion, and they fail to apply when the water output is greatly diminished. We make it a general rule not to attempt to apply the index when a rate of urinary outflow equal to at least 500 c.c. in twenty- four hours cannot be attained. Otherwise there are practically no limitations as to its applicability." URIC ACLD (0.2 to 1.0 grams daily). — This is a body of that "purin group" which also includes guanin, adenin, xanthin and hypoxanthin, and the methyl xanthins of tea and coffee, caffein, theophyllin and theobromin. THE EXAMINATION OF THE URINE 211 Purin-poor, Cayenne- pepper sediment. Exogenous pur ins arc those derived from ingested foodstuffs, especially such as are rich in nuclein. Such are thymus gland (sweetbreads), liver, spleen, pancreas, brain, kidney, and the roe of fish. Endogenous pur ins are products of the cell metabolism within the body. ^ Nuclein or nucleo-protcin is the basis for all the purin bodies of the urine, 90 per cent, of the total being uric acid. A purin-rich diet greatly increases the output of exogenous uric acid. A diet of milk, cheese, eggs, fat and vegetables keeps the purin bodies at a minimum though no adequate dietary can be wholly free from nuclein. Uric Acid Sediment.- — As a sediment, uric acid is easily recognized by microscopic examination or by the deposit of a macroscopic substance resembling cayenne pepper. The urinary conditions favoring a uric acid deposit are: (a) Concentrated urine, (b) High acidity, (c) Deficiency of salts and pigment, (d) Excess of the uric acid. The amount of uric acid in centigrams, contained in each liter of the given urine, may be roughly approximated by multiplying the last two numbers of ; Rough the specific gravity by 2, but as a matter of fact, neither the ratio of uric acid to urea nor to total nitrogen is constant. Any sediment may be tested for uric acid by heating with a drop of dilute nitric acid upon a porcelain plate. Upon evaporation a reddish residue appears which strikes a beautiful deep red with dilute ammonia. Quantitative Test. — There is no accurate simple test and the complicated exact tests (Hopkins- Worner, etc.) are not adapted to the practitioner's use in view of the slight clinical value of the procedure. But one approxi- mate method will be given and it, like other quantitative tests, must be applied to a portion of the twenty-four hours' urine to show an actual excess of uric acid. Heintz's Test. — To 200 c.c. of clear urine add 10 c.c. of C. P. HC1 and mix thoroughly. After twenty-four hours filter through a dry filter-paper of known weight. Dry and reweigh. The difference in weights represents the amount of uric acid in each 200 c.c. of urine. Clinical Importance. — The uric acid sediment is not a clinical index of uric acid excretion, and an actual excess of uric acid is much oftener due to a diet rich in nuclein than to other causes. In chronic gout there is a diminished excretion of both exogenous and endogenous purins tending to produce an accumulation of these bodies in the blood, and during, and for several days preceding, an acute attack a more or less decided retention of the latter group occurs.* During an acute attack the excretion rises rapidly only to fall far below normal a few days later. In leukemia the amount of the daily uric acid excretion may be treble the normal and u uric acid showers" may at intervals replace sugar in certain cases of diabetes. * Brugsch and Schittenhelm have found uric acid in the blood of gouty subjects even when the diet was purin-free. Rich in purins. Chronic gout. Acute gout. 212 MEDICAL DIAGNOSIS Old theories upset. Ferment deficiency. Lithemia. — Certain cases of so-called "lithemia" behave like and probably represent irregular gout, but most of the cases so named are examples of faulty diet or mere chronic indigestion* Nevertheless, the recent work upon the physiological chemistry of gout gives to uric acid a renewed importance and indicates that such a condition as the "uric acid diathesis" apart from frank clinical gout may deserve consideration. On the other hand, it has left us once more in the dark as to the causes of uric acid deposits in the joints of gouty subjects inasmuch as late researches show that in gout the blood is neither saturated with uric acid nor does it lose its alkalinity and thus throw this substance out of solution. It would seem that in certain individuals the transformation of purin bases into uric acid and the oxidation of uric acid itself are alike deficient. Gout and its congeners would seem, therefore, to represent an acquired or congenital ferment insufficiency combined perhaps with a tendency to diminished renal permeability for uric acid especially marked in certain chronic arthritic cases. The true cause of gout remains obscure. The presence of an uric acid excess in itself is certainly not the determining factor. URINARY CHLORIDES (10 to 15 grams daily,, usual proportion to urea is as 1 : 2). Rough Test. — Filter the urine if it be not perfectly clear; remove albumin by boiling if necessary (a trace does not matter). Prepare a solution of silver nitrate and distilled water (silver, 1 part; distilled water, 8 parts) Add this, drop by drop, to a portion of the suspected urine, which has been treated with a few drops of nitric acid. A curdy precipitate indicates normal chlorides. Milky turbidity or simple cloudiness shows a marked reduction of the chlorides. Xo precipitate indicates absence of chlorides. A simple quantitative test may be used if desired, its errors being so slight as not to affect its clinical value. Mohr's Test. — 10 c.c. of urine freed from albumin is diluted with 100 c.c. of water, a few drops of potassium chromate solution added (enough to pro- duce a yellow color) and the whole placed in a porcelain capsule. This is then titrated with a standard silver nitrate solution (AgN03 C. P. 29.06 grams to the liter), 1 c.c. of which should precipitate 1 eg. of sodium chloride; a perma- nent and diffused orange color ends the titration and multiplying the number of cubic centimeters used by 0.01 gives the amount of chlorides present in 10 c.c. of urine. The Centrifugal Estimation. — Purdy's method is simple and clinically sufficient. 'test. — Fill one of the graduated tubes with urine to the 10 c.c. mark, add * It is but a few years since "lithemia" was as common a diagnosis as "heart failure," "liver trouble" and the like. It was not only a convenient cloak for ignorance but highly popular with patients be- cause of its kinship with that most aristocratic of ailments, "gout." THE EXAMINATION OF THE URINE 213 15 drops of nitric acid to prevent precipitation of the phosphates (more if the specific gravity be high), add (1 to 8) nitrate of silver solution, mix thor- oughly, and centrifugalize at high speed for fifteen minutes; normal bulk percentage reading is from 10 to 12 and each division represents 0.123 by weight. Clinical Application. — The outpouring of either a serous or fibrinous exudate of slight importance in acute disease may be associated with a marked diminution or total absence of the urinary chlorides. The reappearance of the lost chlorides is one of the clinical evidences of resolution in pneumonia or of the reabsorption of an exudate or transudate. The absence or marked diminution of chlorides in lobar pneumonia is j not pathognomonic of that condition even in the absence of meningitis or j effusions into the great lymph spaces, inasmuch as the same diminution may occur in many other sthenic fevers though usually to a lesser degree. Their estimation is sometimes of slight value in making a differential diagnosis between meningitis and typhoid fever,* they being markedly reduced in the former, and little affected in the latter disease. They are also greatly reduced in acute rheumatism and their sudden entire disappearance without an extension of the joint involvement suggests pericarditis with effusion. In normal individuals a rapid increase of body weight follows the ingestion and retention of the chlorides in quantity and a reduction of weight follows if the substance be withdrawn. Chloride excretion is more or less decidedly diminished in various types of renal disease, in most wasting diseases, in starvation or a milk diet, in cancer of the stomach with obstruction, in severe vomiting and in diarrhea. Relation to Edema and Albuminuria. — It is now believed that the albumin- uria and edema of Bright' 's disease is in some measure due to the retention of chlorides in the tissues. Water retention is favored by the chemical combinations formed by the chlorides, the relative impermeability of the kidney and a poor circulation, hence it is urged that in both incompensated heart disease and nephritis the amount of sodium chloride ingested should be reduced to a minimum if edema is present. The author believes this to be good advice with respect to per- sistent edema of the renal or cardiorenal type but would not advise or prac- tice it as a routine procedure or continue it radically over long^periods. THE PHOSPHATES (normal excretion 2.5 to 3 grams).— Urinary phosphoric acid is met with largely in combination with potassium, sodium, and ammonium (%), to a less extent with calcium and magnesium. It is derived to some extent from tissue and food nucleins and is increased under a vegetable diet or a rich proteid intake. The term " phosphaturia" is probably a misnomer representing merely a condition of reduced urinary acidity which leads to the constant or almost constant presence of the phosphates as a precipitate. It is met with chiefly * E. S. Wood. Of slight importance. Lobar pneumonia. Meningitis. Acute rheumatism. Weight loss or gain. Renal disease. Phosphaturia. 214 MEDICAL DIAGNOSIS Two varieties. Clinical value slight. Of slight importance clinically. in cases of asthenia or temporarily in nervous overstrain, and may accompany hyperchlorhydria. A marked increase occurs in severe anemias, leukemia and wasting diseases in general. A marked decrease is observed in most febrile diseases, with high tem- perature, acute and chronic rheumatism, acute yellow atrophy of the liver, lead or copper poisoning, Addison's disease and hysteria. Phosphates are readily recognized by the methods mentioned elsewhere and their quantitative determination is of too little importance to be de- scribed here. It should be remembered that a phosphatic sediment occurs frequently in normal individuals and many u phosphaturias" are little more than the result of morbid introspection and too careful attention to the appearance of the excreted urine. In ammoniacal urines both the fixed and the volatile alkali combine to form the characteristic crystals so frequently found in the precipitate. THE SULPHATES (normal excretion 1.5 to 3 grams) .—These exist either as preformed or as ethereal or conjugate sulphates. The former run nearly parallel with urea, while the latter follow indoxyl so closely as to justify but slight attention here. These latter are, however, increased by the ingestion of drugs such as creosol or phenol and phosphorus and occasionally without an indoxyl excess. THE OXALATES. — "Oxaluria" is another condition which modem in- vestigation has shelved. The diagnosis was based chiefly upon the presence of calcium oxalate crystals in quantity in the urinary sediment. These occur usually as a result of gastro-intestinal disturbances to which the symptoms formerly attributed to them are more properly ascribed. The relation of the crystals to the for- mation of calculi and their suggestion of disturbed metabolism are the only clinical features of importance. Dunlop has shown that their presence indicates about 25 mg. of oxalic acid to 1000 ex. of urine, but this amount does not exceed the maximum normal. Very frequently they are associated with an increase of indoxyl and sometimes with increased ethereal sulphates without increase of indoxyl. IRON. — This exists in the urine to the amount of 1 mg. but its estimation has no clinical value. AMMONIA (normal 0.6 to 1.2). — The ratio of nitrogen derived from urinary ammonia to total nitrogen is about 5 to 100 and the variation of the two substances under dietetic influence is almost parallel. In cirrhosis of the liver ammonia is usually increased as also in hyper- chlorhydria, pyloric stenosis and acute gastro-enteritis. It is diminished slightly upon a vegetable diet and the administration of fat not only increases it, but causes a corresponding but later increase in the urinary acetone, and such urine may show beta-oxybutyric and diacetic acids. The methods of estimation are too complicated and time-consuming and the results too at- tenuated to be of clinical use and they are therefore omitted. THE EXAMINATION OF THE URINE 21 ALBUMINURIA Albumin in Normal Urine. — Normal urine does not contain a sufficient amount of serum-albumin to respond to certain approved clinical tests if these are properly made; therefore a reaction under such conditions is pathologic. Temporary albuminuria due to exposure to extreme cold, to excessive exertion, profound fatigue and other like causes doubtless occurs, especially in individuals of the asthenic type. Such urines are not normal but temporarily abnormal. Derived Albumin. — On the other hand, the presence of albumin does not of itself prove a nephritis, as both pus and blood yield a portion of their albumin to the urine and any hemorrhagic or suppurative lesion within or communicating with the urinary tract may cause albuminuria. Occasional Absence in Nephritis. — The absence of albumin in a given specimen does not exclude chronic interstitial nephritis, as in that disease the urine may be albumin-free for long periods, appear only at certain times of the day or occur only in definite relation to some exertion, mental or physical, or a dietetic indiscretion. The mere detection of albumin is but a part of the diagnosis, the arterial tension, tests of renal permeability, and recourse to the microscope playing the larger part. One of the commonest sources of error arises from contamination of the specimen by leucorrheal discharge or the pus and blood of urethritis, less commonly from fistulous openings draining abscesses of the surrounding structures. Varieties. — The term "albumin" means in its clinical sense, serum-albumin usually associated with serum globulin, which acts the same, has essentially the same significance and need not be separately sought. NUCLEO -ALBUMIN. — This substance frequently obscures some of the more delicate tests. It is increased after overexertion, in actual inflammation of the urinary tract, especially in purulent accumulations, in leukemia, jaun- dice and in acute infections with marked toxemia. Test. — Nucleo-albumin is readily detected by diluting the urine with three times its bulk of water, rendering it strongly acid with acetic acid and setting it aside until the substance forms a cloud. It may produce confusion if the physician is satisfied with the heat test for albumin and fails to use the acid layer test as well. In the latter the nucleo-albumin ring lies well above (i cm.) the zone of contact. ALBUMOSES. — These, chiefly the secondary (deutero-albumoses), appear in the urine and have some clinical importance because of their association with suppurative processes outside the urinary tract. Their presence, for example, in a pleurisy would suggest empyema; in meningitis, a septic rather than a tuberculous process; in a severe intestinal lesion, dysentery or typhoid rather than tuberculous ulceration; in hepatic disease, abscess or suppurative cholecystitis; in tumors, malignant ulceration. Combined with a leucocytosis, albumosuria speaks positively for infection Transient Albuminurias "Accidental albuminuria. Misleading findings. Vital factors. A clinical nuisance Septic processes. 2l6 MEDICAL DIAGNOSIS Practical value of test. Osteomalacia and myeloma. Altered renal or glomerular epithelium. Multitude of etiologic factors. I by a pyogenic organism or the actual presence of a purulent accumulation or focus. Albumose appears, however, in many non-septic conditions both febrile and afebrile. Test. — Secondary albumoses are precipitated by acetic acid saturated with sodium chloride or the biuret reaction may be obtained as follows: Re- move all albumin by treating the urine with sodium acetate and then with ferric chloride until it produces a deep red color, neutralize carefully with sodium hydrate, boil and filter. Repeat if a potassium ferrocyanide test ap- plied to the fluid shows albumin. Nucleo-albumin and mucin may also need to be first removed if present in quantity. This is readily accomplished by strongly acidulating with acetic acid and filtering after several hours. 50 c.c. of albumin-free urine are then acidulated with HC1 (5 c.c.) and phos- photungstic acid solution added until no further precipitate is obtained, gentle heat is then applied until the precipitate shrinks and collects on the bottom of the receptacle. After decanting, the precipitate is repeatedly washed, dilute sodium hydrate added and the solution warmed until the deep blue becomes a light yellow. After cooling, a dilute solution of copper sul- phate is run down the side of the tube or beaker and a rose color indicates albumose. Practically all cases of so-called peptonuria are albumosurias and their significance is exactly the same. THE BENCE-JONES PROTEIN.— A Clinical Curiosity.— This was form- erly supposed to be an albumose, but is as yet a doubtful body. It appears in cases of osteomalacia and multiple myeloma and constitutes one of the clinical curiosities. Its most characteristic feature is its behavior when heat is applied to urine containing it. Commencing as an opacity at 5o°C, becomes precipitated at about 58°C.,"and increases up to 7o°C. when it begins to disappear and at boiling point has returned to its first opalescence. The presence of the Bence- Jones protein in the urine indicates, almost invariably, multiple myeloma, characterized by pains in the bones, deform- ities of those of the trunk and the Bence- Jones protein. Without discussing the theories relating to the causation of albuminuria, one may say that under certain conditions any or all of the protein bodies found in blood plasma may appear in the urine. THE SIGNIFICANCE OF ALBUMINURIA.— Osier aptly covered the whole field in saying, u the presence of albumin in the urine in any form and under any circumstances may be regarded as indicative of changes in the renal or glomerular epithelium, a change, however, which may be transient, slight and unimportant, depending upon the variations in the circulation or upon irritating substances taken with the food, or temporarily present, as in febrile states." We know that transient albuminuria may follow emotional disturbances, violent exhausting exercise, cold baths, the ingestion of excessive amounts of nitrogenous foods or infections of various kinds. In young persons it may be irregularly intermittent or occur at definite intervals {cyclical), and wholly lack the general and circulatory symptoms of Bright's disease. THE EXAMINATION OF THE URINE 217 Traces of albumin (0.5 to 1 per mille) constitute the "albuminuria minima" so frequently discovered in the course of life insurance examina- Cold weather tions, especially during severely cold weather. Such cases may entirely clear up, but a considerable proportion later become ' fully developed cases of chronic nephritis. Even the true nephritis albuminurias may be regularly or irregularly inter- mittent and often bear a definite relation to the time of day, exercise and meals. A source of . . . ... serious In most cases of, this kind the first urine passed in the morning is free from al- errors. bumin, but thereafter during the day it is present, and' increases as evening approaches. Muscular fatigue increases it, though regulated moderate exercise fre- quently diminishes the albumin output. Cases in which it is affected by mere changes of posture are known as "orthostatic albuminurias." In albuminuric children and young adults a delicate bony framework, weak circulation and tendency to vasomotor instability and low arterial tension frequently coexist with impaired general nutrition and, in the author's opinion, the entire clinical picture most often resembles the asthenia uni- versalis congenita of Stiller which carries with it the visceroptotic habitus so favorable to circulatory renal disturbance. In every case the adequacy of the kidney, as proven by the excretion of solids, special tests, the absence of true casts and of secondary vascular changes, must be the guide to prognosis, and inquiry as to past infections, such as scarlatina and diphtheria, is often illuminating. Unrecognized Chronic Infections. — Every physician who has followed the j recent investigations relative to chronic infections of the tonsils, accessory nasal sinuses, teeth and prostate, or who fully appreciates the frequency of unrecognized Septic foci. tuberculosis and lues, must realize the frequency with which an albuminuria or an actual nephritis rests upon such an etiologic basis. TESTS FOR ALBUMIN.— As a result of an extended series of tests under- taken by Dr. P. A. Hoff and the author, covering both normal and abnormal urines, he is convinced that for the general practitioner the three best tests are: (a) the-heat-and-nitric-acid-procedure; (b) the-heat-test-with-acetic-acid- and-brine; and (c) the-nitric- acid-layer-test which is practical and accurate if per- formed with care and a proper knowledge of its disturbing factors, and should be applied invariably as a check. Every other test used in our experiments gave confusing results when it became a question of determining the small traces of albumin yielding a haze but no definite precipitate. In this connection several other tests are mentioned because of their general acceptance by physicians, but are not recommended. General Considerations. — The essentials of a clinical test for albumin are: (1) Simplicity. (2) A reasonable degree of delicacy. (3) Decisiveness. Simplicity reduces careless or imperfect work to a minimum; if one exceeds a reasonable delicacy he finds disturbing reactions in almost every urine, and, finally, a test must be so decisive as to make unnecessary the more complicated Three best tests. 218 MEDICAL DIAGNOSIS Mere boiling. Nitric acid alone. Layer test. To clear resins. Dark background indispensable. Clear specimen. Avoid urates and nucleo- albumin. Use control tube. Boil upper stratum. Add nitric acid to 4 minims. Stop short. An excellent method. Alternative procedure. tests for disturbing urinary proteids and permit a positive and convincing opinion. Faulty Technic. — The-heat-and-nitric-acid test, as usually applied, does not fulfill these requirements. Merely boiling the urine coagulates both serum-albumin and nucleo- albumin, and precipitates the phosphates. Nitric acid used alone and diffused through the urine coagulates serum- albumin, the primary and secondary albumoses, nucleo-albumin and the resins, and, in concentrated urines, precipitates urates if these be present in excess. The careless application of the layer test (Heller's test) may result in the confusion of the low-lying or, rather, junction- point band of albumin with the higher stratum of nucleo-albumin or resins, or the albumin ring may be obscured in dark-colored urines by the pigment developed at the point of contact. Clouded Urine. — A failure to thoroughly clear the urine before examination is a frequent source of error. If ordinary filtration fails, this is best accomplished by the addition of magnesium oxide or sawdust, not lead acetate, and passing the urine through several thicknesses of filter-paper. Bacterial urine always requires such treatment. Resins may be present and cause opacity if turpentine, oil of sandalwood, copaiba and the like are taken, and bile pigment may precipitate in icteric urines, but both disappear on shaking up with alcohol. Proper Background. — Another astonishingly frequent and unpardonable source of error lies in the failure to Iwld the tube toward the light, but always against a background, such as the coat sleeve or a book. The Proper Application of the Heat-and-nitric-acid Test. — (a) Clear the specimen and set aside a portion of the urine for use as a control and for repetitions of the test. (b) If the urine be extremely concentrated, dilute it with its own bulk of water, if of low specific gravity, add one-fifth its volume of a saturated solution of sodium chloride. (c) Then fiU two perfectly clean and clear test-tubes two-thirds full of the urine and set one aside for subsequent comparison of transparency. (d) Boil the upper portion of the liquid in the remaining tube and directly after boiling add i or 2 drops of strong nitric acid and 1 or 2 drops more if no persistent cloudiness or precipitation appears. Any such persistent cloudiness or precipitate is serum albumin. Caution. — Do not add acid before boiling nor boil again after the addition of the acid. * The Nitric Acid Contact Test {Heller's Test). — Place in a conic glass or test-tube a dram or two of pure nitric acid, and, using a pipette, allow the urine f flow gently down the side of the inclined glass and upon the surface of the acid. * The latter procedure especially will often cause the conversion of large amounts of albumin into a soluble acid-albumin as is readily proven by any one interested. THE EXAMINATION OF THE URINE 219 The albumin ring. Urinary pig- ments. Nucleo- albumin. Mucin. If the mouth of the pipette be placed against the side of the glass, just above the level of the acid, and a very gentle flow established, the result is extremely clean-cut and beautiful.* The tube or glass should be set aside, as two or three minutes may be required to develop the reaction. Albumin, if present, appears as a band or ring at the junction of the two fluids and is more or less distinct in proportion to the amount of albumin present. Urinary coloring matters appear near the surface of the acid, but usually at a point just below the albumin ring, if the test has been properly made. If within ten minutes there ap- pears another ring resembling albu- min, but at a distinctly higher level (0.5 to 1 cm.), one may assume it to be nucleo-albumin. A relative excess of uric acid or acid urates may pro- duce an obviously crystalline deposit if the specimen be over concentrated Urate ring or if the individual from whom the urine was received has fever. f . Mucin, even if present in excess, is usually dissolved promptly and is not a disturbing factor. The heat-and-nitric-acid and the cold-nitric-acid tests as thus applied are excellent and quite sufficient for ordinary purposes. If space permitted, much that is of interest might be said of the urinary chromogens and pigments. If one wishes to bring out certain of the coloring matter, the urine should be placed in the glass and a con- siderable quantity of the acid poured rather briskly down the side. When this is done, the colors are prominently"displayed and the albumin ring, if present, is raised to a level that nearly corresponds to that of uric acid and acid urates, when the test is applied by the first method. Of the two, the heat-and-nitric-acid test is the more definite and positive. As too often carried out, they are most misleading and fallible. Faulty Older Method. — It will be remembered that this method consisted in adding nitric acid, drop by drop, while boiling the urine. The following errors may result from such methods: (a) A small amount * The use of the " horismascope " (see Fig. 64) yields even better results. t According to C. E. Simon, the subsequent appearance of a film-like hoarfrost on the sides of the glass indicates that about 25 grams of urea are contained in a liter of the urine under examination. Similarly spangles of this urea nitrate point to 45 grams, and the separa- tion of a dense mass to 50 or more grams to the liter. It must be remembered that such deductions are not of much value unless the specimen be a part of the twenty-four hours, urine. Fig. 64. -Horismascope: adding the reagent. (Todd.) Robin's method. Relative value of test. To be shunned. 220 MEDICAL DIAGNOSIS Soluble acid- albumin. Soluble alkali- albuminate. Esbach's test. of albumin boiled with an excess of acid might form a soluble acid-albumin and escape detection* (b) In an alkaline or neutral urine with phosphates present in excess, a failure to acidify the specimen might result in the disappearance of any albumin present through the formation of a soluble alkali- albuminate, and neither acid nor alkali albuminates are precipitated by subsequent boiling. Furthermore, according to Purdy, mucin, globulin and albumoses are precipitated by this method. The Potassium Ferrocyanide Test. — Into a clean test-tube pour a dram or two of acetic acid (50 per cent)., to this add twice its volume of an aqueous solution of potassium ferrocyanide (1-20). Shake the mixture and overlay with the suspected urine, as is done in the nitric acid contact test. Albumin, if present, appears at once as a band at the junction of the two fluids. Albumoses may give a cloudiness, and hence the urine should always be heated after the ring is obtained, and its behavior noted. The full amount of acetic acid must be added. Disadvantages. — It precipitates albumoses and nucleo- albumin. Robert's test solution (HN0 3 1 part, saturated solution of magnesium sulphate, 5 parts) may be used as in Heller's test, but is, if anything, too delicate and subject to the same elements of error. Spiegler's Test. — This is too delicate for clinical work, showing one part of albumin in 250,000 of urine containing abundant chlorides. The trichloracetic acid test can be made by dropping a crystal into the urine contained in a small test-tube. It is extremely delicate, partially precipitates albumose and, in concentrated urines, urates, as a distinct upper ring. These three tests may show albumin in all urines, or so nearly all as to rob the rinding of a mere trace of albumin of all clinical sig- nificance. Nevertheless the author has seldom found a dis- tinct ring with trichloracetic acid without confirmatory micro- scopic findings. QUANTITATIVE TESTS FOR ALBUMIN.— Two simple tests suffice for the quantitative estimation of albumin. The first demands the use of Esbach's albuminometer ; the second requires a centrifuge. Both tests are extremely simple in execution, and as no physician's office is complete without a centri- fuge and as the Esbach tube is inexpensive and easily obtained, no hardship is involved in their application. Esbach's albuminometer is merely a glass tube graduated and lettered as shown above. This tube is filled to the letter U with urine, if necessary previously diluted until its specific gravity is 1008 or lower, and a solution of picric acid (picric acid, 10; crystalline citric acid, * The author recently saw a case in which a specimen of urine containing 0.25 per cent, of albumin was reported normal after the application of this test in the faulty manner described above. Fig. 65. Esbach's albuminometer. THE EXAMINATION OF THE URINE 221 20; distilled water, 1000) is added until the level of the liquid has reached the letter R. A rubber stopper is then inserted, the tube is inverted several times to thoroughly mix the urine and test solution, and is then set aside for from twenty-four to forty-eight hours. The albumin is precipitated, and its height, measured by the numerals upon the scale, represents in grams the amount of albumin present in 1 liter (1000 c.c.) of the urine. This method is sufficiently accurate for practical purposes (although peptones, mucins, etc., if present, are precipitated together with the albumin), but is slow and jar inferior to Purdy's direct centrifugal method. Centrifugal Method. — Fill the graduated tube supplied with the centrifuge to the mark 10 c.c. Add 3 c.c. of a 10 per cent, solution of potassium ferrocvanide and 2 c.c. of acetic acid (50 per cent.). Mix thoroughly, set Best clinical 7-7 'x *7 7 method. aside for ten minutes, and thoroughly revolve in the centrifuge until the super- natant fluid is clear and the albumin evenly deposited at the bottom of the tube. Each mark represents Jro c.c. and corresponds to a bulk measure of 1 per cent, or 1 qq of 1 per cent, by weight (Ogden).* The old-fashioned methods Fig. 66. — Electric centrifuge. Fig. 67. — Purdy's graduated tubes for the centrifuge. of estimation by boiling the urine in a test-tube, or by judging the amount by the depth of the ring produced by the contact test with nitric acid are useful, but not sufficiently accurate and introduce too much of the personal equation. On the otherhand, the very exact methods of the chemical labora- tory are laborious, and demand more time than the busy practitioner can give. * If urates are present in excess the supernatant fluid may be replaced by boiling water after centrifugalization and the process continued a short time longer. 222 MEDICAL DIAGNOSIS Rough estimation. Effect of reaction. Color deceptive. Small quantities. A misleading color. E. S. Wood's Approximation Method. — The following classification for rough work is based upon the cold nitric acid test performed as follows: An ordinary wine-glass is half filled with urine, inclined until the liquid nearly overflows and then underlaid with nitric acid, poured in as slowly as possible, until it equals one-third of the urine volume. If then the wineglass be per- fectly clean and placed obliquely in front of a dark background, the observer facing the light, one distinguishes: i. The self-explanatory u faintest possible trace" 2. A very slight trace, i.e., a. faint cloud definitely seen only against the dark background. 3. A trace, visible without background, both from the side and from above but not concealing the bottom of the glass when so viewed. 4. A large trace, i.e., a sharply defined zone, but not flocculent nor wholly opaque when viewed from above (represents about J^o of I P er cent.). 5. A % of 1 per cent, reaction i.e., a sharp, non-flocculent zone obscuring the bottom of the glass. 6. One-fourth of 1 per cent., band flocculent and opaque. 7. One-half of 1 per cent., band dense and flocculent.* PUS. — Pus in the urine is readily recognized by chemic or microscopic tests. As a gross sediment phosphates and the pale urates may mislead the careless observer, but should never cause confusion. Urates are dissolved by heating. Phosphates disappear if an acid be added, whereas both the foregoing pro- cedures will increase a turbidity due to pus. Chemic Test. — Add liquor potassce to the suspected urine and shake the solution vigorously. The persistence of suspended air bubbles and viscidity indicates pus. If the amount be very large or if the liquor potassae be added to the sediment after decanting the supernatant fluid, a gelatinous mass results. T.he microscopic test is more definite when mere traces of pus are present. The addition of a drop of very dilute acetic acid solution to a microscopic preparation clearly brings out the nuclei of pus cells under the microscope. BLOOD {Hematuria, Hemoglobinuria). — In general, acid urines containing considerable blood are dark or smoky, and alkaline urines bright red. Oftentimes, however, its presence must be detected even though the amount is insufficient to color the urine, and, moreover, mere color cannot be depended upon in any case. For the detection of small quantities of blood the microscopic examination, chemical tests and the spectroscope are extremely important, as only the coloring matter may be present either primarily, or later as a result of fer- mentation changes. The color due to poisoning by coal-tar products closely simulates the smoky urine of hematuria. Heller's Test for Blood. — (a) Boil the urine in a test-tube, (b) Add caustic soda and continue the boiling as long as precipitation continues. * It will be seen that such distinctions require much practice and the method can hardly be justified at the present day, but from personal experience in the old Harvard laboratory the author can attest the accuracy there attained. THE EXAMINATION OF THE URINE 223 // blood be present, the phosphatic precipitate is brownish-red and the supernatant fluid, a bottle-green. This test is said to detect 1 part of blood to 1000 parts of urine.* The Guaiacum Test for Blood. — Shake in a test-tube equal parts of old turpentine (or hydrogen peroxide solution) and fresh tincture of guaiacum. Pour this mixture gently down along the side of the tube so as to overlay the urine. If blood or pus be present, a blue band appears at the point of junc- tion. If this be due solely to blood, it persists when the temperature of the mixture is raised to the boiling point, whereas, if pus alone be present, the color disappears. As oftentimes both are present in the urine, the reaction may lack precision.! Comment. — 77 need hardly be said that in all cases of hematuria the micro- scopic examination is the usual and proper test. In the rare hemoglo- binurias the chemical methods find their place. The Sources of Hemorrhage. — Aside from acute Bright's disease, severe acute congestion, and the rare cases of so-called " renal epistaxis," the commonest sources of blood are urinary calculi and new growths. Clots occasionally exist if the blood is from the bladder, or small clots may represent the lumen of the ureters. Blood from the kidney is usually well distributed and lacks clots, and further indications of its source are found in the presence of blood casts and fibrinous casts. If from the kidney pelvis, the blood cells are thoroughly distributed and associated with the peculiar epithelium of that region, and may be due to calculi, acute inflammations, or varicosities. Associated leucocytes in quantity point to inflammation, whether simple, septic or tuberculous. Bladder hemorrhages suggest ulceration, calculi, tumors or acute inflam- mation and, rarely, the filaria sanguinis hominis, may be found together with a chyluria. If from the urethra, the first jet of urine contains the blood or pus, though if from the prostatic portion, it may appear chiefly at the end of micturition. Accidental blood may occur, especially in the female during menstruation, and must always be borne in mind as a possibility. In hemoglobinuria or methemoglobinuria the blood cells are scant or absent but the spectroscope shows the characteristic bands of oxyhemoglobin, reduced hemoglobin or methemoglobin and the chemical tests reveal the true condition. The washed out, swollen "phantom" blood cells so often encountered in old specimens may be overlooked and mislead the novice into a false diagnosis of hemoglobinuria. Conditions Associated with Hemoglobinuria. — This condition occurs in poisoning by nitro-benzol, sulphonal, antipyrin, phenacetine, naphthol, * If the urine be primarily alkaline and its phosphates precipitated one may add some acid normal urine before testing. f If the slightest trace of copper remains from a previously performed Haines' or Feh- Hng's test in an imperfectly cleaned tube, a false reaction will appear. Blood vs. Pus. Renal epistaxis. Renal blood. Pelvic blood. "First jet' blood. Menstrual blood. "Phantom' blood cells. 224 MEDICAL DIAGNOSIS Simple and effective. Excellent test. mushrooms, in severe tropical malaria, and certain rare cases of syphilis, typhus and scarlatina. BILE. — Bile acids and bile pigment are both found in the urine under certain conditions. Bile pigment, if present in considerable quantity, is readily detected by the yellow-tinted foam produced by shaking. Test. — The best simple chemic test is made as follows: Filter the suspected urine several times through the same filter-paper. Drop fuming nitric acid upon the wet paper and watch for the characteristic color-play, viz., orange, red, violet, and green, the last being the essential color. Rhombic crystals of bilirubin are readily obtained by shaking up thoroughly with chloroform, decanting and evaporating the chloroform extract. Marechal's Test for Bile Pigment. — Overlay a portion of the suspected urine in a test-tube with an alcoholic solution of iodine (tincture iodine, 10 parts; alcohol, 90 parts). If bile be present, a beautiful green band appears at the junction point. Haycraft's Test for Bile Acids. — This is made by dropping a pinch of "flowers of sulphur" upon the surface of the suspected urine. If the bile acids are present the powder drops to the bottom of the tube. This old test has been recently studied by Frankel and Cluzet. They find it accurate, sensitive, and, as applied to the urine, very definite. The reaction depends upon the diminution of surface tension and the presence of bile acids indicates the presence of hepatogenous jaundice, though their absence does not exclude it. TESTS FOR GLUCOSE IN URINE.— All clinical tests for glucose in solution depend upon one of the following properties: (a) The fact that when glucose is brought into contact with certain oxides, as for example, those of copper and bismuth, it becomes oxidized at their expense, i.e., acts as a reducing agent. (b) Its ready fermentability. (c) The fact that it is dextrorotatory. The Copper Tests. — The well-known Trommer's test has been superseded Relative value. , by better and more accurate methods, but Fehling's solution is so widely used still as to require a description of the test. This solution is distinctly inferior to Haines 1 modification qnd is so unstable that it must be kept in two parts and mixed whenever needed for use. Fehling's Test. — Directions: (a) Remove albumin by boiling and subse- Test fluid { quent filtration, (b) Pour into a test-tube one finger-breadth each of the follow- ing stock solutions, which when mixed should form a deep blue solution. . Stock Solutions. — Solution A. — Dissolve 34.64 grams of pure, dry, powdered copper sulphate in 200 c.c. of warm distilled water and add distilled water to make 500 c.c. of the light blue solution. Solution B. — Dissolve in 306 c.c. of hot water 180 grams of Rochelle salt. Filter. Add of pure caustic soda, 70 grams. Cool, and add distilled water enough to make 500 c.c. of a colorless solution. Keep in a dark place. Test— Heat test solution to boiling point, add at once 20 to 30 drops of the suspected urine and boil no longer, but in the absence of a reaction set THE EXAMINATION <»F THE URINE aside for from hve to thirty minutes. A positive reaction proves nothing but the presence of a reducing agent unless the ultimate precipitate is red, net yellow or green. Objections to Fehling's Solution. — Fehling's solution as ordinarily prepared is open to : (a) It is unstabh An excess of glucose ob- scures the terminal reaction by becoming caramelized if boiling is prolonged. (c) 77 cannot be applied directly to ammoniacal urine unless the specimen be led. [d) A large number of substances may reduce its cupric oxide. Such are glycuronic and glycosuric acid, alkapton, creatinin, uric acid, and various drugs, such as benzoic acid, chloroform, chloral, glycerin, the salicylates, turpentine, etc. Hence, if :■>:>: uses Fehling's solution for qualitative work, he must bear in mind that it is /.liable as a negative than a positive test. A urine that does not reduce Fehling's solution is free from glucose, but reduction does not conclusively establish its presence. Haines' Solution. — This is a much simpler, more stable and permanent copper solution than that of Fehling. Formula. — Take of pure copper sulphate 50 grains; of distilled water 1 ounce. Make a perfect solution and add, of pure glycerine J-9 ounce; mix thoroughly and add liquor potassa? 5 ounces. Application of Test. — Boil a few cubic centimeters of the solution gently in a test-tube, add guttatim 6 to S drops of the urine, boil gently for a moment only. The color reaction is identical with that of Fehling's solution. All concentrated urines should be diluted before a copf :de. This procedure minimizes the risk of misleading reductions due to drugs and other substances. ALLEN'S TEST.— This is said by Hutchinson and Rainy to have the fol- lowing advantages: [a) Albumin need not be removed. b Trie acid, creatinin and like substances do not affect the reaction. The test derives its value from the fact that acid solutions of sodium acetate precipitate the interfering substances without removing or affecting any glucose that may be present. Test. — In a perfectly clean test-tube heat S c.c. of urine to the boiling point. Pay no attention to any precipitate ('albumin' 1 . Add 5 c.c. of the solution of copper sulphate used in making Fehling's solution (solution A. as described . Cool partly. Add 2 c.c. of a saturated solution of sodium acetate that has been rendered faintly acid by acetic acid. Interfering substances are now precipitated. Filter and add to the clear nitrate 5 cc. of the solution B used in making Fehling's solution. Boil twenty seconds. If sugar is present, the solution becomes opaque and green, and deposits, either immediately -:utes. a fine yellow precipitate. Control Positive Copper Tests. — The tests already given are pla: direct order or their convenience and rapidity, but tlie inverse order of accuracy. Yet error will seldom occur if every sugar reaction is cliecked by the one accurate test for glucose, namely: is Coppery red is true color. Of value in negation. A better test. Avoid overboiling. For albumin- ous urines. Avoidance of error. 226 MEDICAL DIAGNOSIS ^ Quick but inaccurate. THE FERMENTATION TEST.— This test depends upon the fact that glucose is a fermentable substance, and practically the only one that urine ever contains. The Test. — The most convenient apparatus is that of Einhorn. If Einhorn's saccharometer is not to be had, the Doremus ureometer tubes will answer the purpose of proving sugar present or absent. Each step in the process should be checked by comparison with a normal urine, therefore, two tubes are required. Technic. — (a) Boil the two specimens for several minutes, to drive of any air they may contain. (b) Add to each a pinch of tartaric acid in order to maintain their acidity and prevent ammoniacal decomposition. (c) Dissolve in each the same amount of yeast (about one-sixth of a fresh yeast cake is sufficient). If there be any doubt as to the freshness of the yeast, it is well to test it with a control solution of glucose. (d) Fill the long limb of the fermenta- tion tube of the saccharometer or of the Doremus ureometer with urine, and place the two specimens side by side in a warm place. About twenty-four hours are re- quired for complete fermentation and quantitative estimation, but the diagnosis can often be made in a very short time, as the appearance of any considerable amount of gas proves the presence of glucose. By using Einhorn's saccharometer, the amount of sugar may be determined with sufficient clinical accuracy by the scale measuring the volume of gas produced. Rougher Method. — Lacking any form of fermentation tube, the test may , be made by first taking the specific gravity of the two specimens, to one of I which yeast is added. Both are then set aside in a loosely stoppered flask or bottle and in a warm place. If glucose be present, fermentation occurs, the specific gravity is thereby lowered and each degree of density lost roughly corresponds to i grain of glucose to the ounce of urine (0.21 gram to 100 ex.). The specific gravity sJwuld not be taken the second time until the urine has cooled to the temperature it had when the first estimate was made. QUANTITATIVE ESTIMATION WITH WHITNEY'S REAGENT.— (Much used but not recommended). — In addition to the previously described tests may be mentioned that of Whitney, which, more rapid than the fermen- tation test, but inaccurate, depends upon the decolorization of an am- monic-cupric-sulphate solution. Fig. 67a. — Einhorn's saccharometer. THE EXAMINATION OF THE URINE 227 Test. — One dram of this solution is heated to the boiling point and the urine is added drop by drop, the mixture being boiled for from three to five 1 seconds after each addition. If no change occurs, the process is continued until 10 or 15 drops have been added. If sugar be present, the blue color begins to fade, and is finally entirely removed, leaving a colorless solution. The amount of sugar present is then estimated by the following table: If reduced by minims It contains to the ounce Percentage I. 2. 3- 4- 5- 6. 7- 8. 9- 10. 16 or more grains 3 . 33 5-33 4 3.20 2.67 2. 29 2 1.78 1.60 grains grains grains grains grains grains grains grains grains .1.67 .1.11 .0.83 .0.67 0.56 0.48 0.42 0.37 o.33 Caution. If the amount of sugar be large, as indicated by the loss of color following the addition of 1 drop, the urine should be diluted by doubling or trebling its j Dilution volume by the addition of distilled water, and the result then obtained must be multiplied by 2 or 3, as the case may be. The duration of the boiling period must be neither more than jive nor less than three seconds. In the author's hands it has proven far inferior to the fer- mentation test, yet convenient for rapid rough w T ork. THE POLARIMETER.— Direct estimation of the sugars by this means is by far the most satisfactory method and requires no special training, but the instrument is somewhat expensive. The percentage of sugar is read directly from the vernier scale in the clinical instruments, such as Ultzmann's, but it is necessary to decolorize the specimen with lead acetate and magnesium oxide, if necessary, to attain a clear solution. The urine must be albumin- free and the containing tube dry or, if containing water, it should be rinsed out with some of the urine to be tested. LEVULOSE. — Levulose is abundant in ripe fruits and honey, is absorbed unchanged and occasionally appears in the urine, yet it can be taken in quan- tity in diabetes without causing a marked excretion, and in ordinary gly- cosuria may replace cane-sugar or glucose in the diet. Instances of pure levulose diabetes have been reported, but they are exceedingly rare. // 100 grams of honey be taken on a fasting stomach by a non-diabetic not more than 10 to 15 per cent, will show levulosuria, but in diseases of the liver, such as cirrhosis, carcinoma and syphilis, the same test may result in a marked excretion and indeed the same substance may appear spontaneously in such cases. Test. — The polarimeter shows rotation to the left, but the substance reacts to fermentation and Fehlings solution exactly like glucose. For identification, therefore, one must often use Seliwanoffs test. Add to 10 c.c. of urine (showing levo-rotation) a little resorcin, and 2 c.c. of dilute HC1: a bright red reaction appears on heating if levulose be present. I A glucose substitute for diabetics. Levorotatory. 228 MEDICAL DIAGNOSIS Appears post partum. Specific test. Non- fermentable. Levorotatory and non- fermentable. Acidosis. LACTOSE appears in the urine of women after childbirth (not during pregnancy), and more frequently in those who do not nurse the child (80 per cent, as against 20 per cent.). It is most abundant about the fifth month after delivery and seldom exceeds 0.5 per centr Rubner's Test. — // reduces Fehlings solution and is fermentable with diffi- culty, but whenever any sugar reaction appears in women after delivery Rubner's test should be applied: To 10 c.c. of urine are added 3 grams of lead acetate, the resulting precipitate is filtered off and the filtrate heated until it assumes a brownish color, and again after the addition of ammonia. The appearance of a brick-red color and a cherry-red precipitate indicates lactose if there be more than 0.3 per cent. Specimens of high specific gravity should be diluted one-half and less amounts require evaporation of the urine and a test of the residue. PENTOSE. — After the ingestion of large quantities of fruit, or more rarely after taking excessive amounts -of vegetables, coffee, tea or milk, pentose may appear in sufficient amount to reduce Fehlings solution slowly and atypically. A very few cases of true pentosuria with otherwise unimportant symptoms have been observed. It does not yield gas production by fermentation even though the pentoses are thereby decomposed, which differentiates it from the more important substance, glucose. Bial's Test for Pentose. — Test Solution. — One gram of orcin and 30 drops of 10 per cent, ferric chloride solution are added to 500 c.c. of concentrated hydrochloric acid. Test. — To 10 c.c. of the solution 5 c.c. of the suspected urine is added and the mixture raised to the boiling point but no further. A green precipitate on cooling indicates the presence of pentose. If the urine has shown glucose this reaction will be imperfect. F. C. Wood recommends short preliminary fermentation with a pure culture of saccharomyces in such cases. MALTOSE. — Its chief interest lies in its presence in certain cases of pan- creatic disease, but the tests are not suitable for the practitioner. GLYCURONIC ACID. — This substance may in certain combinations reduce Fehling's solution, but it has no definite clinical significance, does not undergo fermentation with yeast and is levorotatory in acid solution. The only specific test for this substance is the complicated one of Neuburg, a description of which may be found in the physiological chemistries. ACETONE, DIACETIC ACLD AND OXYBUTYRIC ACID.— Although oxybutyric acid as the mother substance plays a basic part in acidosis, one need only consider here the clinical recognition of the two former substances. A distinction may be drawn between the diabetes of a severe and that of a mild type by the behavior of the acetone and diacetic acid as affected by diet. These substances may be found in conditions other than diabetes and in this ailment are prone to appear if the diet is rigidly and excessively proteid and fatty and disappear when a proper regimen is established, but if they persist in excess in a case of diabetes the case is a bad one and the end not far distant. (See " Diabetes.") THE EXAMINATION OF THE URINE 229 Acetone and diacetic acid have essentially the same significance, but the former precedes the latter and should be sought in diabetic urines if diacetic acid is proven to be absent. DIACETIC ACID.— Test.— If a few drops of the tincture of ferric chloride be added to the freshly passed urine containing diacetic acid, a bordeaux-red appears together with a precipitate of phosphates. For accurate results these should be allowed to settle or be filtered out and the addition continued.* Heat should be applied and should cause a diminution of intensity in the color on boiling if it be due to diacetic acid. The presence of diacetic acid indicates the presence of acetone to an amount of at least 0.02 gram in the twenty-four hours' urine, and is seldom absent when the daily acetone excretion reaches 1.5 grams. Acidosis. — Diacetic acid in the urine, with or without oxybutyric acid, indicates acidosis. This represents a condition of the blood inviting fatal coma in cases of diabetes and demanding immediate recourse to alkalies, periods of starva- tion, the introduction of carbohydrates to tolerance and the withdrawal of fats and diminution of proteids. Increased diacetic acid excretion with coincident diminution of acetone is said to be an immediate forerunner of diabetic coma. ACETONE. — LegaTs Test. — Distil a few cubic centimeters of urine by using a simple distillation flask with its neck corked and its lateral arm lead- ing into a test-tube or ordinary flask; a bunsen burner or alcohol lamp completing the outfit. The distillate collected in three or four minutes is treated with a few drops of a fresh solution of sodium nitro-prusside, a few drops of acetic acid are added and the mixture rendered alkaline by sodium hydrate. If acetone be present a red appears deepening to carmine and purple-red. Lieben's Test. — Add to distillate a few drops of Lugol's solution and sodium hydrate. If acetone is present it will form a macroscopic or micro- scopic sediment of the star-like yellow crystals of iodoform, and on heating the characteristic odor may appear. The excretion of acetone may promptly follow the withdrawal of carbo- hydrates in diabetes and in such cases is removed usually by the adminis- tration of even relatively small amounts of such foods. As stated previously, the best, most effective and. in fact, obligatory method of relieving the acidosis of the diabetic lies in brief periods of total starvation, administering sodium bicarbonate until the urine is neutral or alkaline, and adjusting a carbohydrate intake to the tolerance of the patient. Acidosis in Non-diabetics. — Acidosis may occur in- many conditions other than diabetes. Among these are advanced gastric or intestinal malignant growths, locomotor ataxia, melancholia, prolonged chloroform anesthesia, severe * Crofton states that color due to ingested drugs is permanent, whereas that due to diacetic acid soon disappears. Use fresh urine. Filtration important. An ominous symptom. Simpler method. 230 MEDICAL DIAGNOSIS Chloroform. Light and leases. Avoid over- illumination. Misleading objects. typhoid, senility, terminal cardiac incompensation with general dropsy, and many other conditions. It should always be sought for and if present corrected in cardiorenal insufficiencies, and in stuporous states or low delirium associated with pro- found exhaustion or inanition. The Preservation of Urine for Microscopic Test. — As previously stated, the preservation of specimens is best accomplished by the addition of a slight excess of chloroform which is easily removed by heat before any tests are applied. Many agents may be used if the sediment alone is to be examined (for- malin, chloral hydrate, thymol, boracic acid, etc.), but are likely to cause some confusing reactions in the tests for albumin or sugar. THE EXAMINATION OF URINARY SEDIMENTS.— The accurate microscopic examination and correct interpretation of urinary sediments demand a thorough knowledge of the special technic involved. Gross error is possible in two directions: (i) Through failure to detect important abnormal elements. (2) Through misinterpretation of the elements found. Every physician must not only own a microscope, but be able to use it, and no time can be more profitably employed than that which is spent in acquiring a correct technic. He who graduates from the schools of today is, or at least should be trained to a degree that will enable him to do reason- ably accurate work in this line. On the other hand, many excellent men of the older generation through lack of early training and opportunity are still sadly deficient in this important branch of clinical medicine. In many med- ical schools, moreover, even at the present time, the training is wholly inadequate. Illumination. — In examining a urinary sediment microscopically, the first essentials are correct focusing and a dim light. Every microscope should be provided with an iris diaphragm and a nose- piece holding three objectives, one low-power, one medium, and for the third, a high-power oil-immersion lens. In urinary work only the first two are required, save in those cases in which the tubercle bacillus is the object sought. The physician should commence operations with a dim light and his low-power lens (1 inch or J^ inch objective), this being by far the best for finding casts as it distinctly shows their outline and gives a larger field. He should then slightly increase his light and bring his medium-power objective (J4 to }/§ inch) into focus. This brings out the structure of casts and renders distinct any cellular elements or crystals that may be present in the field. Having once found any object of interest, the lenses and the illumination may be changed at will. Substances Found in Urinary Sediments. — The following are the inorganic substances most frequently found in urinary sediments: (a) Extraneous material, such as fibers of cotton,- linen, wool or silk, various vegetable forms from the rinsing water, if it be not distilled, starch grains, etc. (b) Phosphates. — The macroscopic appearance of the phosphatic deposit is well known. This grayish-white material so often mistaken for pus is THE EXAMINATION OF THE URINE 2 3 I composed of amorphous calcium and magnesium phosphates and their ready solubility in mineral acids at once identifies them. They are found only in alkaline urine, and, if ammoniacal fermentation has occurred, will be asso- Fig. 68. — a. Calcium phosphate, b. Calcium sulphate. (After Jakob.) Fig. 69. — Calcium oxalate crystals. ciated with beautiful crystals of the triple phosphate. Calcium phosphate may also appear in crystalline form. (c) Urates. — The ordinary deposit of urates occurs in moderately acid, 232 MEDICAL DIAGNOSIS "Brick-dust' deposit. concentrated urine during the process of cooling or when exposed to an unusual degree of cold. The color varies from yellow to rose-red, the latter constituting the so-called brick-dust deposit (sedimentum lateritium). Fig. 7.1. — Ammonio-magnesium (triple) phosphate. Fig. 72. — Uric acid crystals. Upon application of heat they promptly disappear. When nitric acid is added to a urine rich in urates, a deposit of nitrate of urea is formed. The deposited urates are amorphous, excepting only the ammonium urate, which THE EXAMINATION OF THE URINE 233 occurs in ammoniacal urine as the so-called thorn-apple crystals (see Fig. 74). a Fig. 73 — a. Cystin. b. Leucin. Fig. 74. — Calcium carbonate. (After Jakob.) (d) Uric Acid. — Uric acid may be precipitated from any urine, if con- centrated, during the so-called acid fermentation or in hot weather when the 234 MEDICAL DIAGNOSIS Cayenne pepper deposit, high temperature prevents precipitation of the urates. Excessive acidity and concentration or a pathologic excess may occur in certain conditions, but, when passed, urine should never contain the crystals as a precipitate. The macroscopic deposit resembles cayenne pepper. The microscopic appearance : is best shown by the plate (see Fig. 71). (e) Calcium Oxalate. — This rarely forms a visible sediment and is ab- normal if found in urine freshly passed. The crystals are characteristic and unmistakable (see Fig. 69). Leucin, tyrosin, and cystin are rarely seen, but may be readily recognized by comparison with the illustrations (see Figs. 72, 75). (J) Calcium Carbonate. — This is occasionally precipitated with the 'earthy phosphates. Usually it is amorphous but occasionally it forms crystals Fig. Ammonium urate. Effervescence. Normal vs. Abnormal. Easily overlooked. Crenation. shaped like a dumb-bell. It is easily recognized by the effervescence produced when a mineral acid is added (Fig. 73). (g) Blood. — Erythrocytes. — The blood as it appears in the urine may be quite normal in appearance or, on the other hand, be so changed as to make its recognition difficult. If hemorrhage has taken place in the urethra, pros- tate, bladder, ureters or in the pelvis of the kidney, and the urine is acid and fresh, the red corpuscles appear as yellow biconcave discs, with rounded edges and a light central portion. Phantom Cells. — If, on the other hand, the hemorrhage has taken place into the cortical portion of the kidney, the urine has stood for some hours or is alkaline, the corpuscles may become pale and swollen, their diameter lessened and they may appear as mere shadowy circles and as such are easily overlooked. Crenation of the normal cells mav also occur in a urine that is THE EXAMINATION OF THE URINE 235 deficient in salt. Such cells have irregular, star-like processes along their border, but retain the yellow tinge of the normal cell. (//) Pus. — Pus in quantity is in most cases easily detected by the chemic test. The pus cell as seen under the microscope is identical with the white cell seen in a smear preparation of normal blood but is less easily recognized as such in the urine. /;/ the acid urine the pus cells are usually larger than the red cells, are color- Differentia- less, granular and, as a rule, in fresh specimens, their nuclei may be readily distinguished by careful focusing. The presence of these nuclei serves to distinguish them positively from the red cells and any doubt upon this point may be readily removed by allowing | a drop of very dilute solution of acetic acid to run beneath the cover-glass, maneuver. tion. Fig. 76. — Tyrosin. assisting the process, if necessary, by laying the edge of a piece of filter or blotting paper against the opposite edge. The acetic acid dissolves the granules and brings out clearly the cell nuclei, but unless very dilute, will destroy any hyaline casts that may be present. In ammoniacal urine, the pus corpuscles are soon destroyed, becoming agglutinated and losing their structural characteristics. This maneuver is also useful in differentiating the leucocytes from renal cells. Varying Significance of Pus in the Urine. — As to the significance of pus ! Diagnostic in the urine, it may be remembered that: (a) Pus that comes with the first jet of urine, the remainder being clear, is from the urethra. (b) A moderate amount of pus, appearing in an acid urine, is usually from the renal pelvis, but may be due to tuberculosis of the bladder. 236 MEDICAL DIAGNOSIS (c) Large quantities of greenish pus point to rupture of an abscess* in the urinary passages or to a pyelonephrosis. (d) Pus in a urine which is ammoniacal when passed is usually, but not always, from the bladder. In all cases the diagnosis must depend upon the character of the associated epithelium and the presence of casts or specific microorganisms. (i) Spermatozoa are easily recognized by their well-known form. (j) Bacteria and Yeasts. — Bacteriurea. — Aside from the tubercle bacillus, many forms of bacteria may be found in the undecomposed urine, and their presence may be unattended by symptoms or accompanied by a variable amount of irritation of the bladder. So, also, in fermenting urine one finds Fig. 77. — a, b. Various forms of fungi and bacteria, c. Pus cells before and after treat- ment with acetic acid. d. Various forms of red blood cells. both bacteria and spores. The spores are highly refractile and tend to form chains. The most important bacterium is the tubercle bacillus, only to be recognized by such staining methods as are described elsewhere. The ordinary bacterial urine is persistently cloudy, has a musty odor, and presents on shaking a swirling appearance, as if fine grains of sand or dust were put in motion. (k) EPITHELIUM.— Limits of Differentiation.— In spite of the efforts put forth by microscopists, the exact differences existing between the epithelial cells of different portions of the urinary tract have been determined only in part. Such variations are shown by the plates, but must be learned from the careful study of specimens obtained from known cases of cystitis, nephritis, etc., a mere description being of slight value. * Most commonly prostatic. THE EXAMINATION OF THE URINE 237 »The renal cell as seen in the urine is usually small, though almost double the size of a red blood cell, round or cubical, and mononuclear. Cells from the straight tubules are somewhat larger and have a more irregu- FiG. 78. — Renal cells. Various forms, including compound granule cells. Fig. 79. — Bladder epithelium. {Various forms.) lar shape, being sometimes polygonal or cubicular, but, as contrasted with the leucocyte, all renal cells are mononuclear * * Degenerated cells may of course show no trace of a nucleus. Always mononuclear. 2& MEDICAL DIAGNOSIS Pelvic cells. Pavement epithelium. Significance. In cases of "obstructive" jaundice the renal cells are often distinctly bile- stained. Caudate cells arranged in overlapping layers are often described as the characteristic cells of the renal pelvis, but, as a matter of fact, they represent only the superficial layer, and are seen only in early or mild cases of pyelitis. The cell from the deeper layer strongly resembles the renal cells. Ureteral cells are spindle-shaped: Bladder epithelium is large, mono- or polynuclear, and generally of the well-known tessellated or pavement variety. Such cells often occur in aggre- gations, may be distinguished from vaginal epithelium only by the fact that the cells are somewhat smaller, never overlap, and occur in a single layer. Fig. 80. — a. Epithelium from renal pelvis, b. Vaginal epithelium. Bladder cells from the middle layers are smaller, often somewhat drawn out, or perhaps definitely "tailed." Those of the deep layer may be round, cuboid or polygonal. All carry a vesicle-like nucleus. Vaginal epithelium is rather larger : the cells overlap like the shingles on a roof, and are likely to occur in masses consisting of several layers. The epithelial cells from the neck of the bladder, prostate, and the calices of the kidney pelvis are almost identical. An absolute differentiation of the epithelial cells in a urinary sediment is oftentimes impossible and will often demand the corroborative testimony of other findings. Fatty Renal Cells and Compound Granule Cells. — The former are much smaller than the latter which are large, round, bulging with refractile granules THE EXAMINATION OF THE URINE 239 and frequently spiculated by fatty crystals. They have no exclusive disease relation, but may be found in any form of renal lesion characterized by fatty casts and in other chronic inflammatory and ulcerative lesions of the urinary tract. Renal cells reflect the same changes as are shown by the various types of casts. CASTS. — Casts are of two kinds: (1) The true cast, which has its origin in an exudate from the tubules of the kidney. (2) The pseudo-casts, or cast- like bodies, which may or may not originate in the kidney. True Casts. — The exact nature and source of the true casts are not positively known. Whether they consist of disintegrated and modified epithelium, or a morbid secretion of the epithelium itself, or are simply a coagulated albuminoid transudate from the blood, the fact remains that they appear clinically as casts Fig. ii. — This figure shows the appearance of a group of casts under correct dim illumination. of the renal tubules, having to a great extent a form and caliber corresponding to that portion from which they come, and appearing hyaline, waxy, fibrinous, granular, fatty, epithelial or bloody, according to the nature and extent of the underlying pathologic changes. If we assume, for convenience of description, that their basis is that pathologic change known as hyaline degeneration, it becomes very easy to understand most of their modifications. Such a process would lead ordinarily to the formation of a hyaline cast. If the granules of the degenerated cell adhered to or became intermixed with the deposit, a granular cast would result, and this would be finely or coarsely granular, light or dark, according to the activity of the pathologic process. Fatty degeneration in the cells would be reflected in the fatty cast. Adherent Exact nature unknown. Possible origin. Varieties. A convenient hypothesis. Hyaline. Granular. Fatty. 240 MEDICAL DIAGNOSIS Epithelial. desquamated cells would form epithelial casts; adherent blood cells, the blood cast, etc. A Reasonable Assumption. — It is reasonable to suppose that the basis is the same for all varieties, and that in the hyaline, waxy, and fibrinous casts we have but slight variations in fundamental structure, though the conditions attending their presence maybe quite different and distinct, and their clinical significance definite and important. The Hyaline Cast. — This is transparent, and shows an apparently homogen- eous structure; its size is variable, its ends rounded, and its sides nearly parallel. Its shape is best shown in Figs. 80, 84. Unless careful focusing and proper shading of the light be employed, it will certainly escape detection. Representing, as these hyaline casts do, the least degree of pathologic or at least of inflammatory change, it becomes at times a difficult question io determine the significance and importance of an occasional cast. Albuminuria minima. Fig. 82. — This figure shows the obliteration of same group by high illumination. Some observers report them as present in nearly every urine if the centri- ! fuge be employed, but such has not been the author's experience. Occurring alone and unassociated with albuminuria or other symptoms pointing to dis- eased kidneys, it must be admitted that their significance is less grave than would have been assigned them by the older teaching. It is certainly true that they may represent transient and hence often negligible conditions or localized rather than general renal changes, but as a persistent constituent of the urinary sediment they still demand serious consideration and have lost little of their old significance. It is also a much debated question as to whe- ther they are ever found without some degree of albuminuria and, according to E. S. Wood, the hyaline cast is always associated with the pale very finely THE EXAMINATION OF THE URINE 241 granular cast.* It rapidly disintegrates in alkaline urine or in that treated with acetic acid. Significance.— The chief significance of the hyaline and finely granular cast, existing alone, is found in its special relation to acute and chronic infec- tions, acute or chronic intoxications, chronic passive renal congestion, and the early stages of arteriosclerotic kidney, and true interstitial nephritis. Infection and Toxemia. — We are but just beginning to appreciate the part played by persisting foci of chronic streptococcic infection, and by other forms of persistent or recurring toxemia in the etiology of nephritis. The readiness with which even a marked albuminuria, associated with hyaline cylinder showers, may be induced by heavy drinking is apparently little appreci- ated. In the author's practice this has several times led to the detection of the " sneak drinker." a - Hyaline and finely granular forms. Isolated findings. Fig. 83. — a. Waxy casts, b. Fatty and fat-bearing casts. Fibrinous casts closely re- semble waxy casts but are always yellow or brown. The Waxy Cast. — This is dense but highly refractile and is usually relatively short and of large size. It is either without color or slightly gray, never carrying the yellow or brown of its simulator, the fibrinous 'cast, stands out as clearly upon the field as does the triple phosphate crystal, and, once seen, is never forgotten. It points to one of three conditions: amyloid kidney, advanced chronic paren- chymatous nephritis and the terminal stage of interstitial nephritis.] * This corresponds to the author's own observations as applying to ordinary clinical work and to true casts and seems to have a logical pathologic foundation, t Ultzmann states that it may be present in tuberculosis of the kidney. 16 Alcoholic excess. Unmistakable. Commoner associations. 242 MEDICAL DIAGNOSIS Forerunner of death. Active or subsiding inflammation. Inflammation. Important variety. Good or bad omen. Epithelium- bearing. In amyloid kidney, it appears earlier than in interstitial nephritis. Indeed, in the latter it marks the beginning of the end, and cases of contracted kidney in which it is found will usually terminate fatally within one year. The Fibrinous Cast. — This misnamed cylinder resembles the waxy cast save in color. It is always yellow or even brown, deriving its color from blood pigment, and, as might be expected, points to an active or subsiding inflammation; ordinarily to acute Bright's disease. The Blood Cast, and the Brown Granular Cast. — This points to acute inflammation as does the brown (dark) granular cast. If, as is usually the case, the cast carries washed-out cells (abnormal blood) it indicates slow effusion of blood or its high origin; if normal blood, more abundant hemorrhage or an origin in the straight tubules or pyramids. Granular casts. Light and dar£. The dark granular cast is actually a blood-pigment cast. The Finely Granular Cast. — The special significance of this common form has been discussed together with that of the hyaline cast. The Coarse Granular Cast. — This is usually associated with fibrinous or waxy casts. The Fatty Cast. — This is most frequently seen in convalescent cases of acute nephritis, or in chronic parenchymatous nephritis. True Epithelial Casts. — These occur only in active or subsiding, acute or subacute inflammation, in acute Bright's disease, or the subacute exacerbation of a chronic parenchymatous nephritis. Many casts carry here and there an epithelial cell and should be so described in case reports, yet these cannot properly be called epithelial casts. Pus Casts. — These are found in suppurative disease of the kidney or in THE EXAMINATION OF THE URINE 243 pyelitis extending to the straight tubules and frequently require treatment with dilute acetic acid to distinguish them from certain epithelial casts. Significance and Associations of Casts. — Hyaline and finely granular casts indicate: (a) Interstitial nephritis, (b) Amyloid kidney, (c) Chronic congestion of the kidney. They are also frequently found in acute and chronic infections and intoxications and even in asthenic albuminurias of the orthostatic or adoles- cent types, though in many or most of such cases some chronic obscure infection exists (tonsils, teeth, nasal accessory sinuses, cryptogenetic tuber- culosis, etc., etc.). Waxy casts indicate as stated : (a) Terminal stage of chronic interstitial nephritis, (b) advanced parenchymatous nephritis, (c) amyloid kidney. Fig. 85. — a. Blood cast and hyaline cast carrying red blood cells, b. Leucocyte or pus cast. c. Hyaline cast carrying leucocytes, d. Epithelial casts. Acute and Subacute Nephritis. — In these ailments one finds: (a) Fibrin- ous; (b) blood; (c) epithelial; (d) hyaline; and (e) dark granular casts. Convalescence from Acute Nephritis. — rHere one finds fatty, dark granular, epithelial and hyaline casts. Uncomplicated Chronic Parenchymatous Nephritis. — In this disease one finds fatty, hyaline, and finely granular casts, and with any decided disturbance, epithelial casts. Sources of Error in Searching for Casts. — Cast-like Forms. The amor- phous urates are frequently grouped in cast-like forms and similar accumu- lations of bacteria and other sedimentary substances may perplex the tyro. They will seldom or never deceive the trained eye as they lack the definite linear boundaries of the genuine cast. Urates, moreover, are promptly dis- solved by heating the preparation. More deceptive still are the cylindroids. Indicate suppurative focus. Misleading forms. Pseudocasts. 244 MEDICAL DIAGNOSIS Mucous cylindroids. They are usually longer and more band-like than the hyaline cast, and more likely to be convoluted or twisted; usually they take the form known as mucous cylindroids which occur in many non-albuminous urines and cannot be mistaken for true casts as they appear flattened and ribbon-like, often | with frayed ends and faint longitudinal striation. Demand Typical Forms. — The author believes that fewer casts would be important rule, reported in otherwise normal urines if the observer regarded all doubtful forms as disproven until he could find in the same urine a definite cast of the ordinary size and form, and with both ends rounded. If of renal origin, the unusual will certainly be accompanied by the common form. Cylindroid Storms. — In certain cases, periods of mental depression are Cast showers. I accompanied by showers of spurious casts without the slightest change in Fig. 86. — Spermatozoa and associated substances in urinary deposit, a, a, a, a, Spermatozoa, c t c. Spermatozoa, tail out of focus, d, d, d. Amyloid corpuscles, e, Prostatic cast. g. Crystals, h. Lecithin-granule cells, k, k, k. Epithelium. the chemical constitution of the urine and in convalescence from a toxic nephritis of mild grade repeated showers of true casts may be observed. "Showers" of short granular cysts may precede the onset of a diabetic coma and in the exacerbations of actual nephritis the great and abrupt increase of casts in the urinary sediment sometimes justifies the term "shower " though with less aptness than in the other instances here detailed. Prostatic Plugs. — These may closely resemble the large hyaline or fibrinous cast, but usually carry, or are associated with, spermatozoa, and evidence of prostatic irritation or inflammation. THE GONOCOCCUS— As indicating the infectivity of any persistent secretion after urethritis, however remote the original attack, the presence of gonococci is important. THE EXAMINATION OF THE URINE 245 Method. — The usual smear is made, dried in the air and fixed, and, indeed, may be made by the patient if no discharge is present save in the early morning or at irregular times. Ordinarily Jenner's stain or the alkaline methylene blue is sufficient. The specific cocci appear like pairs of coffee beans with flat surfaces apposed and almost in contact and lie for the most part within the pus cells. If in doubt, one should apply Gram's stain, the organism being Gram-negative. In rare instances it may be necessary to use cultural methods as it is claimed that the micrococcus catarrhalis and the diplococcus intracellularis meningitidis are also negative to the Gram stain. Shreds. — The so-called urethral thread, though common after gonorrheal infection, indicates no more or less than chronic congestion of the deep urethra. Fig. Gonococcus. Fig. 88. — Tubercle bacilli in urine. Observe tendency to form groups. EHRLICH'S TYPHOID DIAZO REACTION.— This test was intro- duced by Ehrlich in 1882, and, after meeting with much overpraise as well as . much opposition and criticism born of misunderstanding and mis- application, has at last been accepted at its true value in many of the in- portant clinics. Solution Required.— Solution A . — Hydrochloric acid, 50; distilled water, 1000; sulphanilic acid, q.s. ad. sat. (It should be thoroughly saturated.) Solution B. — Sodium nitrite (not nitrate), 0.5 per cent. (j£ of 1 per cent.) solution in distilled water. Solution C. — {Test solution.) — One hundred parts of A plus 1 part of B. The original test solution of Ehrlich was made by adding to 40 parts of solution A 1 part of solution B. This the author has slightly modified by using 100 parts of A to 1 of B, with the effect of eliminating many disturbing factors and doubtful reactions. Dr. C. E. Simon suggested the ring method of testing described below. Technic. — Take equal parts of solution C and the urine. Shake thoroughly and add aqua ammonia in excess, allowing it to run gently down the tube so as to overlay the mixture below. If the reaction be present, a deep red band appears at the line where the ammo- nia meets the mixture. When shaken, it yields a pink or rose-colored foam, and, after standing several hours, a green precipitate forms. All-important Rules. — The following rules must be carefully observed: (1) Use fresh urine. (2) See that the reaction is acid and the urine filtered. (3) Use a freshly mixed test solution. (4) Keep the sodium nitrite solution in a black bottle and in a cool place and renew it frequently {the sulphanilic solution Usually intracellular. Gram- negative. "Tripper Faden." True value established. Author's modification. Terminal reaction. Strict adher- ence to detail essential. 246 MEDICAL DIAGNOSIS Color reactions. Absurd errors. Sources of confusion. Constant in severe typhoid, Differential value. Value in negation. Exact cause unknown. Retained waste. keeps indefinitely). (5) Hold the tube near, but not against, a white background, the source of light being behind the observer. Artificial light should not be used. (6) Accept no color but a distinct red, and regard no reaction as a true one in which the solution when shaken does not yield a pink foam. False or imper- fect reactions occur in which the band is of the proper color, but the foam is yellow or brown* One may oftentimes follow the imperfect but suggestive reaction of early typhoid to its typical manifestation a day or two later. The most absurd errors have arisen from a failure to observe the exact technic and precautions here outlined and adverse reports under high author- ity have been based upon the use of sodium nitrate instead of the necessary nitrite, or of weak instead of strong ammonia, and indeed one eminent observer omitted the end reaction altogether and naturally failed to get consistent results. Others have accepted the meaningless yellow and orange reactions with confusingly catholic positive results, or have even used a 5 per cent. solution of sodium nitrite (10 times the proper strength). True Value of the Reaction. — The test is not pathognomonic, as was originally maintained by Ehrlich, but is constant in all severe forms of typhoid, appearing sometimes as early as the fourth or fifth day, though more generally at the end of the first week or ten days, and persisting until the fever begins to decline. The importance of the test is at the present time of course greatly diminished by the availability and specificity of the agglutination test and the even better, but less available, blood-culture method. If the test is applied according to the author's method the true and com- plete reaction is absent in the ordinary forms of malaria, in appendicitis, pneumonia and in the earlier stages at least of miliary tuberculosis. According to the author's experience it occurs only in some of the acute exanthemata; in certain cases of advanced malignant disease with fever; clarifyingly late in miliary tuberculosis and, unfortunately, in its typical form, in febrile cases associated with septic absorption. Pseudo-reactions are found in a considerable number of diseases and the inclusion of the universally obtainable yellow and orange reactions has tended to discredit a good test. It is of great value in negation, for it is the author 's firm belief that, within the period previously defined, it will be found present in all cases of severe typhoid, and that its persistent absence in any such case quite certainly negatives the diagnosis of typhoid fever .^ UREMIA. — Any form of Bright's disease may be associated with symp- toms grouped under the head of " Uremia." The exact cause of this Condi- tion is still unknown, but its occurrence apparently depends upon the reten- tion of certain products of retrograde metabolism distinctly toxic in their * Upon one or the other of these reefs, shipwreck apparently has befallen most of those who have tried this simple test. f Recently Unverricht, in quoting Michaelis, an enthusiastic advocate, has raised anew the old question of color and demands a more definite reaction. A deep red band and a pink foam should be demanded by every clinician before the individual reaction is accepted. UREMIA 247 nature, and perhaps, of certain toxic substances (nephrolysins) associated with the progressive destruction of renal tissue.* Deficient Excretion. — // is a well-known fact that no living organism can resist the poisonous effect of its own retained waste products. In the elimination of these substances the kidney plays the chief part and in almost all cases of uremia the phenomena of relative, or even absolute temporary renal insufficiency, are evident. The onset of uremia is attended not only by a diminished excretion of urinary solids in general, but of urea nitrogen itself, and the molecular con- centration of the blood is correspondingly increased, as has been shown by the demonstration of a lowering of the freezing-point of the serum. It mjist be remembered, however, that during an established seizure, and its subsidence, these conditions may be reversed. Symptomatic Expression. — The symptoms of uremia are made manifest chiefly through the nervous system, although the gastrointestinal and respiratory tracts are almost invariably involved in the severer forms. No concrete picture is -presented in this curious toxemic state, the symptoms being irregular and inconstant in appearance, grouping and duration. Single symptoms of every grade of intensity may be the only signs, apart from the con- dition of the urine, which seldom fails to show a diminished excretion of solids. Nervous Symptoms of Uremia. — Almost every disease of the nervous system may be simulated by uremia but the cerebral symptoms are the most interesting and important. Headache, drowsiness, stupor or coma may be found alone or in transition stages. There may be slight twitchings or the more terrible convulsive seizures closely simulating epilepsy, while violent outbreaks of acute mania, profound melancholia, or the so-called delusional insanity of Bright's disease such as occur in certain cases may easily lead to serious error in diagnosis or even to the committal of such patients to an asylum for the insane, f Sensory Symptoms. — Various disturbances of general sensation may be encountered, such as itching, anesthesia, hyperesthesia, formication, and abnormal response to heat and cold. Vertigo is often a prominent feature and is usually associated with periods of high arterial tension or its opposite, marked circulatory depression, diminution of total solids or the predominance of the dyspeptic symptoms, often so prominent a feature in chronic renal disease. * Although all of the older theories have been abandoned, the specific cause of uremia is as great a mystery as ever and the subject is, perhaps, even more involved in conflicting opinions. At least ten new theories of causation are now before the profession, all unproven. t A remarkable case in the author's practice showed the existence of an uremic delusioD, single but fixed and dominant, which lasted about three years, during which period the patient was converted from the warmest friendship to the most bitter enmity, returning abruptly to his first status of exaggerated loyalty at the end of the period. In this case the albuminuria was intermittent with frequent periods of marked deficiency of excretion, as indicated by estimation of the urinary solids. Several physicians had pronounced the man wholly free from disease, because of the absence of albumin from individual specimens of urine. Chiefly nervous. Cerebral. Insanity of Bright's disease. Varied symp- tomatology. 2 4 8 MEDICAL DIAGNOSIS Transient paralyses. Blindness and deafness. Time limit. Uremic asthma. Misleading symptoms. Minor uremias. Extreme forms. Motor and Special-sense Symptoms. — The most remarkable symptoms of uremia are those extraordinary attacks of transient paraplegia or hemiplegia simulating true apoplexy, and the disturbances of the special senses re- sulting in tinnitus aurium, deafness or sudden temporary blindness (uremic amaurosis).* Various more serious eye symptoms may co-exist with uremia and the diagnosis of chronic interstitial nephritis is often first made by the oculist, who discovers evidence of a neuro -retinitis of the albuminuric type. Uremic amau- rosis usually lasts but one or two days and ordinarily follows some profound manifestation of uremia, such as coma or convulsions. Cases presenting marked symptoms of actual albuminuric neuro-retinitis seldom live longer than one year. Respiratory Symptoms. — Cases of chronic nephritis are often peculiarly subject to inflammation of the pulmonary structures, but aside from these, we have curious disturbances of respiratory rhythm. Uremic dyspnea may be continuous, paroxysmal, alternating, or Cheyne- Stokes. The paroxysmal type is often mistaken for true asthma, the mode and time of onset being precisely the same. Continuous dyspnea of uremic origin is not uncommon, and medical lit- erature furnishes many evidences of the ambulatory Cheyne-Stokes type.\ Gastrointestinal Symptoms. — These so closely simulate various independ- ent diseases as to render diagnosis impossible, except by recourse to the urinary examination and particularly the estimation of blood pressure, the urinary solids, and the use of the phenol sulphonephthalein test whenever possible. As previously stated, these uremic symptoms may be evident in any case of nephritis. They may also be present in minor degrees, at least, in the absence of demonstrable nephritis, though many if not all of such cases represent probably an early chronic nephritis. In all observed by the author the functional activity or permeability of the kidney has been temporarily reduced. Its most extreme and bizarre manifestations are en- countered in chronic interstitial nephritis, or, even more commonly, in chronic parenchymatous nephritisj during periods of low urea excretion. The Onset. — The onset of uremia of the severer types is almost invariably associated with lessened quantity of urine, excessively high arterial tension, and a sharp reduction in total solids and urea, or almost complete impermeability * Amaurosis, i.e., blindness usually temporary and removable and without apparent lesion may also be encountered in hysteria, migraine, acute severe hemorrhages, tobacco and cocain habituation and diabetes. t In one case of interstitial nephritis in the author's practice, typical Cheyne-Stokes breathing was present at night for over three years before the patient's death and was occasionally observed in the daytime during hours of active business. % A case under the author's observation for five years showed during that period nearly every symptom to which reference has been made in a preceding page, and among these were attacks closely simulating hysteria, but promptly removed by radical therapeutic measures, while no less than three times before death the patient was found in deep uremic coma. UREMIA 249 to solids as proven by the phenolsulphonephthalein and other tests. In the rarest instances decided polyuria precedes the attack. Uremic Coma. — This may closely simulate that of apoplexy in which condition interstitial nephritis plays so large a part, but is rarely so sudden in onset and is more generally preceded by convulsions, a history of which should be carefully sought. Such cases are the bete noire of the hospital physician on account of the difficulties attending "emergency" differen- tiation. The following points should be carefully noted: .(a) Examination of the urine obtained by catheterization is of the first importance, as it may yield evidence of an active or chronic nephritis or show a marked reduction in solids, (b) A history of antecedent convulsions or convulsive movements may be obtainable, (c) The pupils yield no certain signs, (d) Paralyses are rare, though transient hemiplegia is a rare possibility and there may be muscidar twitching and rigidity of the extremities if severe convulsions have occurred, (e) The temperature may be elevated, but usually it is normal or subnormal. (J) Opthalmoscopic examination may or may not show retinal changes, (g) The general aspect of the patient may clearly indicate the existence of renal disease, (g) No absolute dependence can be placed upon the odor of the breath as indicating renal toxemia, yet it is strongly suggestive and helpful. High Blood Pressure. — High arterial pressure may prove a most valuable and suggestive finding. Uremia vs. Acetonemia. — The uremic odor is sweet, nauseating, chloro- form-like and may pervade a whole apartment, but is found in connection with profound toxemia, resulting from cardiac failure, advanced hepatic disease, renal disease and sometimes in connection with malignant growths. It lacks the peculiar quality of the breath encountered in diabetic coma, in which there is an actual fruity fragrance of the most penetrating quality. CRYOSCOPY. — The introduction of cryoscopy by Koranyi represents an effort to secure more exact information especially concerning renal activity and efficiency by determining the freezing point of the blood and urine. The greater the molecular concentration of a watery fluid the lower is its freezing point, and assuming that the average freezing point of normal blood ranges from — 0.56 to — o.58°C, and that of urine between — 0.9 and — 2°C, it is evident that the lower freezing point on the part of the blood indicates a greater concentration and that a higher figure for the urine indicates a lessened molecular content. It further appeared that a test of the urine taken by catheterization from each kidney might determine the relative functional activity of those organs and that the procedure would prove a guide to the surgeon in nephrec- tomy as well as to the physician in connection with the so-called uremic states and renal inefficiency. As a matter of experience the cryoscope has proven a distinct disappoint- ment, being wholly untrustworthy in ordinary clinical urinary work by reason of its extreme delicacy and the serious errors incident to its use. Clinically useless. Untrust- worthy. 250 MEDICAL DIAGNOSIS No hard and fast lines. Blending of lesions. All nephritides "mixed." Diagnostic reverses. Total nitrogen. THE CLASSIFICATION OF RENAL DISEASES.— The student would be spared much distress of mind and disillusionment were it more generally taught that a rigid clinical classification of renal lesions is an absurdity. We may divide the nephritides into acute or chronic and distinguish anatomically certain leading types such as the acute and chronic parenchy- matous nephritis, chronic primary interstitial nephritis, and amyloid de- generation, but neither clinically nor anatomically can we draw hard and fast lines. We know little of the "real beginnings" of an interstitial nephritis or of that vague zone where "functional changes" end and il degenerative changes" begin. We do know that there is no "interstitial nephritis" without some degree of parenchymatous change, and vice versa. Classifications are Artificial. — In the main, all classifications are clinical conveniences based upon the preponderance of clinical evidence or of suggested anatomic changes, rather than upon clean-cut and convincing data. These incontrovertible facts should discourage fine-spun diagnosis, yet emphasize the value of thoroughgoing intelligent examination. Arbitrary grouping is a teaching necessity hallowed by custom, but let us neither forget that no man has defined successfully "physiologic albuminuria" in clinical terms, nor lose sight of the fact that all forms of actual nephritis are in some degree "mixed." Life insurance companies find "physiologic albuminurias" expensive and clinicians are sometimes appalled by the scant autopsy findings in apparently clean-cut nephritides or, rarely, astounded by the demonstration of an acute nephritis in a case yielding no clinical urinary symptoms. RENAL INADEQUACY.— Aside from cryoscopy and the estimation of urinary solids, many efforts have been made to determine directly and by simple means the functional efficiency or inefficiency of the kidneys, espe- cially with relation to actual or suspected medical or surgical diseases of those organs, but until recently no method had been evolved which was free from serious objection and, at times, gross error. McLean's method, already described, is not adapted to the use of the practitioner (see p. 203). The accurate estimation of total nitrogen can hardly be adapted to the examination of specimens obtained by ureteral catheterization which repre- sents small separate specimens, and furthermore involves an absolute knowl- edge of the ingesta, of excretion through channels other than the kidney, a complicated chemical estimation, and repeated tests covering a considerable period; all of which requirements place it entirely outside the possibilities of the everyday clinical work of the general practitioner. Rough estimations are of course extremely helpful and at times of great value but all medical men have felt keenly the need of some method at once simple and accurate. Methylene Blue. — Achard and Castaigne some years ago recommended and used methylene blue for the determination of the functional activity of the kidneys, using intramuscular injections and noting the time elapsing RENAL INADEQUACY 251 between its administration and the subsequent discoloration of the urine as well as the approximate amount of the coloring matter recovered. It has been found, however, that the test is of little value as a measure- of renal insufficiency, the elimination being unmodified in parenchymatous and amyloid nephritis and too widely variable in different cases of interstitial nephritis. The Relative Toxicity of Urines. — Bouchard's method of determining the relative toxicity by injecting urine into guinea-pigs is entitled to little respect, nor is it in any way adapted to ordinary clinical work. The Phloridzin Test. — It is probable that the sugar excretion following the hypodermic use of the glucoside phloridzin furnishes a reasonably accu- rate index of renal secretory activity. Test. — -i c.c. of a sterile 1 : 200 watery solution of the glucoside, gently heated to dissolve any persisting crystals, is introduced into the tissues. Sugar should appear in the urine within from thirty to sixty minutes and sugar excretion should cease within four hours. The total amount excreted varies from 0.5 to 2.5 grams. If the functional capacity of each kidney is to be determined, the ureteral catheters should be introduced and left in position during the whole test period. No sugar, or but minimal amounts, will be secreted in acute or subacute nephritis and advanced interstitial nephritis. As the clinical evidences of the first two forms is almost invariably frank, the test can only be of great value in certain rare cases of interstitial nephritis. Determination of Electric Conductivity. — This is little more than a complicated, and clinically unimportant, method of estimating the mineral constituents of the urine. THE PHENOLSULPHONEPHTHALEIN TEST.— The Best Procedure.— Rowntree and Geraghty have introduced a test of renal functional activity* which has maintained its place for several years and represents the highest degree of accuracy so far obtained by simple and practical methods. The procedure proved of distinct usefulness and value in the author's clinic. Drug. — The drug is a non-toxic, bright red powder moderately soluble in alcohol and water and readily soluble in the presence of alkalies. Normal Excretion. — 77 is excreted with almost incredible rapidity, appear- ing in the urine a few moments {five to eleven) after hypodermic injection, and being eliminated in normal cases almost wholly within two hours. From 50 to 60 per cent, of the drug should be excreted during the first hour, and from 70-90 per cent, by the end of the second. Test Solution. — 0.6 gram of the phenolsulphonephthalein and 0.84 c.c. of a 2/N NaOH solution (8 per cent.) are added to normal salt solution suffi- cient to make 100 c.c. The addition of a few drops more of the 2/N NaOH * It should be thoroughly understood that normal excretion does not prove that the kidneys are free from disease. It does show that, at the time, the renal function is not seriously affected. We do not know what degree of change is required to produce recog- nizable impermeability. Simple and accurate. Renal. Time limits. 252 MEDICAL DIAGNOSIS End coloi reaction. Standard color. solution to the injection fluid at the time it is used changes the color of the test fluid to a wine red and renders it non-irritating to the tissues. Technic. — (a) The patient is given 300 to 400 ex. of water to insure free secretion, (b) A catheter is passed into and retained in the bladder after this viscus is completely emptied, (c) At a carefully noted time, twenty to thirty minutes after the ingestion of the water, 1 c.c. of the test solution (6 mg. of the drug) to which 2 or 3 additional drops of the 2 /NNaOH solution have been added to prevent irritation, is injected into the upper arm. (d) From this time all of the urine is led into a test-tube containing a drop of 25 per cent, sodium hydrate solution and the first appearance of a pink color carefully noted. This represents the initial excretion period which normally varies between five and eleven minutes. Obstructive vs. Unobstnictive Cases. — If no obstruction to micturition exists the catheter now may be removed, the patient voiding at the end of both the first and second hours. In obstructive cases the catheter is clamped and maintained in situ until two hours have elapsed, the bladder being drained at the end of each hourly period. Colorimeter. — The amount excreted is measured by a colorimeter.* Each hour's voiding, being measured and its specific gravity determined, is placed in a 1 -liter volumetric flask and treated with sufficient 25 per cent. NaOH solution to alkalinize it and thus develop the maximum color, a brilliant purple red. Sufficient distilled water to bring the solution to the 1 -liter mark is then added, the mixture thoroughly shaken up and a filtered portion taken for comparison with a standard solution consisting of 1 c.c. of the test solution in 1 liter of water, plus 1 or 2 drops of a 25 per cent. NaOH solution. The standard solution is accurately adjusted to the 10-mm. mark of the scale and compared with the unknown solution, the percentage of drug excreted being calculated by the differences in scale required to secure unifor- mity of color in the two solutions. f Clinical Application. — In renal disease, both parenchymatous and in- terstitial, but especialiy the latter, the excretion is retarded and greatly diminished if the kidneys are insufficient. Advantages Claimed for the Test. — Its originators claim for it the follow- ing advantages: (a) It represents a non-toxic agent promptly secreted by normal kidneys, or by diseased kidneys, while functionally efficient, but retained for suggestively longer periods in actual renal insufficiency. * Geraghty and Rowntree's recent modification of the Autenrieth-Konigsberger color- imeter permits a direct percentage reading by an indicator on the scale of the instrument. (See also "Kuttner's colorimeter," described in "Blood" section.) t As the standard is 10 it is evident that a reading of 20 for the unknown solution indicates the presence of but 50 per cent, as much dye as is contained in the standard solution (3 mg.) which represents but one-half the quantity of dye injected for the test (6 mg.). Hence the reading of 20 on the scale indicates an excretion of but 25 per cent, of the dye and the same proportion will be true for any other readings obtained. DISEASES OF THE KIDNEY 253 (b) The brilliant red of the solution lends itself readily to colorimetric determinations. (c) In cardiorenal cases the drug may show clearly the extent of actual renal insufficiency inasmuch as simple chronic congestion, save in the most extreme degrees of incompensation, affects excretion but slightly as compared with actual nephritis. (d) It permits better prognosis, forecasts or determines the presence of uremia and is oj great importance with relation to proposed surgical procedure, and in warning the obstetrician of impending eclampsia. (e) Within reasonable limits and in conjunction with ureteral catheteriza- tion it permits an estimate of the relative functionating values of the two kidneys. Uremic Seizures. — During an actual uremic attack the elimination during two hours is almost nil. Impending Attacks of Uremia. — In any nephritic patient a showing of 10 per cent, or less indicates an impending uremic seizure. CHRONIC PASSIVE CONGESTION OF THE KIDNEY The Kidney of Stasis. — This is always obstructive in the clinical sense, whether the primary disease be of the heart or pericardium, lungs or liver, pressure on the renal veins by abdominal tumors (including the pregnant uterus and ascitic fluid) or the cardiac weakness of prolonged exhausting disease. Minor degrees of passive venous congestion are much more common than is generally taught or believed. Morbid Anatomy. — The kidneys ordinarily show a simple venous hy- peremia though in cardiac incompensations of long standing or such as result from or are associated with an actual nephritis, both parenchymatous and interstitial changes may be manifest. Indeed simple cases of long standing may show the well-known "cyanotic induration" kidney in which marked atrophy of the secreting structures and some interstitial changes may be manifest. Symptoms. — There are no symptoms of importance save the urinary find- ings and those referable to the primary lesions. Urine in Chronic Passive Congestion. — The total amount is diminished, the total solids approximately or actually normal. Reaction. — Acid. Color. — Distinctly high save in diseases characterized by marked im- pairment of nutrition. Albumin is present only as a trace, except in pregnancy when large amounts may be found, as is also the case when decided parenchymatous changes co-exist. The amount of albumin in simple passive congestion usually varies in- versely with changes in the heart strength, and such variations often assist one in the diagnosis of the minor cardiac decompensations. Microscopic Findings. — An occasional hyaline or finely granular cast, together with a few renal cells constitute the usual findings. Differential value. Prognosis and prediction. Relative excretion. Venous obstruction. Often "mixed." Important fact. 254 MEDICAL DIAGNOSIS Caution. Total solids. Faulty classification. Chief cause. THE KIDNEY OF PREGNANCY.— There is no single and distinct anatomic type which fits this clinical condition. Even though the condition may be one of simple pressure hyperemia, the amount of albumin is likely to be larger than in other instances of chronic passive congestion, and it must not be forgotten that active hyperemia or acute or chronic inflammatory diseases of the kidneys may accompany this state, a toxic tubular nephritis is the commoner type. In this connection it is of the utmost importance that specimens of urine be submitted frequently to the attending physician and that these represent the twenty-four hours' urine, and not the individual haphazard specimen. Furthermore, the essential feature of the examination, as indicating danger to the patient, lies in the estimation of urea, the blood pressure and in the use of the Rowntree and Geraghty test when deemed necessary. This point is often overlooked by the practitioner, who may mistakenly regard the amount of albumin as the important feature. ACUTE SEVERE CONGESTION AND ACUTE NEPHRITIS Clinically Inseparable. — These conditions should be considered together, inasmuch as the causes operating to produce them are essentially identical and, further, because no line can be drawn clinically between actual acute nephritis and severe congestion, save that based upon the duration of symptoms. Mild congestion of the arterial type occurs under many conditions of slight potency, and is the antithesis of the severer types, the amount of urine being increased, but a small trace of albumin being present, and the urinary solids being actually or approximately normal. Etiologic Factors. — Irritating Drugs. — Among these are copaiba, cubebs, sandalwood oil, turpentine, cantharides, carbolic acid, phenol compounds generally, arsenic, lead and mercury. These cause trouble only when ingested in excessive doses or for too long a period. Insoluble Urinary Constituents. — Uric acid, calcium oxalate, cystin, acid urates and phosphates, as constituents of "gravel" or "calculi" are the chief factors. Toxins. — These may be divided into three groups: (i) Those asso- ciated with acute febrile infections and especially with the exanthemata and certain virulent tropical diseases, of which yellow fever is the chief. (2) Suppuration with septic absorption which should include the acute and chronic disease of the tonsils, peridental abscesses, chronic prostatitis, sinus diseases and like obscure sources of infection. (3) Chronic diseases, such as syphilis, gout, malaria, pulmonary tuberculosis, diabetes mellitus and certain of the anemias. Streptococcus infections are especially potent. The toxic albuminurias may be extremely mild and transitory, as acute clinical conditions, and are best exemplified by the so-called "febrile" albu- minuria. Whether such conditions leave'permanent lesions behind them or not, depends upon the virulence of the toxemia and the condition of the DISEASES OF THE KIDNEY 255 patient prior and subsequent to the attack. Clinically, they represent no more than a mild renal congestion. Nervous Influences. — Formerly it has been customary to place under this head the nephritis attending such conditions as acute mania, delirium tremens and the so-called ascending or reflex congestions connected with diseases of the bladder, seminal vesicles, urethra and the prostate. This is incorrect, for the ingestion of large amounts of alcohol is in itself sufficient to produce marked albuminuria and reduce resistance to infection from within and without the body. Add to this the exposure to the elements and the excessive exhaustion attending delirium tremens, and acute renal congestion or an actual nephritis is readily explained. In many cases of acute mania, nephritis is the ante- cedent factor of which mania may be but a symptom. In delirium tremens the habits of the individual, the likelihood of preexisting disease, the exposure and exhaustion attending a debauch, leave little room for the older classifi- cation. In the case of the so-called reflex or ascending congestion, save in the rarest instances, we are dealing with an extension of infection. Pregnancy. — The acute renal disturbances of pregnancy are associated with a marked diminution in the amount of urine, a profusion of casts and albumin, and an associated edema of varying degree, often decided or even excessive. Toxic symptoms are decided and the condition tends to the production of convulsive seizures of an uremic type. Blood cells are present in the urine in many or most instances but not to the degree usually observed in connection with the actual acute nephritis of the ordinary type. Empty- ing the uterus, if timely, is followed by a rapid recession of the symptoms and, in most instances observed by the writer, an uneventful and complete recovery on the part of the patient. General Causes. — Sexual excesses, the excretion of large quantities of bile, and extreme concentration of the urine seem adequate to produce mild congestion. Fatigue, mental or physical, particularly when combined with exposure to cold or wet, would seem to be a predisposing cause, but the most potent active factors are the chronic infective foci already mentioned. Morbid Anatomy. — The complex description and varying terminology in use embarrass the student when he approaches the subject of renal pathology. Essential Factors. — All renal lesions, acute or chronic, actually fall under four heads: 1. Those in which glomerular changes predominate. 2. Those in which tubular changes dominate. 3. Those in which the interstitial changes are most prominent. 4. Those in which all structures are affected without determinative dominance of any one group. The finer classification and subdivisions are of pathologic interest only and in any severe nephritis, acute or chronic, one finds all structures involved in some degree, so that it becomes simply a question of relative predominance. Clinical Aspect. — In an acute nephritis or severe acute congestion of the Negligible. "Reflex" a Misnomer. 256 MEDICAL DIAGNOSIS Variable onset. Early edema. Hypertension. Peculiar facies. kidney, any one of the three pathologic types, glomerular, tubular, or interstitial, may be primary or predominant. Aside from the rare and clinically unrecognizable acute nonsuppurative interstitial nephritis, the three fundamental structures are in some degree involved and, in any event, no consistently accurate clinical distinction can be made. Microscopic Pathologic Findings. — We ordinarily find cloudy swelling, desquamation, and hyaline, dropsical and fatty degeneration or complete necrosis of the epithelium of the tubules, which are crowded with inflamma- tory detritus. We are likely to find acute intracapillary glomerulitis, the capil- laries being filled with cells and thrombi and the epithelium of the tuft and capsule being involved. The latter is crowded with blood cells and leucocytes, and interference with the renal circulation and nutrition, no less than with the excretion of the urine and contents, is inevitable. Furthermore, the loss of integrity on the part of the filtration apparatus must necessarily lead to the escape of albumin. In rare instances a portion only of the kidney may be involved, or the process may be unilateral. Macroscopic Appearance.- — The gross appearance of the kidney varies somewhat; it is ordinarily swollen and red, dripping blood on section, having a succulent feel and an easily stripped capsule. Rarely it may be pale and mottled, exuding on section a milky fluid (acute non-suppurative interstitial nephritis). The glomeruli are usually red and prominent, but may be pale and indistinct. GENERAL SYMPTOMS.— The onset may be sudden and frank, with chill and sharp temperature rise, but is usually gradual, afebrile, and insidious. There is usually some pain or heaviness in the loins, a dry skin and in- creased frequency of micturition, the pulse tension increases, and nausea, vomiting, headache and thirst may be present. The severity of the initial symptoms bears no definite relation to the type of the disease, save that those of simple acute congestion are ordinarily milder and more evanescent. In many instances the first thing noted is pufiiness under the eyes, the development of general edema, or even uremic convulsions or coma. As a rule, however, these two last symptoms occur only after several days of illness. Arterial Tension. — One of the best guides when nephritis complicates other disease is found in the arterial tension, which is usually but not in- variably increased in the presence of either severe acute renal congestion or inflammation (180 to 200 mm.). Fever. — Though ordinarily present, it is seldom high and often is masked by that of some primary disease of which the nephritis is a complication. Edema. — The edema of acute nephritis is oftentimes extreme and is likely to appear first in the eyelids and tissues of the face, the skin being pallid* and "pasty." * A secondary anemia of considerable or excessive degree may be present but the "pallor" does not prove its presence nor conform to the degree of anemia when that does coexist. DISEASES OF THE KIDNEY 257 In the extremities the swelling is comparatively firm, though pitting deeply on pressure, and, because of the blue veining on the dead-white back- ground which is especially well marked on the child's skin is often termed 14 marble edema." There is a special tendency to secondary complicating symptoms espe- cially affecting the serous membranes and the myocardium and to attacks of edema of the glottis which, if not immediately relieved, may cause sudden death by suffocation. Special Precautions. — At least once daily the attending physician should by careful examination exclude endocarditis and myocarditis, no less than pericarditis and pleurisy, with or without effusion, the condition last named often coming on rapidly and insidiously. Edema of the glottis with urgent stenotic dyspnea usually demands imme- diate recourse to the most radical measures; the free scarification of the engorged tissues, prompt application of astringent preparations and, very often, an emergency tracheotomy. A few moments of indecision and delay has more than once caused death. URINARY FINDINGS. — The urinary findings in acute congestion vary with its severity, but tend to assume, pari passu, characteristics identical with those of acute nephritis. // is evident that severe acute congestion can be differentiated from acute nephritis only by its shorter duration, but the mildness of the slighter grades makes their recognition easy. The student should refresh his memory regarding the subject of albumi- nuria and the finding and significance of casts before taking up the following section. The findings fall naturally under three heads: First Stage. — Quantity for twenty-four hours, 100 to 400 c.c. Color, dark smoky or black. Specific gravity. This may be high or low for albumin may raise it even to 1030. It is invariably low if albumin is removed. Re- action, acid or, from large quantities of blood, slightly alkaline. Solids, the solids are absolutely diminished, urea being greatly lessened and the chlorides absent if dropsy is extreme. Sediment. — An abundant dark sediment is present. Casts are abundant, the urine containing dark granular, epithelial, fibrinous and blood casts with a few T hyaline and fine granular forms. Casts carrying leucocytes, caudate pelvic cells, and round cells from calices are present in severe cases. Albumin. — This varies from y± to 1 per cent, according to the degree of tubal involvement. Red blood cells are abundant, as are leucocytes and brown granular epithelial cells. Second Stage. — Quantity for twenty-four hours, 600 to 1500 c.c. Color, dark and smoky. Specific gravity, 1015 to 1020, Reaction, acid. Solids, still diminished. Albumin. — This will vary from }£ to ^ per cent, diminishing pari passu witfrurine increase. Sediment. — Profuse and dark; fatty changes now become evident through fatty casts, fatty renal cells and compound granule cells. The amount of fat 17 Marble edema. Serious complications. Glottic edema. Acute congestion. Acute stage. Lasts 5 to 10 days. 5 to 10 dayt Improvement. Characteristic changes. 25* MEDICAL DIAGNOSIS in some degree measures both the improvement and the severity of the primary attack. Third Stage. — Edema if originally present has now disappeared. Urine, the quantity is increased (1500 to 4000 c.c.) and the tendency to polyuria may last for weeks. Color, pale or slightly smoky. Reaction, acid. Specific gravity, 1006 to 1020. Solids, normal or slightly increased by absorption of exudate. Albumin. — This will vary from a mere trace to ^ of 1 per cent. Sediment. — This is scant and of lighter color and contains abnormal blood cells (rings) (ghosts) , and occasionally hyaline and granular casts both light and dark. Possibly an epithelial, fatty, or fibrinous cast may be found and a few renal cells. The casts and renal cells may carry fat droplets or abnormal blood cells, but as improvement continues the evidence of active degenerative and regenerative changes disappears and the urine at last becomes normal. Any chronic renal disease may undergo acute or subacute exacerbations and a most common diagnostic error lies in the failure to appreciate the fact that in adults most of the apparently acute cases are but exacerbations of an unrecognized chronic nephritis. Prognosis. — The disease is less common and less fatal in dry than in damp climates. Children give a large mortality (30 per cent.), especially scarlatinal cases. Low tension, extremely high tension, major uremic symptoms, and serous effusions are ominous, and lack of any decided improvement after ten days means a probability of chronic disease. Persistent profound anemia is also a threatening sign but recovery may take place even after one or two years. Relapse and multiple relapses are frequent. ACUTE FOCAL GLOMERULONEPHRITIS.— These cases are clinically undemonstrable as such, and represent focal embolic nephritis, involving especially the glomerular capillaries in minute widely scattered areas. Albuminuria, a few red blood cells in the sediment, and, sometimes, fugitive edemas, constitute the only bases for diagnosis. In the presence of " endocarditis lenta," or other conditions of a similar sort, this condition may be assumed with some justification if the symptoms named above are present. ACUTE INTERSTITIAL NON -SUPPURATIVE NEPHRITIS.— This interesting pathologic picture is revealed only at autopsy, and, chiefly, in fatal cases of scarlatina or, less frequently, acute rheumatic arthritis. As stated previously, the change is almost exclusively confined to the inter- stitial tissue, in which round cell infiltration is demonstrable. Clinical signs of renal involvement may be wholly absent during life. CHRONIC PARENCHYMATOUS NEPHRITIS Etiology. — An antecedent acute nephritis, prolonged exposure to wet and cold under conditions of fatigue, chronic malarial infection, syphilis, alcoholism, chronic suppuration and chronic obscure infections are the common factors. DISEASES OF THE KIDNEY 259 The many sources of streptococcic infection must be considered, for this organism plays the chief part in all probability. Morbid Anatomy. — Glomerular, tubular, and interstitial changes are present, the two first predominating. The kidney is large, its capsule may be adherent, but usually strips easily from the pale and mottled kidney surface; section shows increased resistance and a swollen white cortex with curious areas of opacity. Microscopic Findings. — These include obliterative hyaline degenerative changes in the vessels of the glomeruli, involving both the cells and the vessel walls, and swelling and nuclear proliferation of the tufts is evident. There is a tendency to connective-tissue ingrowth and to proliferation and desquamation of the capsular epithelium. The tubules show degeneration, desquamation, and necrosis of their epithelium and edema and connective- tissue infiltration of the intertubal tissues. Symptoms. — The onset is insidious but the general symptoms usually become frank, anemia and edema alike being prominent. The various uremic phenomena are common, early, and recurrent, there being a special tendency to headache, dyspepsia, intractable neuralgias, nausea, vomiting and diarrhea. Pleurisy and pericarditis with effusion are frequently observed. Ulceration of the colon occasionally occurs. There is constant tendency to general anasarca, and quiet, insidious transudations into the pleura, pericardium, peritoneal cavity, and tunica vaginalis testis may complicate the case. Although edema of the face and pallor are ordinarily the first noticeable objective signs, the edema usually appears promptly in the ankles and may at this time act much like the cardiac form though far more shifting and inconstant with respect both to degree and location. About the face, head, and neck it is particularly pronounced in the early morning. The circulatory changes are less marked and constant than in interstitial cases, though the pulse tension is usually increased and may become very high as the disease progresses. The second aortic and apical first sound are in such cases markedly accentuated, the left ventricle enlarged and changes in the retina are common. In many cases the heart remains throughout a weak dilated or readily dilatable organ, the myocardium being persistently affected by the toxemia. URINARY FINDINGS.— It is customary to separate the urinary symp- toms into those of the active, as compared with the inactive stage. It will be noted that the essential symptoms are the same under both conditions, i.e., a decided albuminuria, the presence of fatty casts, and marked diminution of the urinary solids. The disease is especially liable to subacute exacerbations, giving to the urinary findings a resemblance to an acute nephritis of the early stage of convalescence. Active Stage. — Amount, 200 to 800 c.c. Color, high or pale, yellow or greenish, often smoky from exacerbation. Reaction, acid. Specific gravity, high from albumin, 1026 to 1035; but with this removed, low. Misleading exacerbations. 260 MEDICAL DIAGNOSIS A misnomer. Essential features, like interstitial form. Solids, greatly diminished, especially chlorides and urea as in all dropsical cases of renal disease. Albumin. — This is profuse and the urine may boil solid. One-half to two per cent, is the common variation (5 per cent, has been reported, but the average is 1 per cent.). Sediment. — This is always considerable and one finds hyaline, granular, fatty and epithelial casts, fatty epithelium and compound granule cells. Epithelial casts indicate in any form of nephritis a superadded or recent acute or subacute trouble. Free fat, fat crystals, cholesterin and waxy casts occur in the late stages. Red blood cells are present and may of course be very plentiful and associated with blood casts. The number varies with the intensity and stage of the active process. Inactive Stage. — Quantity, 800 to 1200. Color, pale or greenish. Reaction, acid or neutral. Specific gravity, 1010 to 1015. Solids, greatly diminished. Albumin, J4 to H P er cent. Sediment, as in active stage. Prognosis. — If the disease is strongly intrenched and not merely a pro- tracted case of acute Bright's disease, its victims rarely recover, but die in a few years of pulmonary edema, general anasarca or uremia, the average duration of the disease being a little over two years. Cases of Mixed Type. — Cases are frequently observed which present evi- dences of marked tubular and glomerular involvement for long periods without excessive general edema, and ultimately become clinically almost typical cases of interstitial nephritis. In these mixed cases the urinary findings much more closely resemble cirrhotic kidney than do those assigned to the type described below. THE SMALL WHITE KIDNEY (Secondary Contracted Kidney).— This misnamed condition is supposed to represent an advanced stage of an unusually prolonged chronic parenchymatous nephritis with ultimate predominance of the interstitial elements. It represents actually a "mixed" nephritis. Morbid Anatomy. — The kidney is sometimes small and yellowish but more often approximates the size of the large white kidney. Connective-tissue hyperplasia is marked, the capsule being thick and adherent, and the kidney surface under it rough and granular and on section there is increased resist- ance. The cortex is thin, pale, yellow, and covered with yellowish-white spots. Microscopic Findings. — The interstitial changes are marked, there is arterial thickening, and the glomerular and tubular structures are degenerated and largely destroyed. General Symptoms. — These are essentially those of a combination of parenchymatous and interstitial nephritis, changes in the heart and blood vessels being more pronounced than in the parenchymatous form. Urinary Findings. — Quantity, normal or slightly increased. Color, pale. Reaction, acid or neutral. Specific gravity, 1004 to 1010. Total solids, greatly diminished. Albumin, Y± of 1 per cent, or less. Sediment. — This is like that of chronic parenchymatous nephritis of the DISEASES OF THE KIDNEY 261 "inactive" stage, save that casts are less abundant, and that, in some cases, late in the course of the disease, waxy casts are found in unusual numbers. FOCAL ARTERIOSCLEROTIC FORM.— This represents the senile type of diseased kidney and is characterized pathologically by its tendency to maintain an approximately normal size, associated with a certain amount of induration. The involvement of the vessels is patchy, irregular, and not confined to the arterioles. This condition is reflected in the macroscopic "patchy" depressions scattered over the surface of the kidney. In nearly every in- stance, the condition is associated with decided peripheral arteriosclerotic changes throughout the body. Urinary signs are scant, and may be wholly absent over long periods. Arterial pressure may be high, low, or inconstant and widely variable. Signs of renal insufficiency may be lacking up to the time of death. CHRONIC INTERSTITIAL NEPHRITIS ("Gouty" kidney, "contracted" kidney, "cirrhotic," "granular," "sclerotic" or "small red" kidney, "chronic diffuse" nephritis, etc.) Morbid Anatomy. — The kidneys are usually small, an extreme instance having been reported in which their combined weight was but i}^ ounces. The capsule is thickened and adheres to the dark red, nodular, granular surface, and section shows an increase in resistance. The arteries are prominent, the cortex very thin, the pyramids wasted and the pelvic fat increased. Microscopic Changes. — These are essentially those of connective- tissue overgrowth, with atrophy and degeneration of both glomerular and tubular structures. Many of the glomeruli and tubules are entirely destroyed. Etiology. — Here, as in arteriosclerosis and aneurysm, the worship of Venus, Bacchus and Vulcan have long been regarded as the primary factors in causation, though to this group one might well add Minerva and also Mammon, the non-Olympian. In other words, overwork (mental and physical), syphilis, sexual excess, exposure and privation, heavy eating and drinking, all play a prominent part. The author believes, nevertheless, that with the exception of lues, these are merely predisposing factors. Chronic foci of infection and the obscure and subtle changes wrought by past illnesses are probably the most potent elements. Arteriosclerosis is a prominent feature in cases of interstitial nephritis and one is not surprised to find what seems like a direct hereditary predisposi- tion to the development of the latter disease. Lead poisoning, lues, alcoholic excess, chronic malaria, and the various forms of gout are common and promi- nent in the case histories. As in the case of arteriosclerosis proper, we here find the "young old man," old by virtue of inherited vascular weakness or gout, or through sexual excesses, syphilis, or excessive mental strain. It A masked process. 262 MEDICAL DIAGNOSIS Incredibly slow. Often unrecognized. Urine and circulatory organs. Silent hypertension. Certain hypertension symptoms. Significance of extreme hypertension. is wholly probable, however, that acute infections or obscure chronic infec- tions of the streptococcus type play a large part or the leading role. The chronic or remittent toxemia of interstitial nephritis itself doubtless promotes and advances arteriosclerotic changes in the general arterial system. General Symptomatology. — The pallor, edema and the frankly albuminous and cast-filled urine of chronic parenchymatous nephritis makes mistaken diagnosis in the case of that form of nephritis unpardonable. The reverse is true of chronic interstitial nephritis. In the earlier clinically recognizable stages of the disease the patient may appear to enjoy unusually good health, this being particularly true of the sthenic type. Pallor, edema, and pigmentation are late symptoms, and the urinary findings are sometimes both variable and obscure. Many cases die under other diagnoses and in the case of many others, recogni- tion is deferred until autopsy. It must be borne in mind also that most of these cases exist for years before clinical recognition is possible. We know but little of such ailments in their earlier pathologic stages. Much dependence must be placed upon the secondary signs in the heart and blood vessels, and the urinary examination demands care and the intelligent application of a full knowledge of the vagaries of this extraordinary disease. Most patients with well-established lesions seem to become habituated to, and carry well an arterial systolic pressure of 170 to 180 or 185 mm. of mercury, but usually show symptoms if the higher figures are much exceeded. Sensory Disturbances. — These symptoms are often obscure and consist chiefly of numbness, tingling or a sense of weakness in the extremities. The general symptoms are essentially those of arterial hypertension or uremia, either or both of which may be present at any time in any of their various forms. The severer manifestations of uremia may be postponed to the very end of the case, or never occur. (The section dealing with uremia should be carefully reviewed.) Circulatory Signs. — Advanced interstitial (diffuse arteriolar) nephritis is invariably attended by increased arterial tension, at least until the extreme ter- minal cardiac incompensation supervenes. This hypertension is indicated by the sphygmomanometric readings and reflected in the overacting or hypertrophied left ventricle, a hard radial pulse, and, usually, marked accentuation of the aortic second sound and mitral first sounds, with or without reduplication of the latter. In advanced cases with uremic manifestations the systolic pressure, ordinarily 165 or 170 to 215, may reach 250 or even 300 mm., though the last figure has been seen by the author only just before or a few days preceding an apoplectic stroke, uremic convulsions or coma. Most authorities state that abnormal tension follows rather than precedes definite urinary findings, but the author believes this to be an exact reversal of the true sequence. It should be understood that in many cases of decided arterial hypertension, DISEASES OF THE KIDNEY 263 the aortic sound is not heard as a sharply accentuated tone. Many errors result from the usual teaching with reference to this matter. In many cases, early or late, the classic accentuation of heart sounds is lost or modified by reason of valvular changes or a weakened myocardium. The sphygmomanometer will ultimately give us, in all probability, our first knowledge of the true "early stages" of interstitial nephritis and the phenolsulphonephthalein test may also aid us. Neither, however, can take us back more than a part of the way to the beginnings of interstitial nephritis of the common type. Arterial tension is often maintained at a high figure even when death is impending and cardiac insufficiency extreme, and indeed excessive tension in any case is often found to be due in part to stasis and decided amelioration may follow brisk cardiac stimulation.* Edema. — When marked edema appears in this disease, it is usually due chiefly to cardiac failure, and shows the characteristics of a passive congestion edema, the most dependent portion being first involved, as is the case in primary valvular or myocardial diseases of the heart. In many cases of established interstitial nephritis, however, one may see for years a curious fullness of the eyelids, especially the lower. In the morning the skin appears thinned, pearly, and almost translucent, whereas later in the day the fluid may disappear and the delicate integument subsides into fine wrinkles. Some of the cases come under the head of u mixed.nephritis" and in these the renal facies is likely to be more marked and unmistakable, owing to the presence of parenchymatous degeneration and glomerular changes. Traube's Heart. — In the case of the heart of long established renal dis- ease and arterial hypertension the whole organ may be affected, indicating quite clearly an underlying general toxemia. This is not always the case, however, and in many instances observed by the author the left ventricle only has shown change during many years. The Fundus Oculi. — In these as in other forms of renal disease, the eye changes may be pronounced and important; indeed, many cases are referred by the oculist to the internist under a correct diagnosis without urinary examination. The usual changes consist of flame-shaped hemorrhages, papillitis, retinal edema, or peculiar fawn-colored patches, radiating from the macula lutea. Glaucoma is not uncommon, and uremic amaurosis may occur. As a rule, these eye changes indicate a fatal termination in a short period, yet the author has observed one case in which the original diagnosis was made by the oculist, and a subsequent glaucoma led to enucleation of the affected eye; yet the patient is still living after fifteen years of apparent good health. The rule admits few exceptions nevertheless. Respiratory Tract. — It is important to remember the special liability of renal cases to attacks of bronchitis, pleurisy, asthma, edema of the glottis, and dyspnea in its various forms. * Probably because of the varying degrees of asphyxial irritation of the vasomotor center. A mis- conception. Stasis hypertension. Usually cardiac. A suggestive^ sign. Mixed cases. Warning. Readily recognized. Prognostic value. Pleurisy, asthma, and glottic edema. 264 MEDICAL DIAGNOSIS Scant findings. Nightly increase. Often important. Variable. Valuable warnings. Watch urea excretion. Deceptive findings. A massive pleural or pericardial transudate may come on so quietly as to attract no attention save through the embarrassment in respiration. In a case recently observed the acute edema of the laryngeal tissues, that followed a sharp attack of tonsillitis, proved to be due to the acute toxic congestion superimposed upon an old nephritis associated with passive con- gestion due to a weakened myocardium. The inflammation of serous membranes which may complicate Bright's disease are for the most part, doubtless, mere streptococcic infections which attack by preference a weakened body. URINARY FINDINGS. — The essential symptoms in the typical case consist in the increased amount of night urine, attended by increased frequency of micturition; a total increase for the twenty-four hours; a more or less persistent and extreme tendency to diminution in the total amount of solids; traces of albumin, and a few hyaline and granular casts. Increased night frequency may be due to causes other than nephritis, such as enlarged prostate, chronic irritability of the neck of the bladder, or cystitis, but when the symptom is associated with a marked disturbance of the normal ratio between night and day, the symptom becomes one of primary importance. Diminution of Solids. — Urea Variations. — A man with interstitial nephritis may during years pass a normal or nearly normal amount of urinary solids the greater part of that time, though unrecognized periods of retention undoubt- edly occur. In the later stages of the disease the excretion of solids will almost in- variably fall below normal, and this is especially true of urea. Valuable information is often given by sudden drops in urea excretion, associated with heightened arterial tension and in many such cases, under close observation, one may avert an impending attack of uremia or apoplexy through these warnings. Albumin. — Albumin may be present continuously or intermittently, at one time of the day and not at another, but in uncomplicated cases will be found only in small traces. The specimens least likely to show it are those passed in the early morning, those most likely being the ones voided several hours after a full meal taken in the middle of the day or after a heavy dinner at night. Exposure to cold, slight infection, physical exertion and the process of digestion seem to increase the albumin output. A negative examination of the single specimen, even of the twenty-four hours' urine, proves no man free from interstitial nephritis. Briefly we may summarize as follows: Color, usually pale. Specific gravity, low — 1002 to 1014. Total amount, 2000 to 4000 ex.; may reach 7000 or 8000 c.c. Reaction, faintly acid or neutral. Urinary solids, diminished, coloring matter diminished, except indoxyl, which is usually increased. Albumin, usually a trace, rarely reaches J^ of 1 per cent, in the later stages. Sediment.; — This is usually slight or absent macroscopically in undecom- posed urine. Casts. — The casts are chiefly the hyaline and faintly granular varieties. DISEASES OF THE KIDNEY 265 Cells. — A few renal cells may be found and some cases are associated with cylindroid storms. Even with the use of the centrifuge casts may be very few in number. Note. — All urinary findings may be modified by a superadded passive congestion due to a failing heart or by a subacute exacerbation, though the latter is unusual in the straight interstitial type. Defective elimination, as shown by the phenolsulphonephthalein test, is especially marked in this form of nephritis. Blood-pressure. — It is wholly probable that an abnormal arterial ten- sion is the earliest sign available for the practitioner. Symptoms of the Terminal Stage. — Cardiac and Renal Symptoms. — There may be passive congestion due to a failing heart, resulting in an increased amount of albumin, and, as a rule, more numerous casts showing coarser granules and an occasional waxy cast. The amount of urine is dimin- ished, the total solids are low, though the specific gravity may be relatively high. The general appearance of the patient is that of a cardiac edema and such cases offer great therapeutic difficulties especially to those who undervalue the need of supporting the weakened heart. Uremic symptoms usually become prominent and such cases may ter- minate in pulmonary edema or uremic coma. Prognosis. — Duration Indefinite. — Inasmuch as we know little or nothing of its beginnings, we cannot say for how long a period the individual may endure changes of interstitial nephritis nor can we recognize its earliest stages. It is safe to assume that cases have endured in some instances for forty years, and that the average duration is a long one. Through inheritance of cases, the author has been able to follow certain patients through a known period of at least twenty-five years, and is pre- pared to believe that some of them will add several years more before the end comes.* Such represent, however, the few surviving out of a large group observed, and in most instances of interstitial nephritis, as in chronic myocardial disease, a patient is far advanced before the disease is recognized or even encountered. Subacute Attacks. — Some cases, and especially those of the "mixed" type, are greatly jeopardized by the occasional occurrence of subacute attacks which may be sufficiently severe to produce symptoms of acute congestion or be so mild as to show little more than a few blood cells or epithelial casts. Prognostic Factors. — The occurrence of certain characteristic retinal changes, symptoms of marked and persistent or decidedly resistant cardiac incompensation and the appearance of waxy casts usually mean that the terminal * One patient whose case seemed very definitely to represent the consecutive small white kidney, died a short time ago in uremic coma after being under observation for twenty-four years. Strangely enough he had lived the life of a bon vivant for the greater part of that entire period upon the old theory of "a short life and a merry one." The old physician who attended him during his original attack twenty-six years before gave him two years to live and he proposed and proceeded to make the most of them according to his lights. Watch the heart. Support the heart. Extreme chronicity. Belated recognition. Intercurrent exacerbations. Heralds of death. 266 MEDICAL DIAGNOSIS stage has been reached though death may be postponed for a year or two in favor- able cases. Apoplexy. — As might be expected an apoplexy is a very common event, terminal or otherwise. TRENCH NEPHRITIS.— The attention of military authorities was directed to nephritis during the Great War of 19 14-18 because of the extent to which this disease played a part in the morbidity of attending Army service especially at the front, although there seems to have been nothing in the types of the disease occurring which would permit any separate classifica- tion or demand detailed consideration here. The term "trench nephritis" is not an accurate one, inasmuch as the disease occurred amongst men in all branches of the service though naturally to a greater extent amongst those whose duties were especially arduous and who were exposed most to cold, wet, and profound fatigue. The conditions of service at the front throughout the war were peculiarly trying, as all men know; minor infections were frequent and the relighting of hidden foci extremely common. Hence every condition suited to the redevelopment of an old nephritis or the excitation of an acute congestion or an actual acute nephritis was present. By far the greater number of cases were of such a nature as to suggest apparently the presence of a relatively severe degree of acute congestion or an actual acute nephritis. It would appear that for the most part the duration of these attacks was relativelv short and the mortalitv low. Diagnosis by association. Significant syndrome. Spleen and liver. Valuable guide. Bimanual palpation. AMYLOID KIDNEY Urinary Findings Indeterminate. — From the urine alone the diagnosis can- not be made in this disease, but the presence of conditions with which it is known to be associated, viz., chronic suppuration, chronic ulcerative tuberculosis, or inveterate syphilis, is suggestive, particularly if hepatic and splenic enlargement co-exist. Symptoms.— Polyuria with a large amount of albumin, hyaline casts in variable numbers, associated not infrequently with granular and occasionally fatty and waxy casts, constitute the urinary findings. The most significant diagnostic feature is the combination of polyuria, low specific gravity and a large albumin content in a patient showing the amyloid changes in the spleen and liver which usually occur in this form of nephritis. Edema and effusions occur as in other forms and cachectic fades is common. Other Differential Factors.— The urinary findings vary greatly and the total solids are usually little affected. The consequent absence of marked toxic hypertension and cardiac changes is of some diagnostic significance. MOVABLE AND FLOATING KIDNEY.— The normal kidney may or may not be palpable, but usually, in the female, its lower border may be detected under proper conditions of muscular relaxation and correct technic. Technic of Palpation. — To palpate the kidney, one hand should be placed over or just below the floating ribs behind, the other below the costal margin I on the outer side of the rectus abdominis border. By steady firm pressure DISEASES OF THE KIDNEY 267 Caution. Useful postures. Movable vs. floating kidney. the two hands should be approximated, during a forced full inspiration and allowed to separate slightly, when the movable kidney may be felt to pass between them and may be directly engaged and palpated during the maneuver. No attempt should be made to grasp the kidney primarily, and in any event it sJwuld be engaged between the fingers of the two hands by simple approxima- tion rather than by any grasping or clutching movement such as is sometimes recommended. Patient's Attitude. — Though ordinarily such an examination can be carried out when the patient is in a dorsal position, it is often useful to examine them in a position between the dorsal and the lateral, the arm on the side under observation being allowed to hang loosely forward and the patient receiving some support to relieve the abdominal tension. So also one may often rind that the organ is most readily reached when the patient is standing and bent forward or even when in the knee-chest position. Degrees of Renal Displacement. — The palpable kidney is one whose lower edge can just be felt by the examiner. Such a kidney is not abnormal; the movable kidney is that which slips back and forth like a "pea in a pod," or one which can be fixed by passing the examining fingers above its superior border during full inspiration. The term floating kidney is applied to those having more than a vertical displacement, or such as are vertically displaceable to a lower level than the umbilicus. The range of mobility is often extraordinary and in some instances the kidney may be found in the pelvis. Important. — Not infrequently albumin may be found in the urine after the kidney has undergone such manipulations and may lead to a faulty con- clusion. It is trivial, transient and unimportant. Etiology. — The disease is ordinarily congenital and but a part of what Stiller has justly called "asthenia universalis congenita." Almost without exception a floating kidney is associated with gastro ptosis, splanchnoptosis, a narrow, mobile, readily dilatable, low-lying, modified or typical, u drop heart," a more or less " phthisical" bony conformation of the chest and a more or less decided tendency to nutritional instability which may or may not be present at the time of examination. There is in such cases a congenital delicacy of structure and unstable func- tional and nutritional equilibrium of the utmost importance to both diagnostician and therapist. It is far more common in women than in men and most marked in multi- paras and in poorly nourished individuals. About three-fourths of the cases occur on the right side and in about one-seventh the condition is double. Congenital relaxation of the ligaments is primary, tight lacing and re- peated pregnancies, the wasting of the peritoneal fat of the capsule, trauma- tism or muscular strain increase the mobility and failure or marked de- pression of nutrition invites symptoms. In most cases a combination of these causes may be operative. A curious relationship, possibly associated with the enteroptosis, sometimes seems to exist between floating kidney and the occurrence of appendicitis. Manipulation- albuminuria. Usually congenital. Important associated conditions. Functional and nutritional instability. Increase of mobility. 268 MEDICAL DIAGNOSIS Production of symptoms. Symptomless cases. Ascending vs. blood-borne infections. Fever of infection. Acid urine. Rarely a colic Symptoms. — In well-nourished phlegmatic individuals extreme ptosis may exist without symptoms, while slight cases may contribute to the general discomfort in the undernourished individual. In view of the exaggerated importance attached to this condition by the laity it is often wise to withhold informatio?i from the patient where no symptoms seem to be present or where the condition is incidentally or casually encountered. When symptoms are present they vary from those of "nervousness," dyspepsia, troublesome psychasthenia, or hysteria, chiefly attributable to the general state of the patient, to the remarkable pain crises, first described by Dietl. Dietl's Crises. — These are attacks, sudden in onset, characterized by severe abdominal pain, nausea, vomiting, and in extreme cases, by chill, fever, and even symptoms of collapse. The utmost care should be observed in diagnosis, as errors are aston- ishingly frequent. The author ventures again to express the opinion, founded upon somewhat extensive observations, that true Dietl's crises are extremely rare; and that the appendix, gall-bladder, gastric ulcer, renal calculus, and especially gastroptosis with pyloric spasm are vastly more likely to prove the essential factors. PYELITIS AND PYELONEPHRITIS Definition. — By pyelitis is meant an inflammation completely or chiefly confined to the pelvis of the kidney; by pyelonephritis, an inflammation involving both the kidney substance and the pelvis. The former can hardly exist without a slight invasion of the kidney texture. Etiology. — Various microorganisms are capable of causing these condi- tions. Among these are: the pyogenic streptococci, staphylococci, typhoid and colon bacilli, gonococci and tubercle bacilli. Infection in some cases is ascending, the bladder or ureter being the pri- mary source. They arise also in connection with certain virulent acute in- fections or in those of the chronic sort, and under these conditions the infect- ive agent would appear to be brought directly by the circulation. Renal calculus is a potent cause, yet stones may exist for years in a kidney without causing any marked disturbance. Symptoms of Pyelitis. — An acute pyelitis is ushered in by fever, pain in the back, or tenderness in the region of the twelfth rib, and is usually marked by frequent micturition. The urine in acute, severe cases is diminished in amount, contains pus in quantity and is usually acid in reaction in primary pyelitis. The reaction is largely dependent upon the microorganism present. The colon bacillus, gonococcus, and tubercle bacillus are, fortunately, as- sociated with acidity. The staphylococcus, streptococcus and proteus cause an alkaline fermentation. The pain which is usually more or less severe at the onset even in simple suppurative pyelitis may be so extreme when, as sometimes happens, com- plete or even partial temporary blocking of the ureter occurs, as to simulate DISEASES OF THE KIDNEY 269 renal colic and may radiate in the same way to the groin, inner side of the thigh or testicle. Chill and fever may occur at any time during the course of an acute attack and certain' cases have been mistaken carelessly for malarial fever on this account. Occasionally in unilateral cases, the ureter or an affected kidney becomes blocked, and retention on the part of the unsound kidney permits a misleading secretion of normal urine from the sound side. In such cases a pyonephrotic tumor is evident on the affected side. So also masses of stringy pus and debris may produce obstruction at the neck of the bladder and pain simulating that of stone in the bladder. Sediment. — The urinary sediment shows large quantities of pus, a vari- able amount of blood, usually of the slightest quantity, and the more or less characteristic cells of the renal pelvis. Ordinarily one will rind also a few renal cells and an occasional cast. Under prompt and efficient treatment these symptoms rapidly subside so that in a period varying from a few days to two or three weeks, an uncomplicated simple case may recover. Symptoms of Pyelonephritis. — These are essentially the same as those of pyelitis, save that the amount of pus is usually larger and the sediment shows a decidedly greater number of renal elements. The characteristic features of the typical case are: (a) An acid urine, (b) containing pus, (c) yielding a sediment showing characteristic elements, i.e., casts and renal and pelvic epithelium. The picture may be much obscured by the presence of a complicating or primary cystitis, in which case the urine may be ammoniacal, and the sediment be so profuse and with such predominance of the cystic elements as to greatly obscure the diagnosis unless modern methods of direct exami nation are employed. RENAL TUBERCULOSIS Misleading findings. Cystitis vs. Pyelitis. Miliary. Its Two Forms. — This occurs in two forms — the acute miliary, which is merely a part of a general tuberculosis, and invariably obscured by the other manifestations of the disease, and, the so-called "tuberculous infiltration" {caseous form), which is of great clinical interest. The latter commences c usually as a miliary or larger nodule which undergoes much the same changes as would occur in other portions of the body. Either one or both kidneys may be affected and the process frequently involves the whole urinary tract, including the urogenital apparatus. Etiology. — Predisposing influences such as trauma, chronic cystitis, pyelitis, urethritis, and the congestion of pregnancy may play a part and it is unquestionably most frequent in persons of the congenital asthenic type who afford a favorable soil for the tubercle bacillus. Tuberculosis of the kidney is now regarded as primary rather than as- cending and we know that it tends to confine itself for long periods to a single kidney and spare the ureter and bladder. It is, therefore, a blood-borne infection and from the standpoint of actual origin is secondary to some pri- mary focus elsewhere in the body. Primary and blood-borne. 270 MEDICAL DIAGNOSIS Frank vs. latent case. Examine for t. b. elsewhere. Dysuria. Not always progressive. Scant findings. May or may not be symptomless. Diagnosis. — The diagnosis may be extremely easy or surprisingly difficult, the development being in some instances that of a frank tuberculous pyelitis or pyelonephritis. In others it pursues a latent course with no symptoms save those of irritation. In every case attention should be given to the organs so often secondarily affected, such as the spermatic cord, testis, prostate, and in the female the ovaries and tubes. So also persistent dysuria without signs of bladder disturbances sufficient to account for the condition will oftentimes prove to be of tuberculous origin. In most cases there is a slight elevation of temperature and, in a goodly number, tuberculosis present or past or a suggestive family history is made evident. Symptoms of lithiasis may co-exist and complicate the picture. The affected kidney may or may not be movable primarily and in some instances becomes greatly enlarged and readily palpable. According to the author's experience the caseous chronic tuberculosis of the kidney acts much as does tuberculosis elsewhere and may go rapidly to the bad, recover temporarily or even become permanently arrested, under the same general conditions as apply to tuberculosis of the lungs. Spontaneous healing under rest, improvement of nutrition and favorable environment is certainly more common than is generally believed. He cannot, therefore, coincide with the opinion expressed by some of our best surgeons that the tuberculous change is of necessity and invariably a pro- gressive and destructive one, however great the comfort and increased sense of safety conferred by nephrectomy in unilateral cases. In a considerable number of cases of slight involvement occurring in patients who declined operation and in a number who presented a double tuberculosis so advanced as to forbid operation, the process has shown the same or indeed a greater tendency to arrest than is observed in the lungs when proper conditions were obtainable. Finally, the diagnosis must depend upon the findings of the tubercle bacilli in the urine and their differential staining by proper methods and the localiza- tion of lesions by means of modern procedure. It must be remembered that they may be found in urines showing but the slightest traces of pus* In some instances the diagnostic use of tuberculin is justifiable and may be followed by the appearance of the bacilli in a urine from which they were absent previously. RENAL INFARCT. — This common condition may produce no symptoms sufficient to attract attention though in rare instances there may be localized pain and tenderness, chills, fever and vomiting associated with albuminuria and perhaps hematuria, f * In several cases recently observed the urine was almost clear and the only subjective symptom was a slight dragging pain over the kidney. t In case the urine is being closely watched, the author believes that even though subjective symptoms are lacking albuminuria will usually be present and hematuria more frequently than is taught at the present time. DISEASES OF THE KIDNEY 271 Such emboli may be suppurative, in which event renal abscess promptly follows, but they are usually non-infective and the irregularly contracted kidney of repeated infarction is a common finding in the autopsy room in connection with valvular disease and myocardial degeneration of the left chambers of the heart. A positive clinical diagnosis of renal infarction can rarely be made but their frequency in diseases involving the left heart should be held in mind. RENAL TUMORS. — Their general characteristics have already been described and the subject is one for surgical rather than extended medical discussion. The malignant hypernephroma is of congenital origin and springs from the suprarenal tissue. It and primary renal sarcoma are peculiarly frequent in children under ten years of age. Otherwise the tumors of the kidney are of the usual types. Malignant disease of the kidney occurs chiefly in children under ten and in adults over fifty years of age. An apparently causeless renal hemor- rhage should always suggest it as a possibility for it is present as an early symptom in from 80 to 90 per cent, of renal tumors and as the first sign in three-fourths of such cases. If tiny clots are present in urine which is but lightly blood-tinted and they are pale red, yellow or white, and of the size of maggots or tripper shreds, the probability of their origin in a malignant growth is somewhat strengthened. Such early hemorrhages as have been described in the preceding paragraphs may be wholly unassociated with pain. If the growth primarily affects the renal pelvis, large hemorrhages are the rule. Preoperative differential diagnosis of the different varieties of renal tumors is usually quite impossible. RENAL SYPHILIS. — Nephritis associated with the secondary stage of syphilis is bilateral and differs in no respect from other forms of Bright's disease save in its response to prompt antiluetic treatment. The rare cases of renal gumma are more likely to be unilateral and may exactly simulate a malignant new growth. In such cases even though the process seems far advanced, vigorous medi- cation will often result in prompt amelioration. RENAL CYSTS.— Classification.— We may divide renal cysts into four forms, viz.: (1) Simple solitary cysts. (2) Paranephric cysts. (3) Echino- coccus cysts. (4) Cystic degeneration. Simple Solitary Cysts. — These are simple hemispherical retention cysts, occurring chiefly in the aged, sometimes reaching a large size, and are caused probably by the blocking of certain renal canals, the formation of multiple small cysts and their ultimate fusion to form a single cavity. Differential diagnosis as between such a cyst and a hydronephrosis is often impossible before exploration. The use of the ureteral catheter is, of course, helpful and often decisive A surgical topic. Hyper- nephroma. Age incidence. Renal hemorrhage. Clots. Secondary bilateral. Tertiary unilateral. 272 MEDICAL DIAGNOSIS Usually escape diagnosis. Characteristic syndrome. Variable urinary findings. May produce cyst -like tumor. as to hydronephrosis. Aspiration yields indefinite results, should be always extraperitoneal and is no safer than an exploratory incision. The fluid from all renal cysts is practically the same, inasmuch as the urinary characteristics pertain to all. Paranephric Cysts. — These are clinical curiosities and their diagnosis from a differential standpoint is likely to be made only by the pathologist. Echinococcus Cysts. — These are relatively rare even in established echino- coccus infection. Small cysts must escape diagnosis unless they discharge their contents into the renal pelvis and large cysts seldom yield the pathognomonic hydatid thrill. If extraperitoneal aspiration or formal incision reveals the hydatid hooks or peculiar membrane, the diagnosis is positive. The content of the cyst is rich in chlorides, poor in albumin, alkaline in reaction, clear as water and of medium weight (specific gravity, 1007 to 1016). CYSTIC DEGENERATION OF THE KIDNEY.— This interesting con- dition is a polycystic degeneration honeycombing the parenchyma of the kidneys which are present as bilateral tumors and are found to consist of a multitude of small cysts varying from the size of a pea to that of a cherry. Diagnostic Signs. — If certain clinical facts are kept in mind the diagnosis of some of the cases of this interesting and relatively rare condition may be rendered reasonably definite. If one encounters bilateral tumors in the flanks associated with high arterial pressure together with uremic manifestations and cardiovascular signs of chronic nephritis, the diagnosis of congenital polycystic kidney is practically the only one fitting the symptoms. The urinary signs are not dependable but in many instances the clinical picture is that of an interstitial nephritis complete, with urinary casts and albumin, plus bilateral renal tumor. Hemorrhage is not uncommon and may be profuse. Leucin-like colloid bodies (Beckmann's rosettes) may ap- pear in the sediment. These show from two to five concentric rings and radiate striae. The tumors representing the degenerated kidneys need not be equal in size and unilateral cases are reported. Summary. — In the presence of such cases as show (a) bilateral tumors of renal origin, (b) high arterial pressure, (c) accentuation of the aortic second and mitral first sounds, (d) hypertrophy of the left ventricle, (e) uremic manifestations, (/) polyuria, (g) albuminuria and (h) the presence of hyaline casts, the diagnosis of polycystic congenital kidney may be made with some certainty. Even in the absence of distinct urinary findings, the cardiovascular signs and the bilateral tumors with or without distinct uremic manifestations make such a diagnosis wholry justifiable, the high arterial tension being especially suggestive. HYDRONEPHROSIS— Definition.— By hydronephrosis is meant an over- accumulation of urine within the kidney due to an obstruction in some portion DISEASES OF THE BLADDER 2 73 of its ureter, or, to a less degree, to persistent bladder retention. A persist- ence of this condition may result in a conversion of a kidney into a large cyst. If persistent the condition is characterized by the large cyst-like tumor which occupies the renal site and may fill and empty in intermittent obstruction. Etiology. — The condition may be temporary or permanent, persistent or intermittent, and it may be either congenital or due to disease. Among the causes are stricture of the ureter or urethra, calculi, clots, a twisted or com- pressed ureter, and in short any blocking of the urinary channel. The con- dition is commonly temporary and intermittent, but due in most instances to temporary torsion, pressure or removable obstruction. ACUTE CYSTITIS.— Etiology.— An acute inflammation of the mucous membrane of the bladder may be due to direct or hematogenous infection, to injury or irritation from calculi, foreign bodies, wounds and the introduction of sounds, or may be associated with urethritis, tuberculosis, prostatitis or mere exposure to cold and wet, sexual excess or the toxemia of infectious diseases. Symptoms. — The onset may be sharp with a decided febrile reaction. Dysuria with increased frequency and marked cutting, burning tenesmus are the chief symptoms, though pain may be severe and radiate, to the perineum, the glans, hypogastrium or thighs; fever is usually slight and may be absent. The urine is scant, strongly acid or variable, usually of high specific gravity and contains an approximately normal amount of solids, albumin, blood and pus in variable quantity. The sediment consists of pus and blood cells in quantity with much bladder epithelium and numerous round cells. CHRONIC CYSTITIS.— Etiology.— This may result from an acute attack or may insidiously develop as the result of an enlarged prostate, a stricture, the frequent use of the catheter, infection from the genitals (female), or from calculi, growths or tuberculosis affecting the viscus. Like every other hollow, muscular organ, the changes may be either atonic or hypertrophic and in many cases of long standing the bladder is greatly contracted and tends to become incrusted with urinary salts. Symptoms. — These are those of the acute form, usually in a milder degree both as to subjective symptoms and urinary findings, though in the latter blood is less often present in quantity, and the reaction is more likely to be ammoniacal. The solids are little affected and the sediment will show triple phosphate and often ammonium urate crystals if the urine is ammoniacal. Comment. — It should be noted that these cases, if primary, lack all evidence of renal involvement and that the albuminuria present is usually in direct pro- portion to the blood or pus from which it is derived. TUBERCULOSIS OF THE BLADDER.— A chronic cystitis presenting no symptoms of stone, stricture, or enlarged prostate, should always suggest tuberculosis. It usually involves primarily the trigone and the urethral orifices. The seminal vesicles and prostate should always be examined for nodular infiltrations and weight should be given to recent hemorrhages. 18 Persistent or intermittent. Dysuria and tenesmus. Contracted bladder. Source of albumin. 274 MEDICAL DIAGNOSIS Acid chronic cystitis. A cause of hematuria. Symptoms. — The appearance is that of a severe or mild chronic cystitis, with or without hemorrhage, but associated usually with acid urine. The diagnosis depends upon the finding of the tubercle bacilli, the use of the cysto- scope and in some instances the tuberculin test. TUMORS OF THE BLADDER.— These fall properly under surgery, and it need only be said that papillomata are the most frequent, aside from malignant growths of advanced age, and that they produce chiefly symptoms of chronic cystitis associated with marked intermittent hematuria. Occa- sionally bits of the growths may appear in the sediment, together with shreds of tissue and caudate cells from the villi of the growth. ACUTE PROSTATITIS.— This may result from the same causes that lead to an acute cystitis and is recognized by the swelling, heat and tender- ness of the gland, associated with throbbing, pain in the back and legs, dysuria and constant urgency, both rectal and vesical, with marked cutting, burning pain and tenesmus and increase of pain attending the end of urina- tion. Casts of the prostatic ducts may be present in the sediment and occasionally spermatozoa as well, otherwise the urinary picture resembles occasionally acute cystitis. Complications. — Prostatic abscess may develop and is usually associated with known symptoms of sepsis and may cause mechanical retention of urine. CHRONIC PROSTATITIS.— This is most frequent at advanced ages in connection w r ith chronically enlarged prostate, but may also follow acute attacks or be associated with chronic posterior urethritis. The association of modified symptoms of the acute form with palpable hypertrophy or swelling of the prostate associated with tenderness and the symptoms of chronic cystitis make the diagnosis. Chronic urethritis need not be considered in this volume. URINARY CALCULUS.— This most commonly occurs in the bladder or renal pelvis, but stones may also occupy the ureters. They vary in number from one to several hundred, and in size from a mere grain to that of a large orange. They also differ greatly in form, usually assuming the shape of the cavity in which they lie and occasionally being polished by attrition when several lie in contact. Uric acid, cystin, and phosphatic stones present usually a relatively smooth surface and the calcium oxalate stone is lobulate and rough (mulberry calculus). Uric acid and urates vary in color from pale yellow to deep brown, phosphatic stones are grayish or wmite, those of calcium oxalate deep brown, of cystin, yellow. Section should always be made to determine the constituents, as several concentric layers may be found. As to frequency, uric acid and urate stones predominate. In all forms the urinary sediment is likely to furnish suggestive findings during the stage of stone formation, con- taining the characteristic crystals of uric acid, ammonium or sodium urate, ! calcium oxalate, or triple phosphate crystals, etc., according to the nature of the process. Tests for Urinary Calculi. — The concentric layers should be sawed through and tests made from the scrapings of the different layers and of the powdered URINARY CALCULI 275 nucleus. The following table is taken from Dr. J. B. Ogden's admirable book.* CHEMIC EXAMINATION OF URINARY CALCULI 1 . Preliminary Examination. — Heat on platinum foil : Albumin = a flame with odor of burnt horn. Urostcalith = a flame with odor of shellac and benzoin. Cystin = a blue flame with odor of S0 2 . Xanthin and uric acid = char without a flame. Alkaline urates = alkaline residue soluble in H 2 0. Earthy phosphates = a residue soluble in acetic acid without effervescence. Calcium oxalate and calcium carbonate = a residue soluble in acetic acid with effervescence. Calcium carbonate = original powder soluble in acetic acid with effer- vescence. Calcium oxalate = original powder insoluble in acetic acid. Silica = residue insoluble in HC1. Murexid Test for Uric Acid. — Original powder + HNO3 and evaporate = pink residue + NH 4 OH = purple color = uric acids and urates. Original powder + HN0 3 and evaporate + KOH = violet color, which disappears on heating = uric acid. Violet increases on heating = xanthin. 2. Systematic Examination. — Presence of uric acid shown by (1). Boil in H 2 and filter. A. Filtrate +HC1. Let stand 24 hours = crystals of uric acid. Bases in solution. Concentrate. Calcium urate = 1 drop of solution + solution ammonium oxalate = crystals calcium oxalate. Magnesium urate = 1 drop of solution + NH 4 OH + Na 2 HP0 4 = crystals ammonio-magnesium phosphate. Sodium urate = 1 drop of solution + Pt.CU = after concentrating, prisms of sodioplatinic chloride. Potassium urate and ammonium urate = 1 drop of solution + Pt.CU = duodecahedra of potassioplatinic chloride and ammonioplatinic chloride. 'Potassium Urate. — Evaporate solution and ignite on mica. Residue -|- HC1 + Pt.CU = potassioplatinic chloride. Ammonium Urate. — Evaporate solution and ignite on mica. Residue = no crystals with'Pt.CU- B. Portion insoluble in H 2 0. Add HC1. Uric acid = insoluble. Calcium carbonate = soluble with effervescence. Filter + NH 4 OH = precipitate of calcium oxalate, calcium phosphate, and ammonio-mag- nesium phosphate. Wash. Calcium oxalate = insoluble in acetic acid. Filter -f- ammonium oxalate to filtrate. Calcium phosphate gives precipitate of calcium oxalate. Filter + NH 4 OH to filtrate = precipitate of ammonio- magnesium phosphate. * "Clinical Examinations of the Urine and Urinary Diagnosis." 276 MEDICAL DIAGNOSIS Seek the normal. Incentive to accuracy and thoroughness. Serious mistakes. The greater achievement. Economy of time. "Harking back." Fundamental knowledge and technic. Genius dispensable. METHODS AND MEANS EMPLOYED IN THE DIAGNOSIS OF THE DISEASES OF THE THORACIC VISCERA Methods of Chief Importance. — The elicitation and interpretation of the physical signs of disease chiefly depend upon: (a) Inspection, (b) Palpa- tion, (c) Percussion, (d) Auscultation, (e) Auscultatory percussion. (J) Fluoroscopy and X-ray photography. To a less degree in practice, one may employ certain other auxiliary methods depending upon special procedures or specially devised instruments of precision such as the polygraph and electrocardiograph* Proper Mental Attitude. — To establish the presence of normal conditions should be the primary aim of the examining student or physician. This makes both for accuracy of observation and thoroughness of ex- amination and the study of the physical signs of health, of normal breath sounds and heart tones, together with the character and extent of normal variation, is of the utmost importance to every student of physical diagnosis. Many damaging and even fatal errors result from the opposite attitude which leads one to seek primarily for rales or heart murmurs and, in their absence, fail entirely to note less obtrusive departures from the norm though these may be matters of even greater importance. To detect the weakened or modified heart sounds of acute or chronic myocardial weakness, a failing pulmonary second tone in pneumonia, the significantly widened area of a murmurless but rotten heart, are far more creditable achievements than the discovery of some frank murmur. Thoroughness. — Superficial examinations are fatal to reputation and prestige. True economy of time depends upon a correct and systematic technic, quick perception, and intense concentration. Avoidance of Multiple Repetitions. — As one avoids asking the same question twice, so should he try to fix firmly in his memory the physical signs as they are elicited, and the well-trained student will make a complete and thorough examination and draw his conclusions, while the poorly trained one is still running in circles. Essentials. — A knowledge of topographic anatomy and of the physiology and pathology of the structure under examination, a good technic and a practised hand, good eye sight and hearing, must be combined with an accurate knowledge of the physical signs of health and disease. Anyone who possesses his quota of members, normally acute special senses, and a combination of diligence and ordinary intelligence, can become a skilled diagnostician. * The polygraph, and electrocardiograph are very valuable instruments, adding much to the exactitude of cardiac diagnosis in the hands of a specialist, but their use by the general practitioner is limited because of the time required for special training and the considerable expense involved in their purchase and maintenance (see "Electrocardio- graph" and "Polygraph"). Mensuration is also used but is of comparatively little value and spirometry and pneumometry are of little use.. THE EXAMINATION OF THE CHEST 2 77 THE PREPARATION OF THE PATIENT.— Proper Light.— The chest surface should be adequately exposed and flooded with light having its source behind the physician who is thus aided in his search for physical signs, his study of physiognomy and the play of the patient's emotions. Being in the shadow he can, in some measure, avoid betraying surprise, disappointment or dismay.* Interest, cheerfulness, encouragement and calm are the only emotions which may be reflected in the face of the physician whether in the office, wards, or sick room. The Arrangement of the Clothing. — This must depend somewhat upon the sex of the patient. In dealing with women or young girls it is usually possible to conduct a satisfactory examination while some thin, soft garment loosely enfolds the patient save for that portion directly under examination. This should be so arranged as to enable one to shift it at will and expose any required area of the chest or abdomen while still preserving a comforting illusion of protective covering. In the male the chest should always be uncovered, and so also in the female if any real necessity exists or if by greater exposure some doubt may be resolved. /j" A Common Source of Error. — No proper examination can be made through heavy or starched clothing. Crepitations in lung apices or heart murmurs may be simulated by the crackling, rustling, or rubbing of superimposed material and their conduction obscured or lost from the same cause. Attitude of Patient and Physician. — Whether in or out of bed, a patient should, whenever possible, be in an easy, unconstrained position, the tissues relaxed and the shoulders square. In the examination of the lung apices especially, both face and chest should be squarely to the front and the head quiet; otherwise deceptive differences in percussion may result from muscular contraction. The physician, himself, should adopt the easiest and most unconstrained position possible for both percussion and auscultation. Changes of Position during Examination. — Whenever practicable and safe, patients should be examined both when recumbent and when sitting or erect, because of the peculiar postural variations of cardiac murmurs referred to further on. the modification of physical signs occasionally encountered in some of the pulmonary lesions and the effect of attitude upon pulse rate and rhythm. Important details. Women. Men. The patient. The physician. Important landmark. THE TOPOGRAPHIC ANATOMY OF THE CHEST Regional Divisions. — The "sternal angle," or " angle of Louis," is a ridge ^^- M - marking the junction of the manubrium with the gladiolus of the sternum. 77 indicates the lower border of the aortic arch, the bifurcation of the trachea, the junction of the borders of the right and left lung, and the second costo-sternal junction. * A matter of some moment in relation to sudden and unexpected revelations affecting intimate friends or relatives especially, as every physician of experience can testify. t Such is the confidence placed in professional honor and clean mindedness that the readiness to comply with such requests is usually a measure of the woman's refinement and real modesty. 278 MEDICAL DIAGNOSIS A useless landmark. 2nd rib above, 7th below. Interlobar fissure. Regional divisions. Topography. Apex resonance. Lung borders. Superficial cardiac area. Mid-clavicu- lar line. The Nipple. — The nipple indicates, ordinarily, the fourth interspace, but is subject to marked variation, both vertical and lateral, particularly in the female, and should not be used as a fixed landmark. The Great Pectoral. — The lower border of the pectoralis major should correspond to the upper border of the sixth rib. The Scapula. — With the arm at the side, the upper border of the scapula corresponds to the second rib; its inferior angle to the seventh or its interspace; the root of its spine to the third rib and to the starting point of the right interlobar fissure. Fig. 89. Fig. 90. Figs. 89 and 8. — Illustrating the absurdity of the mammillary (nipple) line as a landmark. The discrepancies of location encountered in the male are almost as marked. This fissure follows the vertebral border of the scapula when the corre- sponding hand is carried forward and across to the opposite shoulder and represents a region most important in connection with the primary line of invasion by the tubercle bacillus as first detectable by physical signs. The modern regional divisions and orientation lines necessary to verbal or written description are shown clearly by the plates. THE THORACIC VISCERA With Especial Reference to the Lungs, Pleurae, and Bronchi "Contained" vs. "Sheltered" Viscera. — The heart with its great vessels, the lungs and their primary bronchi, are contained viscera. The liver, spleen, and kidneys, and even a part of the stomach are sheltered viscera, though actually subdiaphragmatic and abdominal. The Lungs. — The lungs occupy nearly all of the upper chest, their apices extending usually to the level of the seventh cervical spine behind and 1 to 1 3^ inches above the clavicle in front. The right apex is slightly higher than the left, and their resonance may be elicited over the whole of the supraclavicular and suprascapular regions. The anterior borders of the two lungs meet at the sternal angle and, in contact, pass vertically downward to the level of the fourth cartilage. At that point that of the left lung passes outward, leaving a portion of the heart uncovered and forming the left border of the superficial cardiac area. That of the right continues downward to the sixth cartilage. Lower Borders of Lungs. — In the mid-clavicular line both lower borders are represented by the sixth rib and, from the axillary line outward, the lower borders of both lungs are practically horizontal. THE THORACIC VISCERA 279 Fig. 91. — Regional divisions of the chest (anterior surface-verticals). The various divisions are plainly indicated, a, a. Sternal lines, b, b. Parasternal lines. c, c. Midcla- vicular lines. In m id-axilla they cut the eighth ribs; in the scapular line, the ninth; and near the spine they reach the level of the tenth spinous process. Hence a line drawn from the sixth chondro-sternal articulation on the right side, or from the sixth rib in the parasternal line on the left side, to the spine of the tenth dorsal vertebra, indicates the in- ferior lung border in each instance. Sheltered Viscera. — Below the midriff, as before stated, is an important area including the liver, spleen, stomach and kidneys. The Liver. — The liver y lying beneath and adapting itself to the dome-like surface of the dia- phragm, rises into the thorax to a much greater degree than is shown readily by percussion, but absolute thoracic liver dulness begins at the lower border of the lung and extends downward to the costal margin. Its lower border crosses the epigastrium from the tip of the tenth right cartilage to the tip of the eighth left and meets the left extrem- ity of the organ in the fifth left intercostal space at a point closely approximating the loca- tion of the normal heart apex. Traube's Semilunar Space. — This is included between the lower border of the left lung, the spleen, the inferior costal margin, and the left lobe of the liver, and is normally hyper- resonant because of the under- lying stomach. Loss of resonance means pleural effusion or adhesions, enlargement or tumor of the liver or spleen, or massive growths of the stomach, kidney or bowel. The Pleurae. — The inferior folds of the pleural extend practi- _ n . a . ,. . . e ,, a , . , J J r r Fig. 92. — Regional divisions of the chest (posterior cally to the costal margin and, surface-verticals), a, a. Scapular lines. Axillary and scapular lines. Inferior lung border. Absolute liver dulness. Tracing the border. Normally tympanitic. Clinical value. 28o MEDICAL DIAGNOSIS Fig. 93. — Percussion areas, normal chest (anterior surface). Lungs — red. Liver — horizontal black lines. Relative cardiac dulness — vertical black lines. Absolute cardiac dulness — cross-hatching. Stomach tympany — oblique red lines. This repre- sents the incomplete cardiac area obtain- able by flat-finger percussion in the normal heart. The more modern methods closely approximate the x-ray outline and should be used^exclusively. Fig. 94. — Percussion areas (normal chest, posterior surface), a, a. Lungs. b, b. Pleural space, c. Spleen, c'. Liver. d, d. Kidneys. Area b, b yields percus- sion dulness from spleen, kidneys, and liver, unless lungs are- distended. Fig. 95. — Traube's space. Bounded by the lung, spleen and liver and the costal margin. Shows region of pleural sinus in which movable dulness may appear in left-sided pleural effusion. Fig. 96. — Lung boundaries (anterior surface). (Modified Panch-Fowler.) THE THORACIC VISCERA 28l therefore, lie much lower than the lung margin, being 2 inches inferior in the midclavicular line, reaching a maximum of 4 inches in midaxilla, and of 1% inches in the scapular line. It will thus be readily seen that any small e fusion of fluid into the left pleural sac will, if free, produce an area of movable or shifting dulness in Traube's space, and that any increase in the size of the left lobe of the liver or of the spleen may reduce its lateral dimensions. Furthermore, the flat note of free e fusion will extend lower than any form of lung dulness. The Lobes of the Lung. — Delineation. — A line drawn about the chest from the second dorsal spine through the armpit to the middle of the sixth costal cartilage, indicates the division of the lung into its upper and lower lobes. On the right side a second line drawn from the middle of the first line to the fourth chondro-sternal joint marks the upper boundary of the middle lobe. Relation to Surface. — The front of the chest, largely represents the upper — the back, the lower — lobe of the lung, the apex being accessible both anteriorly and posteriorly. The right middle lobe occupies a portion of the upper axilla and of the anterior surface of the chest. Important boundaries. Pleural sinuses. Upper and middle lobes. Right mid-lobe. Anterior vs. posterior. Right median lobe. 282 MEDICAL DIAGNOSIS The first glance. Certain negligible factors. EXAMINATION OF THE CHEST, WITH ESPECIAL REFERENCE TO THE LUNGS AND PLEURA INSPECTION. — A glance reveals the general contour, nutrition and muscu- lar development of the chest, the symmetry of the two sides, equality of expansion, the presence of scars, pigmentations, skin eruptions or abnormal growths, local bulging or retraction and the absence of normal or the presence of abnormal pulsations. Essential Points. — Inspection is a procedure of great value and its import- ance is too generally underestimated. In order that it should be properly done it is absolutely necessary that the source of light should directly face and illuminate the surface under examination. Furthermore, both anterior and posterior surfaces should be inspected not only in the usual manner but also from above downward and in profile, the patient sitting, the physician standing. In a bedfast patient these rules cannot always be fulfilled but should be observed whenever possible. The utmost care must be observed in the case of very sick individuals to avoid exhausting them by prolonged examinations or throwing an undue strain upon a weak heart by forcing the assumption of a sitting posture. General Form of the Chest. — Absolute symmetry is unusual because of slight lateral curvature of the spine, right- or lef t-handedness, or, the occupa- tion of the individual, and many variations in chest outline are trivial and negligible. Wasting and Deformity. — A slight wasting of muscle in the region of the lung apex is often more immediately important than some gross deformity. Fig. 97. — 1. Unilateral retraction. 2. Spinal curvature. Outline of horizontal section. {Gee; modified.) The kyphotic, scoliotic or scoliokyphotic deformities need no extended visceral discussion, but the student who has seen the bodies of markedly deformed crowding and ., , , , . _ . . ... .. . displacements . persons (hunchbacks) upon the autopsy table will realize the importance, to THE EXAMINATION OF THE LUNGS AND PLEURA 283 diagnosis and prognosis, of the extraordinary displacement and crowding of their thoracic viscera. Unilateral Enlargement or Shrinkage. — Unilateral enlargement may be due to vicarious emphysema, tumors, effusions, or congenital or juvenile heart disease. Unilateral shrinking indicates pleuritic adhesions, cirrhosis, pulmonary collapse or cancer. Harrison's Grooves. — These are zones of retraction frequently encountered in delicate asthenic children who, by reason of congenital asthenia combined with the obstructive effect of adenoid disease or hypertrophied tonsils, have persistently imperfect lung expansion leading to partial atelectasis (air- lessness) of the lung margins and chronic retraction of the chest along the line of the diaphragmatic attachment. Fig. 98 — 1. Normal chest. 2. Pigeon breast. 3. Rickets. {Gee; modified.) 4. Emphysema. General Deformities. — (Chiefly congenital.) — Among these are the rachitic chest, the transversely constricted chest, the flattened chest, pigeon breast and the "trichterbrust" (funnel breast). Emphysema. — The true " barrel-shaped " chest of advanced emphysema is ordinarily manifest only when the compensatory curve of the spinal column A common stigma. The barrel chest. 284 MEDICAL DIAGNOSIS Obscurant spinal curve Chest of forced inspiration. Overdistended inelastic lungs. The winged chest. Opposite of the barrel chest. Common forms. Rachitic rosary "Funnel' breast. is straightened out by placing the patient in the dorsal recumbent position on a table or firm mattress. Such a chest often appears flattened anteriorly when the patient is erect, the shoulders being rounded and slightly stooped. The chest outline in emphysema is that of permanent forced inspiration, the epigastric angle being broad, the neck short, the sterno-mastoid muscles prominent, the ribs unusually rigid and the movement more lifting than expansile. In such cases the lung borders are low; the range of their excursion lessened; the superficial cardiac area partially or more often wholly obliterated; the expira- tory element of the breath sounds is prolonged and the lungs unusually bright in the X-ray picture. The "Alar" Chest.— This, called also the "pterygoid," "paralytic" or 11 phthisical chest" has a small anteroposterior diameter, long vertical measure- ment, broad interspaces and narrow epigastric angle. If the patient is thin the neck is long and slender and the projecting scapulae give it its somewhat fanciful name. Of itself the possession of an "alar" chest or one of its modifications does not prove the existence of a tuberculosis but is rather one of the expressions of "congenital asthenia" which offers to the tubercle bacillus the most favorable soil for its development. The most striking examples are seen in cases of advanced tuberculosis with extreme emaciation, yet the same skeletal type of chest may be observed in plump individuals. Various Deformities. — The rachitic chest is best exemplified by the "pigeon breast," and the "transversely constricted thorax" indicates the coincidence of deficient nutrition and some chronic obstruction to breathing in childhood, usually adenoids. The line of retraction is that of the diaphragmatic at- tachment indicating its close relation to imperfect chest expansion. ^Rg T "'$SS£'' * ' ' - jfl IM&S>~'s-'f-;.'-.^ ^^" I*.. ■PSf -■'^■' Fig. 99. — Pigeon breast (rickets). Fig. 100. — Funnel breast (trichterbrust) . In this case congenital. A "beading" of the ribs at the chondro-costal articulations is well known as the "rickety rosary." "Trichterbrust" is of little importance in diagnosis, though an interesting and striking phenomenon. It is represented by a groove involving chiefly the median inferior portion of the chest deepening from above downward and corresponding to the second portion of the sternum, the ensiform often point- THE EXAMINATION OF THE LUNGS AND PLEURAE 285 ing sharply forward. Usually congenital, it may be occupational in those who in early life have performed work necessitating continuous pressure over this region. The " thorax en bateau" observed in certain cases of syringomyelia shows a deep anterior median groove of less limited vertical extent. Localized Changes in Outline. — These are of much more significance than general deformities, and marked retraction of one side or localized retraction in any area nearly always means an old pleurisy, fibroid phthisis, tuberculosis or injury. Apex Retraction. — Symmetrical retraction of the apices due to chronic nasal or tonsillar obstruction is common, is of slight importance in the absence of physical signs of disease and, even in adults, may promptly disappear after its cause is removed by operation. Unilateral supraclavicular, infraclavicular, or suprascapular hollowing suggests existing or past disease of the lung or pleura. CHEST MEASUREMENTS.— The life insurance requirements in regard to dimensions and freedom of expansion are extremely simple. They demand that the circumference of the chest at the level of the armpits shall equal one- half the height of the individual and that the difference between full inspira- tion and forced expiration shall not be less than 2 inches. As a test of lung capacity this last requirement is an absurdity, for one who under proper instruction cannot expand one-tenth his chest circumference in inches can hardly be considered normal* In measuring chest expansion, one should draw the tape very closely at the level of the nipple, especially in fat individuals. Abdominal measurement should show the maximum girth with lightly drawn tape and for full life insurance eligibility should never materially ex- ceed that of the chest in full inspiration, inasmuch as statistics show that such "bow-windowed" persons furnish a heavy early mortality. Marked unilateral variations in expansion, shown by measurements or visible to the eye, suggest retraction due to fibroid phthisis; pleural adhesions or spinal deformity; or the bulging caused by pleural effusions, aneurysm, congenital or youthful cardiac enlargement, or new growths. CHEST MOVEMENTS.— Normal breathing is of two types: (1) costal; (2) abdominal. The first predominates in corset-wearing women, the second in men. That of women is largely superior-costal, that of men combined in- ferior-costal and abdominal. In normal breathing, the ratio of respiration to pulse rate is about as 1 to : 4, its rate in the new-born being 40 to 45; at the age of five, 22 to 26. It should be symmetrical, easy and quiet, and the two sides of the chest should move equally and synchronously. Counting Respiration. — The respiration is best counted by watching the rise and fall of the epigastrium coincident with the action of the diaphragm or, * Oddly enough, athletes, and consumptives not too far advanced, usually show the highest figures in chest expansion, because both have been especially instructed and the latter practice deep breathing as a therapeutic measure. Congenital usually. Usually important. Symmetrical. Unilatc? al. Insurance requirements. An absurdity. Correct method. Ascertain maximum girth. Bow-windowed risks. Unilateral variations. Costal vs. abdominal. Normal respiration. ratios. A useful expedient. 286 MEDICAL DIAGNOSIS Phantom shadow. Cause. Normal range. Technic. Clinical significance. Subdiaphrag- matic abscess. A valuable adjunct. Wide range. in women, the rhythmic lift of the upper chest. If, at the bedside, one ostensibly counts the pulse, keeping the eye on the proper area, neither cloth- ing, nor bed covering prevents the use of this method nor does the patient's self-consciousness interfere. Litten's Diaphragm Phenomenon. — This is a phantom shadow of inspira- tory rhythm passing downward from the antero-lateral aspect of the sixth rib and vanishing just above the costal margin. It corresponds to the slight drag exerted upon the intercostal spaces by the rhythmically recurring separation of the costal and pulmonary layers of the pleural fold coincident with the descent of the diaphragm and the inferior border of the lung. In the normal chest its movements in forced inspiration and expiration should range from 2 to 4 inches. To elicit the sign the patient should be placed upon the back facing the light, the shoulders being somewhat elevated. The observer should stand with his back to the light 5 or 6 feet away, opposite the patient's knees. The illumination should come from one window only, and be not too intense. This is readily seen in all normal chests not heavily overlaid with fat, but is lost or interrupted in pleural adhesion. It is absent in effusion, pneumonia of the lower lobe or tumors occupying the lower chest, and absent or of lessened range in incipient or advanced tuberculosis and emphysema. All lesions involving the lung or pleura which check expansion diminish the range of the shadow and it is of special value in relation to the diagnosis of adhesions. On the other hand, tumors or fluid below the diaphragm may not entirely obliterate it, and as a differential factor in the diagnosis of subphrenic abscess it has not borne out its early promise. Fluoroscopic Method. — As the descending dia- phragmatic shadow accurately determines the relative range of excursion of the lower border of the lung, this constitutes one of the most definite methods of deficiencies of lung excursion due to the Fig. ioi. — Litten's sign. (a) Reduced excursion in pulmonary tuberculosis. (b) Normal excursion. presence of adhesions, emphysema and incipient tuberculosis, even a small area of tuberculous in- filtration often checking to a marked degree the movement of the affected lung. (See Roentgenography.) PALPATION Scope of Procedure. — Palpation as applied to pulmonary disease has chiefly to do with the detection of fremitus, abnormal pulsation and lung expansion; but also determines the form, consistence, extent, mobility and sensitiveness of morbid growths; the nature of swellings, the presence of abnormal heat, the loca- tion of painful areas, the presence or absence of moisture and the quality, fit and elasticity of the skin. THE EXAMINATION OF THE LUNGS AND PLEURAE 287 Friction sounds, coarse rales, the hydatid thrill or the crackling of a subcu- taneous emphysema may also reveal themselves to the fingers. Respiratory Movements. — In this connection, palpation confirms, cor- rects and amplifies the result of inspection. In deep breathing, expansion of the two sides should be uniform, coincident and equal. One notes: 1. Generally increased or diminished movement. 2. Unilaterally retarded inspiration (inspiratory lagging). 3. Unilaterally retarded expiration (expiratory lagging). Technic. — The hands are placed fairly upon the chest, palm down, and the patient sits facing the light while the physician, standing behind him, views the chest obliquely from above. Two pencils, toothpicks, or matches, placed vertically between the fingers better show the extent of the move- ment. For the upper lobe it is well to place the thumbs in the supraclavicular space and the fingers in the infraclavicular region. In examining the back the patient should be turned about. Justifiable and Necessary Departures from Formal Methods. — The examination of very sick patients must be conducted with whatever of adherence to strict form and rule the circumstances permit and no more. In some instances the physician's examination may be of so thoughtless a nature as to actually injure the patient or jeopardize his life. This statement is particularly applicable to the common custom of rais- ing very sick persons to a sitting posture in an attempt to examine the lung bases, when the same knowledge might be gained by having an attendant turn the patient on the side either wholly or partially as conditions may permit. In the routine examinations of known pneumonia patients sufficient access is usually obtainable with very little disturbance of one to whom sitting up in bed is a positive danger. The same may be said of victims of massive pleural effusions or the dilated heart of diphtheria. The author has witnessed two sudden deaths directly attributable to a failure to recognize the fact that if a patient is too ill to "sit up" he also may be too ill to be "set up." When the lungs of any person in the lateral decubitus are examined a slight allowance must be made for the compression of the thorax on the side in contact with the bed. This tends to slightly dull the percussion note, increase vocal fremitus and intensify the breath sounds. Deficient Expansion. — General bilateral lack of expansion may be due to pain, deficient lung capacity, emphysema, a rigid chest wall, or a lack of skill on the part of the patient. Many persons cannot breathe or cough to order and some do not know how to expand their lungs. Unilateral defects of expansion indicate a crippled lung or diseased pleura, be the cause what it may, the lesion ancient or recent. Pleurisy, pleuritic effusions, pneumonia, tuberculosis, pleuritic adhesions, a permanently retracted^wall, painful or obstructive lesions of the thoracically sheltered abdominal viscera, myalgia of the intercostals, and new growths, Proper light. Calamitous results. Often trivial. Important. Important associations. 288 MEDICAL DIAGNOSIS Significance of reversal of type. Epigastric movement. One cause of shallow breathing. Invaluatle in diagnosis. Counting. Normal predominance. Reversal of normal variation. Voice. Density of structure. Reinforce- ment. constitute the chief and most frequent of the causes of unilateral deficiency of expansion. Deficient upper-chest expansion in women, even if bilateral, suggests apex lesions or naso-pharyngeal obstruction, for costal breathing is the normal feminine type. Conversely, superior costal breathing in men should lead one to examine the lung bases and abdomen, and any lack of the normal inspiratory fullness in the epigastrium, unilateral or bilateral, such as is seen in diaphragmatic paralysis and painful abdominal affections should be carefully noted. The breathing of one who has a painful growth or inflammation involving a movable subdiaphragmatic organ is likely to be shallow and of the feminine type. Tender Areas. — In the detection of tender thoracic areas, the expression of the face is the safest guide. Vocal Fremitus.* — Vocal fremitus, that vibration of the chest wall and pulmonary structures caused by the vibrations attending the production of sounds at the glottis, is best detected by simultaneously placing the palmar sur- faces of both hands firmly upon the chest at corresponding opposite points. The patient is then asked to enunciate slowly, clearly, evenly, and repeatedly the word "ninety-nine, " the resultant vibration of the chest under the hands being noted and that of one side carefully compared with that of the other. It is a useful procedure alternately to raise and lower the palpating hands, thus rendering the contrast in fremitus more distinct, or to apply the same hand, first to one side and then to the other. Palpation often involves the use of one hand only, in unilateral localized lesions. There is normally a perceptible difference in fremitus as between the right and left side, especially in the region of the upper lobes, that of the right being the stronger. This difference is due in part to the larger size and more direct course of the right bronchus but also to the closer and more direct relationship of the right apex to the trachea. A marked difference is a suspicious sign, especially if the fremitus of the left side exceeds that of the right, and even an equality of fremitus should suggest an especially critical examination of both lungs. Laws of Fremitus. — Vocal fremitus conforms to the laws of sound conduction. In general it follows therefore: i. That, if free bronchial communication exists, the louder and deeper the voice, the greater is the fremitus. 2. The denser the conducting material, the greater the fremitus, e.g., con- solidated lung yields increased fremitus provided that it is in proper relation to a patent bronchus. Conversely the fremitus is relatively diminished over emphysematous lung or areas of pulmonary relaxation. 3 . The transmission of the sound through a tube and into an air chamber causes * The palpable vibrations attending cough ("tussive fremitus") and those due to stenosis of the air passages or their obstruction by exudate ("rhonchal") or "stenotic" fremitus) are of slight importance. THE EXAMINATION OF THE LUNGS AND PLEURA Structural homogeneity. Sound dampers. conservation and reinforcement of the sound waves and thus increases fremitus, e.g. } a cavity communicating with a bronchus causes increased fremitus. 4. The more homogeneous the conducting medium-, the greater is the intensity of transmitted vibration (fremitus). 5. The interposition of substances of a diferent molecular structure between the source of vibration and the conducting body or between the latter and the palpating hand acts as a damper and interrupts the conduction of vibrations — e.g., absence of fremitus in extensive pleural effusion, liquid or gaseous, or diminished fremitus in pleural adhesions, save in the case of bands or cords carrying vibrations to the chest wall from consolidated or compressed lung or patent bronchi. In the rare "massive" pneumonias the larger bronchi tributary to the area involved are filled with exudate which acts as an interposed barrier or damper to vibrations.* Deductions. — The following points are to be borne in mind: (a) Markedly increased fremitus points to consolidation of lung tissue or cavity formation. (b) Markedly diminished fremitus suggests emphysema, pleural adhesions, pleural new growths, pleural ejfusions, pulmonary edema or an obstructed bronchus. It is evident that the strength and pitch of the voice and the presence of fat and muscle modify fremitus. Any bilateral increase or decrease in corresponding chest areas is of com- paratively slight significance in the absence of otherwise demonstrable bilateral lesions, such as tuberculosis, emphysema, or hydrothorax. Pressure Palpation. — By a mere thrusting pressure of the finger-tips, or a thrusting stroke, decided resistance areas may be quite easily defined by the specially trained finger, and the resistance felt by the pleximeter finger is used, more or less unconsciously, as an auxiliary to percussion in outlining organs, detecting exudates and large areas of infiltration. PERCUSSION The Finger as a Pleximeter. — The body may be directly struck with the "immediate' tips of the fingers {immediate} or a pleximeter, such as the finger, an oblong percussion, piece of hard rubber, or a pencil, may be struck by the finger or by a percus- sion hammer {mediate). It matters little what the physician uses as a pleximeter provided he adheres to one method, but the finger is something which cannot readily be lost or left behind. The percussion stroke is best made with the middle finger, and should be 1 delivered with a loose wrist as if striking a single note on the piano. Whether it be "staccato" (quickly rebounding), a mere dropping of the hand, or, sustained, depends upon the structure percussed and the direct purpose of the individual stroke. * The interposition of a lead joint constitutes a common device for cutting off sound conduction in an iron pipe circuit. 19 Massive pneumonias. Increase. Decrease. Variable factors. Bilateral variations. Unconscious use of method. 290 MEDICAL DIAGNOSIS "Staccato" vs. sustained. Avoidance of technical error. Accurate comparison Concentration upon tone. Direction of stroke. Defining boundaries. Respiratory stages. Important. Seldom needed. Fig. 102. — Percussion of apex. One of several faulty methods. The pleximeter finger is not flatly applied to the chest. Over hollow air-containing organs or pulmonary cavities or under any conditions where hyperresonance or tympany is present or suggested the "staccato" stroke is preferred. A sustained stroke best brings out resist- ance and if exaggerated becomes a form of palpatory percussion. It is useless to get a special plexor and pleximeter, for two pencils, a coin and a pencil, etc., etc., are sufficient even for the rod pleximeter percussion. Vital Points in Technic. — (a) The strokes should be of equal strength over corresponding bilateral areas. (b) The pleximeter finger should be placed accurately, firmly and exactly but not too forcibly upon the chest and the pressure exerted should be equal over all areas under com- parison.* (c) Exactly the same areas on each side should be alternately percussed. (d) No change in position that involves sus- tained muscular action upon one side only should be permitted. (e) The attention should be so concentrated upon the tone elicited as to render unnecessary a prolonged tapping of the same region, with its resultant loss of time and dulled perception. (/) The direction of the stroke should be perpendicular to the surface percussed, except in defining the right or left heart border, in which instance one should maintain the same vertical plane throughout, regardless of the lateral curvature of the chest ("orthopercussion"). See percussion of the heart. (g) The force of the stroke should be determined by the nature of the underlying structures. (h) In outlining an organ, the pleximeter finger should be kept parallel to the edge of the object percussed. (i) The more forcible the stroke, the firmer should be the pressure of the pleximeter finger. (j) In critically comparing pulmonary tones, the same respiratory stage should be observed. (k) Percussion should be practised both after full expiration and deep held inspiration. (The lung note is normally more resonant and of higher pitch in the latter stage, the lung borders low and the superficial cardiac area diminished.) The nail of the plexor finger should be cut short so that only the pulp of the tip meeets the pleximeter finger, and as in golf, billiards or driving a nail, the eye should be fixed upon, and the stroke fall at, the exact center of the pleximeter. The finger is by far the best pleximeter for ordinary purposes and may be perfectly adapted to every useful type of percussion. Strong Percussion. — This may sometimes be useful when the chest wall is very fat or muscular or when one wishes to detect some non-resonant body * This "flat-finger" percussion should never be used to determine the heart outline. THE EXAMINATION OF THE LUNGS AND PLEURA 291 lying beneath one that is resonant, but should be avoided when possible as too greatly extending the area of vibration and confusing the results. A stroke loud enough to be heard throughout a large classroom is always faulty and the term- "strong" is relative and does not mean a pounding stroke. Light or Moderate Percussion. — This is the more generally useful form and especially so when one has to deal with children, a thin wall, or with a non-resonant body overlying a resonant one. Auscultatory Percussion. — The combination of auscultation and percus- sion is a valuable procedure in competent hands and especially so in deter- mining the boundaries of thoracic or abdominal organs, the detection of Fig. 103. — Normal chest. This figure shows the. conditions affecting percussion of the normal chest, a. Variation in shape and volume of the two lungs, b. Modified resonance due to ribs and sternum overlying pulmonary tissue, c. The uselessness of percussion near the spinous processes of the vertebral column. cavities, or the elicitation of the "coin sound" of pneumothorax. It may be practised by the "rod pleximeter" method with a small coin as plexor and a lead pencil as pleximeter, or, in pneumothorax, two coins. The stethoscope is placed over the part to be tested or bounded and an assistant percusses lightly, gradually receding until a point is reached at which the specific note is lost or abruptly and decidedly changed in pitch and quality. Mere gradual decrease of intensity is not definitive. It must occur abruptly* The heart, liver, spleen, lung apices, stomach and intestines are more or less readily and accurately differentiated, and, save the two latter struc- tures, delineated, by this method. Position of the Patient. — For percussion of the anterior surface of the lungs the hands should hang loosely at the side; for axillary percussion they should be placed upon the head; for percussion of the posterior surface they should be lightly folded in front, not placed upon opposite shoulders, inas- much as the latter position necessarily involves muscular tension that interferes with the elicitation of the true note. In auscultation, however, this position is useful in determining the condition of the interlobar region. * Much the same results may be obtained by stroking the surface, or by using a vibrat- ing tuning fork. Don't pound. Most used. A valuable subsidiary method. Abrupt transition important. Selective postures. 292 MEDICAL DIAGNOSIS Descriptive terms. Practice on the normal body. PERCUSSION SOUNDS.— It is customary to describe the percussion notes as "resonant," "hyper resonant" "tympanitic" "dull" or "flat." Nothing but practice will serve to differentiate these sounds but any one of them may be elicited and studied through percussion of some portion of the normal body. Normal Areas Available for Comparative Study. — The typical normal pulmonary resonance is that of the upper axilla, and its pitch, intensity and duration should be carefully noted and compared with that normally elicited over the apices, interscapular spaces and lung bases. Dulness. — A didl note is yielded by the liver below the lung margin and modified dulness just above this point, where only the thin wedge-shaped lung border intervenes. ^r Fig. 104. — a. Normal. d. Hyperreso- nance (emphysema) . b. Heavy and c, light percussion over consolidation. Fig. 105. — a. Dulness from thick wall. b. Pleural adhesion, c. Normal, d. New growth. tff -> Normal Resonance. -4fj(|J] * Increased Resonance. -4 > Dulness. Both are extremely valuable for training the ear and acquiring an apprecia- tion of "resistance" to the pleximeter finger. Flatness. — The flat note may be elicited by percussing the thigh or the deltoid muscle. Tympany. — The tympanitic note is yielded by the stomach or intestines as in Traube's semilunar space, and an extremely important modification, viz., dull tympany is heard over the main bronchi close to the sternum or over the upper sternum itself. Characteristics of the Percussion Sounds. — All percussion notes possess certain well-recognized characteristics and ordinary percussion also de- termines resistance as felt by the pleximeter finger. Cardinal Factors. — Each sound has a certain quality, intensity, pitch and duration. ■ Intensity depends upon the energy and amplitude of vibrations. Pitch rises with increase of the rapidity of the vibrations, varying with the tension. Quality depends upon the material. THE EXAMINATION OF THE LUNGS AND PLEURA 293 Duration varies with the strength and amplitude of vibration and the density and tension of the structure. Increased resistance goes hand in hand with dulness, and guided by this alone a stone-deaf man might make a very fair percussor. In general, the more air the organ contains and the greater its deep diameter the more marked is its resonance. THE NORMAL PERCUSSION SOUNDS.— It is important that the normal variations peculiar to (liferent areas of the chest should be held clearly in mind, and these standard notes can be learned only by painstaking practice upon a sound chest. The Apices. — The apices yield normally a resonant note, clear but not intense and tending to rise in pitch and shorten in duration (dulness or "im- paired resonance") as the pleximeter ringer approaches the vertebral line posteriorly, or the trachea, anteriorly. The Infraclavicular Region. — The mid-infraclavicular space is typically resonant, the pitch of the percussion note being slightly higher upon the right than upon the left side. Primary Bronchi. — As stated, any tendency to approach the region of the trachea or a primary bronchus results in a note of heightened pitch, increased resistance, and shortened duration (impaired resonance or modified dulness). The Hepatic Area. — Below the right second rib anteriorly there is increased resonance until the fifth rib is reached, when the pitch rises because of the underlying solid tissue of the liver. At the sixth rib resonance normally ceases and a line of absolute dulness marks the lower limit of the lung and the upper border of the uncovered surface of the liver. The Axillary Region. — In the axillary region typical pulmonary resonance persists until the seventh interspace or eighth rib is reached (lung border). The cardiac area markedly modifies the percussion note of the aspect of the left chest anteriorly from the lower border of the third rib downward within the mid-clavicular line. Anteriorly along the whole internal boundary of the lung the note rises as one approaches the sternum. Clavicular Percussion. — The clavicle is usually utilized as a pleximeter and directly percussed and its center yields a markedly resonant note. Internally and externally, pitch and resistance rise rapidly, but as a pleximeter the author believes it to be extremely fallible and often misleading. Posterior Surface. — Here the height and mobility of the apices are best, determined by carrying percussion upward during a forced and held inspira- tion, marking the limit of resonance, and repeating the procedure during forced and held expiration. Mere increase of intensity in the pulmonary tone in inspiration over that of expiration proves nothing. // is the extension, and diminution of the area of resonance that is important. The heavy muscles covering the back make necessary the use of greater force and the note is less clear and satisfactory than in front. This is particularly true of percus- Air content. Study the normal. Typical, resonance. Modifiers of tone. Modified hepatic dulness. Absolute hepatic dulness. Heart dulness. Unreliable. Apex percussion. Resonant area. 294 MEDICAL DIAGNOSIS sion over the scapula itself and a glance at a transverse section of a chest shows the general futility of percussion near the spine, save for the determina- tion of Grocco's triangle. Passing downward, the superficial liver dulness marking the lower border of the right lung is encountered at the ninth rib in the scapular line. Auscultatory Percussion of the Apices.— By placing the stethoscope bell over the suprascapular space and making direct percussion upward over the Liver dulness Valuable but fallible. Fig. 106. — Normal apex resonance. Kronig's method. Fig. >7. — Retracted left apex. Kronig"s method. Fig. 108. — Anterior surface. Lung borders. Forced inspiration. Fig. 109. — Lateral surface. Forced expiration. apex one may mark the upper limit of resonance in full inspiration and expiration. Then without moving the stethoscope the summit along the suprascapular space should be directly percussed from the center outward to right and left to determine the lateral boundaries of transmitted resonance. The use of this method with the stethoscope well below the clavicle will determine approximately the anterior upper level of the apex and THE EXAMINATION OF THE LUNGS AND PLEURA 2 95 the breadth of the resonance zone in the upper subclavicular region. This method, though fallible, is of great value in detecting obscure apex lesions. Kronig's Method. — Kronig uses a light, ringer to finger, percussion mak- ing firm pressure with the pleximeter finger and outlining the whole field of apex resonance. He lays much stress upon, what might seem to many, minor details.* Fig. no. — Anterior surface. Lung borders. Forced expiration. Fig. in. — Lateral surface. Lung borders. Forced inspiration. Fig. ii2. — Posterior surface. Lung borders. Quiet breathing. Fig. 113. — Posterior surface. Lung borders. Forced inspiration. The Lung Borders. — The position and mobility of the lung borders are affected in every serious chronic disease of the lung. In tuberculosis, they show a decided lack of mobility, both at apex and base. * See Deutsche Klinik., Band ii, 1907. Important sign. 296 MEDICAL DIAGNOSIS Compressed lung bases. Of limited utility. In true emphysema, and to a less degree in vicarious emphysema, in pulmonary engorgement and obstructive dyspnea of any type, they are lower than normal at the base, and markedly lacking in range of movement.* In fibroid phthisis, chronic pneumonia and pleural adhesions the change in position and movement is a striking symptom. In Figs. 108 to 113 the respiratory changes of the lung borders are clearly shown. // must be borne in mind that all sound lungs cannot be held to the same limits, that equality of movement as between the two sides is the real test and that a i considerable displacement accompanies mere change of posture. High Inferior Lung Borders. — The lung may be crowded upward or aside by pericardial exudates, a dilated heart, malignant growths, pleural exudates, I meteorism, ascites, or abdominal tumors, and thus an atalectasis may be pro- 1 duced in cases of long standing sufficiently complete to yield a misleading dulness at the bases, though the commoner finding is the hyperresonance of relaxed lung tissue. Fig. 114. — a. Pleural effusion, b. Hyper- Fig. 115. — a. Hyperresonance over re- resonance above fluid exudate, c. Normal laxed lung surrounding tubercular focus, lung. (Some vicarious emphysema.) b. Normal, d. Superficial cavity, e. Thick- walled cavity. *fH|{ > Normal Resonance. •♦tfiffl — > Increased Resonance. •4 » Dulness. Spinal Percussion Zones. — The spine yields a peculiar note susceptible of division into dulness, osteal resonance, modified resonance and fiat tympany (Fig. 115). The osteal tones are so affected by the adjacent structures as to yield some information of value in certain thoracic and abdominal lesions. Thus, "A" would be lengthened in mediastinal tumor and shortened in hyper- trophic emphysema. "B" would be affected by adjacent pulmonary con- solidation or pleural effusion (see page 291). "C" may be affected by hepatic renal, pancreatic or gastric growths. Most painstaking practice is necessary if one would obtain much * In vicarious emphysema the loss is less marked. THE EXAMINATION 01 IIN' LUNGS AND PLEURA 297 information from these areas and it seldom offers diagnostic information which is not elsewhere and otherwise obtainable by more reliable signs. Hyperresonance. — This, a note of lower pitch, relatively longer duration and greater intensity than that yielded by normal pulmonary tissue, is heard listended, relaxed, or emphysematous lung tissue. Low pitch and long duration. Dulness (1st to 4th D.). Ostial Resonance (5th to 12th D.). Flat Tympany (Sacral/ Fig. 116. — Spinal percussion zones. {Koran yi — DaCosta.) Fig. 117. — Emphysema. The distended air-cells and voluminous lung are clearly shown. In some cases of senile (atrophic) emphysema it is replaced by a note that is distinctly high-pitched and somewhat lacking in resonance. Well- defined hyperresonance may be encountered at the lung bases in cases where extreme intra-abdominal pressure exists with upward displacement of the diaphragm and the sheltered abdominal viscera or, as previously stated, the inferior lung margins may be dull and silent under such con- ditions, if of long standing, because of complete marginal atalectasis. Intra- abdominal pressure. 298 MEDICAL DIAGNOSIS Drum-like note. Cavity or hollow viscus. Pitch of note. Excessive tension. Misleading dulness. Free exudate. The "jug sound." How imitated. Effect of tension. How imitated. When normal. Cavity sign. Necessary maneuver. Other associations. Sign of "open" cavity. Effect of posture. Tympany. — Tympany is characterized by its clear, hollow, drum-like quality which is most typically shown in percussion over large, smooth, elastic, thin-walled, empty cavities. The intensity and pitch of a pulmonary tympanitic note varies greatly with the size of the cavity in which it is produced, the thickness of its walls, its proximity to the surface, and the size of the communicating bronchus. The larger the cavity the lower the pitch; the greater the size of the communicat- ing opening, the higher the pitch; and, lastly, the pitch of the percussion note varies directly with the tension of the walls. The tympanitic quality of any note may be lost if tension reaches a certain point. Tympanitic Note in Pneumothorax. — In open pneumothorax the percus- sion note is extremely drum-like over the air-filled pleural cavity, but it should not be forgotten that in certain of the cases of valvular or closed pneu- mothorax the percussion sound is quite distinctly dull because of extreme high tension. It may be metallic, but is never flat, as in the case of liquid effusion, save at the base where a small associated free exudate is usually present. Amphoric Percussion Note. — This relatively high-pitched, hollow, metallic note indicates a large, superficial, thin-walled, smooth, tense cavity, either wholly closed or not freely communicating with a bronchus and so formed as to produce selective reinforcement of vibrations. This tone can be closely imitated by snapping the cheek with middle finger and thumb when it is strongly distended and the mouth closed. It will be noticed during such a test that certain degrees of increase of tension tend to increase the metallic quality of the tone. SPECIAL MODIFICATIONS OF THE PERCUSSION NOTE.— The Bruit de pot fele. — This is precisely like the " chinking" produced when the borders of the palms of the hands are placed transversely together so as to leave a central air space free and struck sharply against the knee. It may be present normally in the thin, elastic chests of children percussed while they are crying. In the adult chest it can be obtained most readily, in the infraclavicular region if there be a superficial cavity with thin walls and either a stenotic or "slit-like" opening. The mouth should be open and the heavy percussion applied during expiration. This sign may be, but rarely is, present in open pneumothorax; in the vicinity of pneumonic areas; or above a pleural effusion. Friedreich's Phenomenon. — The percussion note over a cavity may be higher during deep inspiration than in expiration. Wintrich's Phenomenon. — The pitch of the tympanitic percussion note over an open cavity is higher and clearer when the mouth is open. The changes are best appreciated when the examiner's ear is kept close to the wide-open mouth of the patient inasmuch as the amplification and reenforcement of the percussion vibrations transmitted by the bronchi and trachea are amplified by the pharyngeal and buccal walls. If the cavity contains fluid, change of posture may block the opening of THE EXAMINATION OF THE LUNGS AND PLEURAE 299 bronchial communications by closing the cavity and abolish the sign until another position is assumed. High-pitched trachea! tympany of the same type as regards its tonal changes sometimes occurs over infiltrated or compressed lung tissue of the ordinary type {William's tracheal tone); or over the manubrium in certain cases of mediastinal new-growth, aneurysm or massive pericardial effusion (Hoover). Biermer's Sign. — In hydropneumothorax the percussion note is higher pitched when the patient is in the erect or sitting posture than in recum- bency because of the distribution of the fluid in the latter position which is such as to increase the long diameter of the pleural cavity and lengthen the vibration of the overlying chest wall. Gerhardt's Sign. — This term is applied to the well-known postural variation in the percussion note over a cavity, and is, of course, dependent upon the presence of movable fluid in a vomica freely communicating with a bronchus and possessing unequal axes. // is a Biermer's sign in miniature. Coin Sound. — This is described under " Auscultation." Skodaic Resonance. — This hyperresonant or tympanitic note is heard over relaxed lung tissue, as, for example, in pleuritic effusion above the level of the fluid; in the neighborhood of an advancing pneumonic consolidation; in early edema of the lungs; to a lesser degree, in certain stages of incipient apical tuberculosis, and in pressure upon lung tissue by massive pericardial effusions, new growths or aneurysmal tumors. In tuberculosis it may prove puzzling and lead the physician into a futile search for a lesion in the less resonant sound lung. Diminished Resonance. — As resonance varies directly with the amount of air in the underlying structures accessible to a percussion stroke, deep-seated areas of consolidation covered by air-containing lung tissue yield a mixture of the vesicular and dull note, such as is well illustrated by the relative dul- ness of the liver an inch or two above the inferior lung border. Large areas of consolidation at the surface of the lung yield a dulness exactly like that of the liver just below the lung border. Forms of Pulmonary Dulness. — It is obvious that subtle or decided differences must exist in the so-called "dull" percussion note and that these will depend upon the density and degree of airlessness of the tissue yield- ing it, as well as its depth from the surface, its size, its relationship to other more resonant tissues or organs and the condition of the neighboring or possibly enveloping lung tissue. Lobar Pneumonia. — If central, one may find primarily a hyperresonance which undergoes a gradual transformation to frank dulness as the process becomes superficial. So also in the stage of congestion our first percussion may elicit hyperresonance due to the disturbed tension of the tissues (relaxa- tion) and, for the same reason, as the process of consolidation advances, a band of hyperresonance may precede it. In frank established pneumonia the note is of a dulness comparable to that of the liver just below the lung margin and it is usually definitely limited by William's tracheal tone. Postural change of pitch. Miniature of Biermer's sign. Relaxed tissue. Associated conditions. A misleading sign. Deep vs. superficial lesions. Modified vs. true dulness. Variants. Misleading hyper- resonance. Important points. 3oo MKDICAL DIAGNOSIS Apex pneumonia. Hyper- resonance the nile. Effect of emptying. known lobar boundaries, most commonly being found posteriorly and, in the larger number of instances, on the right side. The upper lobes are often involved secondarily or even primarily, the latter locus being not uncommon in influenza and in the misleading tubercu- lous lobar pneumonia. If the bronchi leading to a pneumonic area are blocked {massive form) fatness results and the entire involved area becomes silent. Broncho -pneumonia. — Dulness does not characterize this form and if present is usually due to the fusion of lesser areas which may previously have been hyperresonant and are usually represented by strips of interscapular dulness or anterior zones along the lateral lung margins. These are usually best defined by light percussion but in exceptional cases a frank lobar consolida- tion is closely simulated. Fig. 118. — Lobar pneumonia (left); Central pneumonia (right). The lobar consolida- tion on the right side would present the classical signs of complete solidification with patent bronchi. The central area of consolidation might yield no percussion signs, or, hyperresonance, and be chiefly denoted by distant tubular breathing obscured by the vesicular murmur of over-lying lung-cells. Lung Cavities. — All pulmonary cavities may yield a dull, or if very large, a flat note when filled with secretion and one often finds a sudden transition from dulness to tympany after free and copious expectoration. Atelectasis. — The percussion note of a beginning compression atelectasis is hyperresonant because of tissue relaxation but when carnification occurs the airless tissue yields a dull note. (See pages 383 and 384.) Tuberculosis. — This ailment otters every variant of dulness calculated to perplex the physician. In early cases the patches are likely to be small and relaxation of surrounding tissue and vicarious emphysema add to his difficulties. Miliary cases of the pulmonary type offer as a rule only an extreme and significantly generalized hyperresonance.* Cavities may show central tympany or its modifications together with the marginal dulness of infiltration. * The author has never seen this sign given the prominence it deserves. The hyper- resonance is usually decided throughout on the lung but may be intensified over certain areas. Cyanosis is usually marked and the combination is of decided clinical value in the presence of fever. THE EXAMINATION OF THE LUNGS AND PLEURAE 30I Pulmonary Edema. — The primary percussion note of lung edema is hyperresonant but in prolonged cases the areas may become airless and the bronchi rilled with liquid, in which event dulness or even flatness may be present as in the case of massive pneumonia. Flatness. — This characteristically dead or toneless note indicates dense adhesions, liquid pleural effusions or solid growths in close contact with the chest wall. The sound is of great assistance in differentiating the puzzling cases of pleural effusion in which the breath and voice sounds have almost precisely the character of those heard in pulmonary consolidation. It is by no means a difficult matter to distinguish between dulness and flatness. The cardiohepatic angle is represented by the resonant area in the right fifth interspace bounded by the cardiac right border and the hepatic Fig. 119. — Various forms of pulmonary cavities; incipient tubercular deposits; area of softening. dulness below. Its angular outline is lost to percussion early in pericardial effusion* ("Rotch's sign") right-sided pleural effusions and adhesion, and right-sided basal pneumonia. AUSCULTATION Unilateral vs. Bilateral Variations. — The first law of auscultation demands that the test of symmetric breathing shall precede inference. In other words, before concluding that a slight departure from the type of breathing on one side represents a pathologic change, the corresponding opposite area should be investigated. Slight symmetric departures from the normal are often transient and negligible. Basis of Auscultatory Phenomena. — The art of auscidtation rests upon the same laws of sound as underlie palpation and percussion. The sound heard when the ear is applied to the chest is chiefly produced in the glottic chink, but transmitted and modified by the bronchial tubes, lung tissue and chest wall. The nearer the ear approaches the glottis, the greater is the predominance of a tubular element in the sounds heard and if the normal pulmonary structure * This, despite the fact that the profile X-ray picture may show preservation of the angle with outward displacement. Growths'and liquid" exudates. Rotch's sign. Fundamental rule. Rationale. Glottic proximity 302 MEDICAL DIAGNOSIS Variants. Broncho- vesicular type. Bronchus caliber. Reinforced vibrations. Cavernous or amphoric. The voice. Diminished conduction. A huge cavity. is replaced by consolidation, the glottic sounds are transmitted almost unmodified. All degrees of shading may occur according to the situation of the areas of induration and their relation to the bronchi. If the patch of thickened lung be remote from the surface, a vesicular sound due to overlying pulmonary tissue will be superadded to, and modify the tubular sound. Again, the larger the bronchus that is in direct communication with the in- durated area and the more superficial the patch, the more intense will be the sound. Cavities. — Lung cavities in communication with a bronchus yield modifica- tions of the same glottic sound, and follow the same general law. In them we have a definite air chamber surrounded by more or less rigid walls of consolidated lung tissue. Fig. i 20. — Pleural effusion. Especial attention should be directed to the compressed lung of the larger effusion. If cavities communicate with an unobstructed bronchus, are wholly or partly empty, and if the communicating tube itself be unobstructed, the glottic sounds take on a hollow, metallic or even muscial quality from the walls of the cavity and thus modified will be transmitted to the surface of the chest. The intensity of conducted sound varies directly as the depth and intensity of the voice and inversely as the thickness of the chest wall. Interposition of Air or Fluid Between Lung and Chest Wall. — Any form of pleural effusion, liquid or gaseous, acts ordinarily as a damper to transmitted vibrations from the glottis. Hence, in any form of pleurisy with effusion, breath sounds are likely to be diminished or lost below the level of the fluid. Certain exceptions to this rule will be considered later (see "Pleurisy"). Open Pneumothorax. — It will be readily understood that in some cases of pneumothorax a free opening between the pleural cavity and lung may be present and that in such a case the physical signs would be those of a very large cavity. Mediate and Immediate Auscultation. — Auscultation may be either mediate or immediate at the pleasure of the auscultator. THE EXAMINATION OF THE LUNGS AND PLEURA 303 The Stethoscope. — As to stethoscopes, it matters little what one is used if the examiner is competent to interpret what he hears. Essentials. — The chief essentials in any stethoscope are: (a) That it shall clearly conduct sound in proper volume from the chest wall to the ear. (b) That its chest piece or bell shall be of a size adequate to the purpose of the instrument, yet not too large or of such a form as to make it impossible to examine thin chests or those of children. (c) That the ear-tips are of a form and size that will properly fit and com- pletely close the external auditory canal without exerting undue pressure. Many of the modern stethoscopes have a diaphragm and are especially useful in auscultatory percussion. The diaphragm intensifies breath sounds, heart sounds and murmurs but often obscures certain faint vibratory mur- murs, such as may be present in certain cases of mitral stenosis. Fig. 121. — Pneumothorax (left); encysted pleurisy (right). The author carries an instrument having a reversible chest piece, one side of which, the larger, carries a diaphragm while the other, of lesser area, is freely open, the original diaphragm having been removed. The chest piece revolves upon the branched, metal conduction tube in such a manner as to leave but one opening patent when either chest piece is employed. He uses also, on all stethoscopes, the frame devised by the late Dr. Arthur Sansom which is perfectly adjustable, being made of malleable metal that has a trifling but adequate resiliency and can be bent to any degree desired. These arms are so jointed as to close quite compactly for the pocket. The more complicated stethoscopes have not proven useful in the author's hands, nor does he believe that it is wise to use those which excessively magnify sound. After all, there is no stethoscope that equals the unaided ear, if that has been properly trained. High-pitched feeble sounds are often lost if the stethoscope alone be used and furthermore, one's ears are always li brought along.' n Familiarity with both mediate and direct methods is an absolute necessity. Cerebration the chief factor. Advantages and dis- advantages of diaphragm. Excessive magnification useless. MEDICAL DIAGNOSIS Study them. Avoid overpressure. Varying pressure. "Losing" extraneous sounds. Pre cautionary measure. The "Sandow Commoner Sources of Avoidable Error. — Every student should study care- fully the sounds produced by muscle contraction, joint motion, stethoscopic rubbing, the presence of hair or remnants of the almost inevitable porous plaster on the chest and also the curious crackles which may be heard over the female breast when this is fat and is subjected to firm -stethoscopic pressure. Muscle sounds, illary tremor or stethoscopic continue after breathing is stopped. If due to other muscular activity or joint motion associated with re effort, it will usually be evident that the patient is breathing over :!y* The presence of h demand the use of water or soap, and the peculiar superficiality of tlie breast crackles, their direct response to stethoscopic pressure the absence of re; dge of their occurrence over that region will prevent error. Stethoscopic Pressure. — The careless or inexpert frequentl much unnecess ■:.'- pain by applying forcible stetlwscopic pressure to tend: forgetting that only such :eed be applied as will accurately an zbly adapt the whole c: nee of the bell to the chest wall. In the- auscultation of heart murmurs, however, it is necessary to vary the contact, as systolic' murmurs are intensified and presystolic murmurs diminished by pressure, but painful, excessive pressure is seldom or never red. Quiet Necessary. — Whatever the form of stethoscope or the ph; natural or acquired power of concentration, a quiet place is essential to good work. Absolute quiet is usually unattainable however and the faculty of uncon- sciously "losing" extraneous sounds while detecting internal abnormalities may be developed to a remarkable degree : ~ be acquis Instruction of Patient. — It may be necessary to show the person under examination just how he should breathe, and ordinarily the mouth should be open and the respiration be thoracic, deep, uniform, regular and free both from blowing and purring on the one hand and extreme deliberation and Sandow-like i: pouter pigeon protrusion" on the other. If these precautions are not observed, accidental sounds will be abundant, disturbing and mis- leading. ! Extreme deliberation kills the pulmonary sounds, which should be dis- tinctly heard, whereas excessive straining procv:r- the misleading murmurs of muscular contraction. In any event it is well to observe and listen to a few of the patient's inspira- tion: before applying :?pe to the chest. Effect of Cough or Crying. — In broncho-pneumonia, or in early apical- tuberculosis, cough, or, in the child, crying, may develop well-dehned, pathologic breathing or suggestive modifications in areas previously silent. * The true source of such sounds oftentimes may be determined by having the patient go through the act of inspiration and expiration with the nostrils stopped and the lips tightly closed. THE EXAMINATION OF THE LUNGS AND PLEUR.E "- Attitude of Patient during Auscultation. — The position of the patient during auscultation should vary with the different areas under investigation, precisely as in percussion, save that the most effective examination of the region of the posterior interlobar space requires that the hand should be carried across the chest to the opposite shoulder. The scapula is thus carried forward and outward, and by its posterior border very nearly defines the posterior line of division between the upper and Pulmonary Areas Demanding Special Attention. — Fowler, of London, has emphasized the necessity for a special examination of certain auscultation areas. He shows that the physical of tuberculosis nearly always first appear at the apex; not the ex- treme tip. but a point nearer to the posterior than the anterior surface and somewhat external, and that they follow a definite "'line of march/' with respect to audibility, passing downward and into the upper portion of the lower lobe along the interlobular fissure. Regions Most Important. — With reference to tuberculosis the most important areas are: (a) Posteriorly, : oppo- site, the second dorsal spine but toward the scapula. (b) Anteriorly, at, or just below the middle of the clavicle. (c) The supra- a ~:dar spaces. (d) Along the inner border of the scapula, when the hand of that side rests upon the opposite shoulder. (e) The upper part of the axillary space. VESICULAR BREATHING.— Its characteristics are a peculiar, . rustling quality, low pitch, moderate intensity, and no definite break or silence interval between inspiration and expiration. The latter has no more than one-third the duration of the former, has less of the typical quality, and may be inaudible in ordinary auscultation. The sound is closely imitated in the prolonged after-sound of the soft, whis- pered enunciation of'F." PUERILE OR HARSH RESPIRATION.— Normal.— In the chest of a normal child, or when listening over a lung that is performing vicarious duties, one hears the so-called puerile breathing, which is practical". tensifed vesicular respiration. TJie prolonged after-sound of a loudly whispered "F" fairly represents it. Pathologic. — It constitutes in adults an important sign of broncho- pneumonia or vicarious overactivity and may be heard over the unaffected Fig. 122. — An important area. Fouler.) Position for auscultation of inter- lobar region. Posterior interlobar region. Tuberculous invasion. "Line of march." Normal breathing. -stated. Children. Broncho- pneumonia. Vicarious activity. 306 MEDICAL DIAGNOSIS Early tuberculosis. Of obstruction, Impaired expulsive power. Suggested ailments. Various causes. Incipient phthisis. Overrated. Spurious form. Title faulty. Impaired expansion. Normal over 7th cervical. side in phthisis, lobar pneumonia, or pleurisy with effusion and over the healthy portion of a diseased lung. It is, moreover, an early, important and suggestive sign of incipient tuberculosis when properly supported by other evidence and may of course be heard in certain pulmonic and extrapulmonic dyspneic states. Prolonged Expiration. — Aside from the stridor of obstructive or spasmodic dyspnea, a respiratory sound possessing this as its most marked characteristic is frequently heard on auscultation, and suggests at once a delayed ex- pulsion of air from that portion of the lung yielding the sign. If the expiratory note be high-pitched, a small area of infiltration is indicated; if the pitch be low, one thinks of distention or relaxation of the lung tissue, such as occurs in emphysema, chronic bronchitis, or in areas immediately surrounding an incipient tuberculous deposit. Absent or Suppressed Breathing. — Ab- sence of the breath sounds over any part of the lungs indicates feeble breathing, the interposi- tion of some substance between the lung and the chest wall, an obstructed chief bronchus or certain types of atelectasis. Senility, profound exhaustion, shock or collapse represent the first; pleurisy with effusion, closed pneumothorax, superficial filled cavities, and pleural growths or thick- ening, the second; and the rare cases of massive pneumonia prolonged pulmonary edema, pressure of growths or aneurysm, or occlusion by foreign bodies, the third. Suppressed or feeble breathing is common at the apex in incipient tuberculosis, when small multiple foci are enclosed by relaxed lung tissue. Such scattered foci are oftentimes too small to yield signs of infiltration. Cog-wheel Breathing. — Much stress has been laid upon this as a symptom of early phthisis. It is overrated and one should remember that mere nervousness may produce marked overaction of the heart, irregular and unequal inspiration, uneven muscular contraction and, therefore, "mislead- ing pseudo-cog-wheel breathing." The Genuine Cog-wheel Breathing. — // genuine, it should be heard when the breathing is regular and deep, and the heart action neither unduly violent nor greatly accelerated. The term "cog-wheel" is not descriptive. The breathing is wavy, and marked by distinct breaks and the change almost wholly pertains to inspiration. When genuine it indicates imperfect or irregular expansion of some portion of the lung. BRONCHIAL BREATHING.— Normal.— If a stethoscope be placed over the seventh cervical spine, bronchial breathing is heard normally. It differs from vesicular breathing in almost every particular. Both inspira- Fig. 123. — Selective points for manifestation of physical signs in pulmonary tuberculosis. THE EXAMINATION OF THE LUNGS AND PLEURA 307 Hon and expiration arc Hgk-pitched; between them is a distinct break. Expira- tion is greatly prolonged, its intensity being equal to or even greater than that of inspiration and its pitch usually higher. Pathologic— Such breathing indicates consolidation, cavitation or com- pression of lung tissue in close relation to a patent bronchus. Thus it is heard in pneumonia and established or advanced phthisical infiltration, over lung compressed by mediastinal or other tumors or by Fig. 124. — Malignant growth (left) and pulmonary abscess (right). The larger mass on the left side involves a bronchus, and would yield signs of consolidation. The anterior superficial mass would present only dulness, diminished voice and breath sounds, with defective lung movement on the affected side. Such abscesses as are here shown present few recognizable physical signs and are often overlooked. Malignant growths of the type shown are usually marked by hemorrhagic effusion. massive pleural or pericardial effusion, but still maintaining communication with a patent bronchus. Because of such compression probably, the locally intensified voice and breath sounds and especially the whispered voice are fairly well conducted from the condensed lung in some cases of effusion. In such instances the flat, toneless percussion note and usually (though paradoxically) a markedly impaired or wholly absent palpatory voice fremitus over the area of flatness suggests the correct diagnosis. The breathing is, moreover, usually distant though tubular in such cases. Occasionally, tense adhesion bands may act as transmitters of these sounds in cases of effusion. Broncho-vesicular Breathing. — Normal. — If the stethoscope be placed over the second intercostal space at the sternal border or is applied to the upper interscapular region of the normal chest, the sound conducted to the ear in a curious mixture of vesicular and bronchial breathing, the latter element being more marked in the expiratory phase. Pathologic. — There is no more important clinical study than this modi- fication, as it frequently represents early tuberculosis, compressed lung tissue, disseminated areas of infiltration or deep-seated central consolidation. TUBULAR BREATHING.— Normal.— Tubular breathing is that heard normally over the glottis and difers from bronchial breathing in being more intense and possessing a peculiar whiffing quality. Infiltration,, compression, or cavitation. Misleading variation. Corrective value of percussion. Heard nor- mally at 2d sterno- chondral angh Deep or disseminated consolidation. Normal over glottis 3 o8 MEDICAL DIAGX Cavity or superficial consolidation. Caution. Hollow and low pitched. Requisite conditions. Hollow metallic and musical. Indicates a cavity. Veiled Pathologic. — Its significance when heard over pulmonary areas is / in its association with cavity formation, bronchiectasis, and superficial consolida- ;' lung tissue. It is important that this breathing should be carefully studied, because of its intimate association with, or near likeness to, cavernous and amphoric breathing. Cavernous Breathing. — The sole important ' c between cavernous and tubular breathing lies in the fact that in the former the pitch is rel I ■:d the quality distinctly hollow. For its production a pulmonary or bronchiectatic cavity is necessary not less than an inch (2 cm. + ) in diameter, empty or partially so, with resilient walls, and free bronchial communication. Amphoric Breathing. — Amphoric breathing is exactly the same as : save that it possesses a distinctly metallic or musical quality, the sound resembling that produced by blowing across the mouth of an empty bottle. It is Jieard over very large superficial cavities and in open pneumothorax and approximates in quality its more complex equivalent, the exquisitely bell-like tone of the coin sound as heard best in pneumothorax. In all cases of cavity, free bronchial communication is necessary : production of the typical sound. Seitz' Metamorphosing Respiration. — Either or both elements in the cavernous or amphoric breathing may carry a simple tubular or bronchial element at its beginning which is transformed into the proper hollow or metal- he tone before the phase is completed. Bruit Voile. — Over infiltrated lung the breath sound may start as a cular sound and become broncho-vesicular or pure bronchial as it proceeds. Cardinal facts. Modified in disease. An important variation. VOCAL RESONANCE Normal. — If the ear or stethoscope be applied to the axillary region of a healthy chest, and the patient slowly and clearly repeats the word '•'ninety- nine," in the lowest range of his speaking voice, the voice is heard but the words cannot be distinguished; moreover, the ear recognizes the fact that the sound is produced at a point some distance from the stethoscope. Such normal vocal resonance is associated with a vesicular murmur and a normal percussion note, but in disease we find variations in vocal resonance to fit every variety of abnormal breath sounds and percussion tones. Important Precaution. — The head of the patient should be turned aside as the test words are spoken, or the misleading external sound may be further muffled by a handkerchief or towel held over the mouth. DIMINISHED VOCAL RESONANCE. — The following conditions usually result in diminution or loss of the normal vocal resonance : Normal Causes. — (a) Weak voice, (b) Excessively thick chest wall. Pathologic Causes. — (a) Emphysema or relaxed pulmonary tension from any cause, (b) Effusion into pleural cavity (liquid or gaseous), (c) Pleural growth or thickening, (d) Massive pneumonia (large bronchi blocked), (e) Occluded bronchus due to foreign bodies or to pressure. (/) Certain phases of atelectasis and prolonged pulmonary edema. THE EXAMINATION OF THE LUNGS AND PLEURAE 309 Increased Vocal Resonance of Heightened Pitch. — Vocal resonance may be only slightly increased in intensity but show a rise in pitch in cases of imper- fect or incomplete infiltration, or over cavities that are not surrounded by con- solidated lung tissue. BRONCHOPHONY ("Bronchial Voice").— "Normal— Bronchophony is normally heard best over the manubrium. At this point the voice or whisper seems to be directly at the mouth of the stethoscope and the sense of remoteness, so marked in normal resonance, is altogether lost. Pathologic. — Bronchophony is heard in varying degrees under the same conditions that produce bronchial and broncho-vesicular breathing. Namely, consolidation cavitation or compression of lung tissue directly connected with a patent bronchus. A faint bronchophony is sometimes termed a "bronchial whisper," but should be called "distant" or "faint" to avoid confusing it with "whispered bronchophony." PECTORILOQUY. — {Tracheal Voice) . —Normal.— Pectoriloquy corre- sponds to the normal voice as heard over the trachea. It differs from bronchophony in that the words seem to be distinctly articulated and spoken directly into the ear. j Pathologic. — -It is heard over superficial cavities, compression and consolidation. "Whispered pectoriloquy" is the term applied when the whispered voice is thus transmitted and is always pathologic* EGOPHONY. — Pathologic— Egophony is a peculiar modification of the voice sound that gives it a bleating or distinctly nasal character. It is most frequently heard at the upper level of pleuritic effusion, and, sometimes, just above the area of advancing consolidation in pneumonia. Attention is not infrequently directed to small pleural effusions, acute or subacute, by encountering egophony at the inferior angle of the scapula. Bell Tympany (Gairdner's Coin Test). — The coin sound proper is a peculiarly beautiful ringing bell-like note heard over the affected side in pneumothorax or some very large smooth-walled tense cavities when a coin is placed upon the chest and lightly struck with another. In eliciting it in pneumothorax the auscuitator usually applies his ear or stethoscope to the back and an assistant manipulates the coins upon the anterior surface of the chest. In certain cases representing either very low or extremely high tension the coin sound may be absent in pneumothorax until the tension is changed, f Amphoric Voice and Heart Sounds. — Metallic or amphoric resonance of the voice and heart sounds may be heard under conditions similar to those producing the corresponding breath sound and also at times because of the close proximity of a distended stomach. Metallic Chink {" Signe du Sou").— A metallic "clicking" or "chinking" * The whispered voice is not of glottic production and is almost inaudible over the normal lungs; wholly so as syllabic speech. t The author has never encountered such an instance in high pressure cases, even though the dulled percussion note was present. Heard nor- mally over manubrium. Distant broncophony. Normal over trachea. Superficial lesions. Whispered pectoriloquy. Nasal character. Accidental aid. Bruit d' airain. Technic. Misleading variant. 3io MEDICAL DIAGNOSIS Pleural effusion. Dry and moist. Sibilant and sonorous. Musical. Modifying factors. Significance. Obstruction or glottic paralysis. Cardinal points. Causes. may be elicitated over pleural effusions by the Gairdner coin test but is wholly different from the exquisite bell tone of pneumothorax. Over a pneumonic consolidation the sound is usually merely a dull thud. D'Espine's Sign. — This somewhat discredited sign is heard occasionally over the upper dorsal vertebrae in cases of tuberculosis of the tracheo- bronchial lymph nodes. It consists merely in a w T hispered prolongation of the final "e" of such words as "we" "three" or "tree" after the voice stops. RALES Their Genesis and Varieties. — Rales are either dry or moist, and a considera- tion of the anatomic structure of the lungs and pleura makes it easy to understand the mode of their production, their significance, and the varying qualities depend- ent upon the condition of the lung itself and the character of respiration. DRY RALES. — Aside from the friction rale, dry rales may be divided into two groups: (a) Sibilant or whistling, (b) Sonorous, "at one time resem- bling snoring, at another the sound of a bassoon, and very frequently it is like the cooing of a turtle-dove." They occur in all grades of pilch and intensity and in passing from the very feeblest wheeze or whistle {sibilant) to the most raucous sonorous rdle, the dif- ferences depend upon the size of the tube in which they are produced; its proximity to the surface; its relation to the consolidated areas; and the depth and character of the respiration itself. Such dry rdles alone or in association with others are most frequently found in bronchial obstruction, bronchitis, asthma and emphysema, but persistent dry rdles are common in incipient tuberculosis and may be distinctly resonant or consonating in the presence of consolidation. Consonance refers to the peculiar quality by virtue of which the striking of a certain note upon a musical instrument will produce sympathetic vibra- tions in other sonorous bodies as seen in the strings of a piano. Rales of various kinds take a higher pitch and changed quality in the presence of consolidation or modify their qualities to accord with the peculiarities of vibration encountered in cavities. Stridor. — Stridor is the loud, whistling sound heard when the trachea or a primary bronchus is obstructed by aneurysm, tumor or a foreign body, or in spasm or obstruction of the glottis by new growth, edema, false mem- brane, catarrhal swelling, abscess, or a foreign body. A similar sound is heard in paralysis of the abductors, such as may result from pressure upon the recurrent laryngeal nerve.* Moist Rales. — In the consideration of moist rales the chief points to be noted are: their character, "size," pitch, and resonance. A moist rale may be produced by respiration at any point from the glottis to a terminal alveolus and may be due to a, tracheal " death rattle;" to the inflow and outflow of air through bronchi filled with the thin, serous exudate of edema; to the mucous or mucopurulent secretion of bronchitis; the thick tenacious sputum of pneumonia, or the purulent fluid of a pulmonary cavity or pyopneumothorax. * See also "Stertorous" breathing. THE EXAMINATION OF THE LUNGS AND PLEURAE 311 Being oftentimes associated with consolidation of all kinds or cavity of any degree and originating in tubes of any caliber from that of the primary air passages to that of the terminal alveolar openings, it must vary with its surround- ings in pitch, quality, size and intensity. Crepitation. — This, the "smallest," "finest," "tiniest," of all moist rdles-, is usually a "shower" of tiny sounds like the crackling of burning salt or the crepitations produced by rolling between the fingers a lock of the hair in front of tlie ear. It is heard characteristically at the end of a full inspiration. Crepitation is not truly a liquid rale, but signifies merely that air is enter- ing into a collapsed vesicle and, at the end of inspiration, i.e., at the moment of maximum pressure, is forcing apart the collapsed and slightly agglutinated infundibular and vesicular walls. The exact period for each of the group of vesicles affected varies by the fraction of a second and thus is produced the "showers" of crepitation. The crepitant rale is one of the early physical signs of lobar pneumonia {crepi- tus indux); is not infrequently present in pulmonary edema, hemorrhage, infarction and incipient tuberculosis. It occurs as a precursor of resolution (crepitus redux) in pneumonia, and together with subcrepitant rales, or alone, may normally be heard with the first deep inspirations at the apex in persons who are habitually shallow breathers. It is present oftentimes at the base of the lung, when the first deep inspirations are taken, and, with considerable persistence, in persons suffering from exhausting disease, espe- cially if they have been lying for some time in the dorsal position. Such rales are also heard persistently at the lung bases early in pulmonary edema and the hypostatic congestion of cardiovascular insufficiency and constitute then a sign of importance. It should be borne in mind that they are heard only at the end of deep inspira- tion, for at first they may be confounded by the student with a more superficial pressure crepitation produced by his own ear or stethoscope but lacking the specific timing of the true crepitant rale. Both crepitant and subcrepitant rales may be closely simulated by modified friction sounds. Friction sounds are unmodified by cough, peculiarly fixed in their apparent point of origin, and are usually distinctly superficial. Oftentimes they are mani- festly intensified by firm stethoscopic pressure which may also reveal tenderness. "Crackling" Rales. — Three varieties of crackles are recognized by the diagnostician. The Subcrepitant Rale. — The fine crackling or subcrepitant rdles are pro- duced in the bronchioles, heard chiefly but not exclusively in inspiration and indicate, as a rule, commencing infiltration. Heard at the apices, they always strongly suggest an incipient tuberculous process; at the base, temporary atelectasis, pneumonia, congestion, or incipient pulmonary edema. They are heard early in resolving lobar pneumonia and are the dominant finer rales of broncho-pneumonia. Medium Crackling Rales. — These are of the same general nature as the foregoing, but coarser. They are heard over softening tuberculous areas, broncho- "Smallest' rale. How imitated. Probable rationale. Showers.' Associated lesions. Significant. Time important. Source of error. Modified friction. Differentia- tion. Not limited to inspiration. Bronchiolitic. Significance. Occurrence. 312 MEDICAL DIAGNOSIS Consonance. Resonant consonating rales. Cavity or pneumothorax. Tiny musical echoes. Pneumothorax. Rare source of error. A rub, squeak, creak or crackle. pneumonia, and resolving lobar pneumonia, change of pitch and quality due to consonance being marked in the presence of infiltration. Large Crackling Rales. — These are still coarser and more distinctly fluid than the foregoing and, if consonating, point usually to extensive softening in a tuberculous infiltration area. Mucous Click. — This sound stands midway between the crackling and the bubbling or gurgling rales. Its name is its best description and it is usually single and oftenest heard at the apices in tuberculosis. Bubbling Rales. — These liquid rales are true to name; may be small, medium, or large, and are usually readily recognized. Gurgling Rales. — These, also sufficiently described in the title, are usually heard over large pulmonary or bronchiectatic cavities during cough or forced inspiration, occasionally in bronchitis'with profuse exudate, and also over the drowning lungs in advancing pulmonary edema. Pitch and Resonance of Rales. — All varieties of rales have a certain pitch and degree of resonance, directly attributable to their surroundings. One that is produced in a bronchus or cavity surrounded by consolidated lung tissue or atelectasis will have many of the qualities of tubular or amphoric breath- ing, hence we speak of resonant rales, echoing rales, consonating rdles, etc., and these may be either moist or dry and at times metallic or ringing* SOUNDS APART.- — There are certain special sounds of great interest, and chief among these are "post-tussive suction," "metallic tinkling," and " succussion." Post-tussive Suction. — This interesting physical sign is pathognomonic of cavity formation and has been aptly termed "the india-rubber-ball sound." It is an inspiratory moist " sucking" sound supposed to attend the expanding of a "collapsed thin-walled cavity communicating with a bronchus. Water-whistle Sound. — A coarse, gurgling sound either inspiratory or expiratory may be heard in pneumothorax if communication with the lung exists (pulmonary fistula)-. Metallic Tinkling. — This term is applied to the exquisitely delicate and beau- tiful musical sounds sometimes heard over a very large wet cavity with dense smooth walls and, more commonly, in pyo- or hydro pneumothorax. The phenomenon is really due to the production of echoes, and when low-pitched is often termed amphoric tinkling. Hippocratic Succussion.— This is the well-known " swashing" or "slosh- ing" sound, often metallic, usually elicited by. the somewhat heroic measure of shaking the victim of a pyopneumothorax or hydro pneumothorax, or rarely, of some huge lung cavity containing fluid. A mere change in the patient's position or a gentle rocking of the body is usually a sufficiently effective maneuver. A similar sound may be heard over the stomach but is seldom so transmitted to the thorax as to cause confusion. FRICTION SOUNDS.— True friction is produced by the attrition of the I apposed pleural surfaces when rendered dry and harsh by inflammation; is usually unmistakable and often palpable. * As stated, it is well to remember that an overdistended stomach or colon may some- times thus influence rales produced over or near the inferior boundaries of the lungs. THE EXAMINATION OF THE LUNGS AND PLEURAE 313 pleura. It is quite closely simulated as to its common phases by the sound heard How imitated, when the palm of the hand is pressed firmly against the ear and the dorsum rubbed by the flat of the finger pulp under varying pressure. Distinctive Features. — The quality of the sound is creaking, rubbing, shuffling, rustling, or, more rarely crackling. It is ordinarily distinctly super- Superficial. ticial; commonly best heard in the axillary and inframammary regions and at the anterior lung margins; is usually jerky or interrupted in rhythm, associated with pain in deep inspiration in acute or subacute cases and unmodified by cough. Unmodified by If friction disappears from some site previously detected it may sometimes be elicited by flexion of the body, or raising the arm of the affected side. < Care should be taken lest a friction-like sound due to movement of the shoulder joint or scapula be confused with true friction. Perez has described mid-sternal friction sounds associated with movements of the shoulder joints. The important dependence of these pseudo-friction sounds upon movement and their ready localization will usually prevent serious error. Friction rales may persist at the margins of the flatness due to a pleural exudate. Reappearance after disappearance indicates absorption. Pleural Crepitation. — This often occurs early or midway in the inspiratory phase of the individual breath sound, whereas true crepitation is late, but this distinction is not always possible. Pleuro-pericardial Friction. — A friction murmur of cardiac rhythm heard over the area of superficial cardiac dulness, or along its borders, synchronous Pulmonary with the heart beat but disappearing in forced expiration, suggests inflam- mation of the pulmonary pleura and apposed pericardium. A similar murmur disappearing with full inspiration suggests inflamma- Costal pleura, tion and attrition of the pericardium and costal pleura. Such friction may also be persistent and yet vary in intensity with the respiratory phases. It is not a very rare sign in cases of pneumonia and indicates direct extension of the inflammatory process. Pneumocardial Crepitations and Crackles. — These sounds of cardiac Show cardiac rhythm, with or without coincident or incidental friction sounds, are oc- casionally heard over the inner edges of the lung adjacent to the heart if infiltration is present. Pure crepitations along the anterior lung borders may also be associated with the fringes of air cells seen in advanced emphysema. BRONCHOSCOPY. — The same apparatus can be used for bronchoscopy and esophagoscopy, and the instruments described elsewhere in this volume are suitable for this purpose. The tubes carry a centimeter scale and measure for adults 7-10 mm. in diameter and 30-45 cm. in length; for children, 5-6 mm. in diameter and 15- 25 mm. in length. Thorough local anesthesia or in resistant individuals and in children general anesthesia will be found indispensable. The position is practically that described under " Esophagoscopy " and " Gastroscopy," and the expert can render visible and obtain access to the interior of the tracheobronchial tree as far as the subdivision of the main bronchi into those of the second class. 314 MEDICAL DIAGNOSIS Appearance of thoracic field. Obsolete tuberculous foci. Hilus radiations. Fluoroscopy. Stereoscopy. Defines relationships. Swollen peribronchial glands. INTRATHORACIC RADIOGRAPHY AND FLUOROSCOPY THE ROENTGENOGRAPHS EXAMINATION OF THE LUNGS AND PLEURA Frank S. Bissell, M. D., Minneapolis, Minn. A Region of Sharp Contrasts.— The thoracic cavity lends itself advan- tageously to roentgen investigation, the air within the lung affording the necessary contrast of the lung structure with the more dense tissue of the other viscera. A sagittal view, on the fluoroscopic screen, is that of two large light fields, separated by a wedge-shaped shadow. The lateral areas are the lung fields and the central shadow is formed by the spinal column, sternum, mediastinal structures, heart and great primary arteries, and the venous trunks. The Hilus Shadows. — On either side of the median shadow, within the lung fields, are the ''hilus shadows" produced by the large blood vessels, bronchi, and the lymphatics, supplying the lungs. Usually, within the hilus areas, even in persons not actively tuberculous, there may be several large nodules of greater density, evidences of some earlier but ineffectual tuberculous invasion. Radiating shadows, some short and broad, others fine and long, extend in ail directions from the hilus toward the lung periphery. These, like the hilus shadows, are composite, being produced by bronchi, blood-filled vessels and lymphatics. Method of Examination. — While the fluoroscopic method is excellent for the study of respiratory movements, the stereoscopic roentgenogram reveals the greater wealth of lung detail, and takes first rank in the roentgen diagnosis of lung diseases. In the stereoscopic roentgenogram, superimposition of the shadows of various structures lying in the axis of a given ray does not occur as it does on the single plate. Thus, with each shadow appearing in its proper relation to every other shadow, the factor of error in interpretation is greatly reduced. In the study of the roentgenogram, it is necessary to bear in mind that the objects appearing dark on the fluoroscopic screen are light on the photo- graphic plate, while the lateral areas, light on the screen, appear dark in the roentgenogram. Tuberculosis. — Mottling of the Pulmonary Field in Early Cases. — Normal peribronchial glands do not obstruct the rays sufficiently to cast a shadow, but when they become swollen, as the result of bacterial invasion, they appear as fine nodules, which, increasing in number, tend to give the lung field a mottled appearance. While this mottling is observed early in many cases of tuberculosis, it is by no means characteristic of this disease but points only to some infection or irritation of the bronchi. Tuberculosis of the adult type tends very early to involve the parenchyma ROENTGENOGRAPHS EXAMINATION OF LUNGS AND PLEURA 315 of the lung, peripheral to the terminals of the bronchial tree, and it is here that the most characteristic roentgen signs of the disease become manifest. The engorgement of the Lymphatic and blood vessels which is an early reac- tion to the tuberculous invasion, produces in the stereoroentgenogram small cone-shaped areas of increased density, the apices of which are directed Fig. 125. — Interlobar empyema (right) with infiltration of left lung, closely simulating that of tuberculosis. {Dr. Frank S. Bissell.) toward the hilus. The anatomical explanation of the "cone" is that each primary lung lobule (the anatomical unit) is triangular or cone-shaped and has its own complement of blood and lymph vessels. Since, however, it is not always possible, even in known cases of tubercu- losis to clearly delineate the "cone" it becomes necessary to rely upon less 316 MEDICAL DIAGNOSIS typical areas of increased density, pointing to congestion or beginning infiltra- tion in the periphery of the lung field. The more characteristic site of such areas is that beyond the extremities of the first and second interspace bron- chial trunks. It is fortunate for differential diagnosis that these areas usually Fig. 126. — Unilateral Pulmonary Tuberculosis. Note marked infiltration of right upper lung field. Pleuro-diaphragmatic adhesions. {Dr. Frank S. Bissell.) remain clear and uninvolved until late in the progress of other chronic infections. Basal tuberculosis, while it has the same general characteristics, is much more difficult to differentiate from other chronic infections. Tuberculosis ROENTGENOGRAPHS EXAMINATION OF LUNGS AND PLEURAE 317 of the base, however, without concomitant involvement of the apex of one or more lobes, is relatively rare. Advanced Tuberculosis. — Paradoxical as it may seem, the more advanced stages of tuberculosis sometimes present a roentgen picture less typical and hence less easv to differentiate than the earlier ones. Fig. 127. — Apical Tuberculosis — Healed or Latent. Note that lesions are closely cir- cumscribed by apparently normal lung. {Dr. Frank S. Bissell.) This is true because the more characteristic changes tend to become masked by the effects of fibrosis and mixed infections. Usually, however, the distribution of the lesions points the way to a correct diagnosis or some area of slight involvement is found where the changes are more typical. Compensatory emphysema frequently exists in some degree, manefesting Emphysema. 3i8 MKDICAL I)IA(;\OSIS itself chiefly by increased translucency of the area so affected. This trans- lucency, when the emphysema is extensive, aids materially in the study and recognition of the tuberculous foci by lending sharper contrast to them. Thus the clinician's handicap becomes the advantage of the roentgenologist. In advanced tuberculosis the greatest value of the roentgen examination Fig. 128. — Pulmonary Tuberculosis with Cavitation. {Dr. Frank S. Bissell.) lies in the accuracy with which may be demonstrated the extent of the disease, the presence and nature of complications, as well as other factors in prognosis. The extent of involvement of a lung is usually found greater than physical signs or symptoms would lead one to suspect because so many of the lesions lie in the deeper portions of the lung where they escape the detection of the keenest clinician. ROENTGENOGRAPHS EXAMINATION OF LUNGS AND PLEURA 310 Cavities.- -Cavita lion is easily recognized although one must be careful not to interpret all ring-like shadows in the lung field as cavities. There must be a total absence of normal lung structure within the ring and special care must be used to differentiate from bronchiectasis or partial pneumo- thorax. Areas of lung consolidation surrounding a cavity filled with exudate Ftg. 129. — Chronic Pulmonary Tuberculosis with extensive fibrosis in both upper lung fields. Tendency is toward recovery but the determination of activity in this type of case must be made upon clinical evidence. (Dr. Frank S. Bissell.) or pus may render its recognition temporarily impossible. Rarely, however, is a cavity so completely filled with fluid that it cannot be diagnosed. Resolution. — In the process of recovery from a tuberculous invasion, the lung may return to normal or nearly normal in its roentgen appearance. An old focus which has become calcified, an apex more dense than normal Cavity'signs. 3 20 MEDICAL DIAGNOSIS Caution required. "Woolly" foci. Isolated apex regions rare. Aids in prognosis. The "Drop Heart." Confusing factors. (thickened or retracted pleura) or a pleuro-diaphragmatic adhesion may alone remain to tell the tale of a previous infection. There are, however, many cases clinically cured which show roentgen signs closely simulating those of active tuberculosis. Here both experience and caution are required and final conclusions as to activity should be based upon clinical, rather than roentgen evidence. The shadows of inactive foci are more definite and circumscribed, while foci of active disease are softer in appearance and the lung immediately surrounding them is more dense than normal. This gives them a " woolly" appearance, their density shading progressively into the relative translucency of the normal air-filled alveoli. Apical Tuberculosis.— The roentgenologist meets with apical tuberculosis as described in text-books and at the bedside with comparative infrequency. A marked increase in the density of one or both apices may indicate consolidation, fibrosis, or thickened retracted pleura. When an active tuberculosis exists, however, the more characteristic signs previously noted are usually present. Prognostic Data. — Roentgen data which may aid in making a prognosis are: (i) the extent of involvement; (2) the amount of fibrosis; (3) the presence of healed lesions; (4) cavitation; (5) the size of the heart. 1. If the process shows a tendency to limit itself to one or two restricted areas, healing there as it spreads to others, the disease may continue active for many years without causing the lung tissue to "break down." If, on the other hand, many areas are involved in one or both lungs and these tend to become confluent, the prognosis is much more grave. 2. Extensive fibrosis, especially without cavitation, is a favorable indication. 3. So too, the presence of healed lesions, associated with the active ones, is evidence that the patient has an established immunity of some degree. 4. Cavities are always of grave prognostic importance. A case may become symptomatically cured, only to die with hemorrhage into a cavity which has escaped obliteration. 5. There is apparently a close association between the atrophic (drop) heart and a low degree of resistance on the part of the patient. Conversely, a large heart is a favorable factor in prognosis. Differential Diagnosis. — Certain chronic infections of the mediastinal and pulmonary lymphatics, secondary to tonsillar, peridental, and antrum or sinus infections, may closely simulate the roentgen picture of tuberculosis. The lesions, however, are prone to be more diffuse throughout both lung fields; there is not so much tendency to fibrosis and there is complete absence of any of the complications of tuberculosis such as cavitation, pleurisy, and the like. Some of these cases cannot be differentiated roentgenologically from miliary tuberculosis. Pneumonoconiosis, Chalicosis, Anthracosis. — Men engaged in certain occupations, of which marble-cutting is the most conspicuous example, frequently show lung changes in the roentgenogram which so closely resemble those of tuberculosis that differentiation is impossible. That these are not ROEXTGEXOGRAPHIC EXAMINATION OF LUNGS AND PLEURA 3 21 actually tuberculous is proven by the fact that the lungs regain their normal appearance when a temporary change of occupation is made. Syphilitic Pneumonia. — Certain cases of tertiary syphilis show lung changes closely resembling chronic pulmonary tuberculosis. The history and other clinical evidence must be relied upon for differentiation. Malignant Metastases. — Metastases from malignant tumors of the mediastinum and elsewhere produce shadow changes in the lung fields not greatly unlike those of advanced tuberculosis. The individual lesion, how- ever, is usually much more conspicuous and massive in appearance. CHARACTERISTICS OF OTHER PULMONARY LESIONS.— Chronic Bronchitis. — In many cases of long standing, one notes the marked trans- lucency of basal emphysema in distinct contrast to the increased density of the poorly aerated lung above. An accentuation of the normal lung mark- ings may be observed and the bronchial tree shadows may have a broken appearance, like the network described by certain authors as characteristic of tuberculosis. Bronchiectasis. — Demonstration of bronchiectatic cavities is relatively easy when they are empty and surrounded by thickened lung tissue. The examination should be made in the morning after the paroxysm of coughing has emptied the cavity or cavities. Repeating the roentgenization on the succeeding day, one may note that a light center has appeared in certain areas w r hich were homologous shadows the day before, the secretory contents of the cavity having been coughed up in the interim. The entire lung field may be sponge-like in appearance, at first glance, but upon more careful study in the stereoscope we may differentiate a multitude of small bean- shaped cavities, connected together by dense strands of tissue. Tumors. — Primary carcinoma of the bronchial mucous membrane has been difficult to diagnose by percussion or auscultation because its usual location is at the hilus, whence as a dense fan-shaped shadow it spreads toward the periphery. Metastases to the lung usually appear as rather dense shadows, often multiple, surrounded by areas of lesser density. After heavy therapeutic radiation, the involved lung area sometimes assumes a heavily striated appearance, suggesting fibrosis. Whether this is a reaction to the radia- tion or the disease is not yet known. Foreign Bodies in the Bronchi. — These may be localized with considerable accuracy in the stereoscopic roentgenogram. Even when not opaque to the X-rays and hence not to be directly visualized, Willis Manges working with the clinical material of Dr. Chevalier Jackson, has demonstrated that it is possible to diagnose foreign body upon the presence of an emphysema on the affected side. t Exudative Pleuritis. — (Pleuritis exudativa). — This presents a variable roentgen picture, according to the size and position of the exudate, its character, and many other factors. There may be marked displacement of the neighboring organs with relatively little exudate, or the reverse may be true. While easy to recognize in typical cases, one may meet with some difficulty Value of clinical data. More distinct and massive. Necessary precaution. Multiple bron- chiectases. Characteristic shadow. Metastases. Localization. Visceral displacement. 322 MEDICAL DIAGNOSIS Surmounting diagnostic obstacles. Small effusions. in those complicated by old fibrous thickening of the pleura the shadow of which may cover that of the fluid. Here the fluoroscopic screen is much superior to the roentgenogram, because one may observe the effect of respira- tion and of change of position upon the density of the shadow. Even a small Fig. 130. — Pleurisy with effusion. Xote density of fluid shadow and its horizontal upper border. Xote also cardiac displacement. (Dr. Frank S. Bissell.) exudate may usually be recognized early as it fills the complementary pleural sinuses, obliterates the phreno-costal angle, and interferes with the normal excursion of the diaphragm of the side affected. As the fluid increases in quantity, one notes its tendency to climb along the lateral wall toward the axilla. This is the so-called "curve of Damoiseau." This curve tends to ROENTGENOGRAPHS EXAMINATION OF LUNGS AND PLEURAE 323 disappear as the upper level of the fluid descends to a point below the lung hilus. It also disappears when the patient is in the horizontal position. The heart and other mediastinal organs may become displaced toward the opposite side before the exudate has become large enough to exert direct pressure. This displacement is the result of an elastic pull of the normal lung, the compressed lung of the affected side having ceased to exert its normal counter-pull. When the exudate is sufficiently large, the displacement of the mediastinum including the heart and great vessels produces an elongated, triangular shadow with its base on the diaphragm and its apex at the sterno- clavicular articulation. This shadow furnishes information as to the amount of effusion and the expediency of puncture. The line of separation between exudate and lung is not a sharp one, there being a noticeable difference between the sharp straight upper border of the usual pneumothorax exudate and the more indistinct washed-out border of a pleuritic exudate. While a very large pneumothorax exudate, such as may follow spontaneous rupture of the lung, may be recognized as such with great difficulty, the air above the fluid having been fully reabsorbed, careful search will usually reveal a small pneumothorax bubble. Unless the roentgenologist is fortified with a suggestive anamnesia, however, he may mistake such an exudate for one of pleuritis. When air still remains above the fluid level, the latter' s sharp distinct line readily suggests the diagnosis. The recognition of the character of this exudate is highly important because its complete removal by paracentesis, as in pleurisy, is a grave technical error. Pleuritic Adhesions. — Pleuritic adhesions occur either as broad lamince or as fine bands. When the former occur in such a manner as to obliterate the costophrenic sinus, their differentiation from a small exudate is difficult but unimportant. A small exudate retained within the thickened pleura may entirely escape detection. If the thickened pleura lies near the plate or screen, its projected shadow is much more distinct than when it is on the opposite wall of the chest cavity. Fine pleuro -diaphragmatic adhesions are rarely if ever seen, but in some cases they may be recognized by the characteristic manner in which they cause the diaphragm to kink, tent-like, during deep inspiration. Fixation of the diaphragm is usually present with pleuritis even though no fluid or adhesions are present. This immobilization may be difficult to determine when there is an effusion on the right side since the diaphragm itself cannot be visualized. . On the left side, however, the presence of gas or air within the stomach renders the lower side of the diaphragm visible. The immobilization may persist for a long time after the fluid has become absorbed. Pneumothorax. — Uncomplicated by adhesions, exudate, etc., pneumothorax is recognized chiefly by the absence of normal lung markings, within the thoracic cavity. The unilateral area involved is much more translucent than its normal fellow, and the compressed lung may be observed, reduced in volume to a variable degree, and crowded sharply against the median shadow. Early visceral displacement. Pull and counterpull. Triangular shadow. Differentiation from pneumo- thorax. Distinct line of fluid level. A point of great importance. Adhesions. Fixation of diaphragm. Differentia- tion of types. 324 MEDICAL DIAGNOSIS Two important questions. Special technic. Early signs. Pneumonic triangle. Hilus pneumo- nia in influenza epidemic. Displacement of the mediastinal organs occurs as a result of the elastic pull of the normal lung and of the pressure from the accumulation of trapped air in the pneumothorax cavity. Artificial Pneumothorax. — Without roentgenograph^ examination, arti- ficial pneumothorax is not practicable. The roentgenologist is usually asked to determine the two most important questions: first, whether pneumo- thorax is possible, and second, whether it is indicated. While it is not possible to determine these points with certainty, it is possible to do so with a considerable degree of probability. Are there pleuro-pulmonary adhesions, and if so, what is their topography, extent and firmness? Diaphragmatic adhesions can at least be excluded when not present. When there is a partial or complete effacement of the costo- diaphragmatic sinus, immobilization of the diaphragm, or suppression of the respiratory movements, the base of the lung is probably adherent. The question as to the indication for pneumothorax is determined by the presence of cavitation and the absence of involvement in the other lung. Examinations made after an attempt at pneumothorax determine the degree of success and thus whether the procedure should be continued or abandoned. Serial examinations may demonstrate a gradual giving way of adhesions with final pulmonary collapse. Pneumonia. — In the study of pneumonia with the X-ray, technic is of the utmost importance. The lobe affected must be brought as close as possible to the roentgen plate, and tubes af slight penetration must be employed. Early in the disease, only a very faint diffuse density, due to decreased air content is noted. In a few hours this may have become a distinct shadow, sharply defined by the boundaries of the lobe involved. The subsequent course is very variable. The shadow of a pneumonic lung rarely reaches the density seen with tumor or effusion. The so-called pneumonic triangle, a dense shadow with its base toward the axilla, occurs most fre- quently in childhood and when present is very characteristic. Hilus pneumonia was a common type during the influenza epidemic of 191 8 and could be recognized only by X-ray examination. This type was often hemorrhagic in character, and very accurate prognoses could be based upon a study of serial plates made during the first days of the disease. When the process became bilateral it was almost invariably fatal. Usually soon after the crisis a clearing-up process is perceptible, proceed- ing most frequently from the hilus toward the periphery. Certain veil-like shadows usually persist, however, and these may be observed many days or weeks after resolution. Broncho -pneumonia. — Here the process is not limited to a single lobe but presents disseminated shadows usually obscure and poorly-defined and involving different lobes of one or both lungs. This disease is characterized by the most bizarre roentgen manifestations, quite unlike those of any other acute infection. However, the chief value of X-ray studies here lies in the aid afforded to prognosis, which apparently varies directly with the number of lobes involved and the rapidity with which the process extends. ROENTGENOGRAPHS EXAMINATION OF LUNGS AND PLEURA 325 The Heart in Pneumonia, Certain German observers (Holzknecht, Steyrer) have called attention to the condition of the heart during pneumonia. Holzknecht noted early in the disease a distinct enlargement of the right side oi the heart and a marked pulsation of the middle convexity of the Fig. 1.3 i. — Resolving pneumonia. Note marked prominence of the intermediate con- vexity of the heart border. This is frequently observed in acute pneumonic conditions; probably represents residual dilatation of the pulmonary artery. left border, representing left auricle and pulmonary artery. This indicates, in his opinion, a dilatation of the right heart and an over-distention of the pulmonary artery, conclusions which are wholly in accord with long-estab- lished bedside observations. Soon after the crisis these signs entirely disappeared. 326 MEDICAL DIAGNOSIS Lung Abscess. — A more or less localized area of increased density sit- uated entirely within the lung field is suggestive of lung abscess. The case history and clinical evidence are necessary to complete the diagnosis. Dr. William H. Stewart has reported successful diagnoses and localizations of abscess by means of bismuth paste injections through the bronchoscope. A pure roentgenological differentiation between abscess and infarct is probably not possible since both occur within the lung and have ill-defined borders by reason of the inflammatory process surrounding them. Gangrene. — Gangrene has no characteristic roentgen signs but the presence of an hydropneumothorax together with clinical evidence, may make the diagnosis. Empyema. — An empyema resembles a simple pleuritic effusion in the intensity and homogeneity of its shadow. Its borders assume various shapes dependent upon the adhesions which surround it. In the inter- lobar form, one depends upon the location of the shadow with relation to various lobes for its identification. Its most characteristic appearance is that of a transverse opaque band completely bisecting the lung field. Emphysema. — With an increase in the air of the lung there is a propor- tionate and usually striking increase in its penetrability to the ray, i.e., the brightness of the pulmonary fluoroscopic fields. While in the normal lung there is a marked difference between the density during inspiration and expiration, in the presense of a general emphysema this variation is not demonstrable. Other roentgenological signs of emphysema are, horizontal ribs, broad lung fields, and a flat diaphragm. COUGH AND SPUTUM COUGH. — Definition. — The term cough 'covers single or multiple, conse- cutive, explosive, expiratory acts immediately following glottic closure. Diverse Causes. — It may be voluntary, involuntary or truly paroxysmal and arise from any of a multitude of causes and from the irritation of widely separated and diverse regions, though commonly purposeful and intended to remove irritating material from the bronchi or throat. This irritant is ordinarily the secretion accompanying acute or chronic disease of the air passages, or, foreign bodies. The most sensitive regions are the inter arytenoid space, the tracheal bifurca- tion, pharynx, base of the tongue, naso- pharynx and certain areas in the nasal passages proper. Reflex Cough.; — Many forms of reflex cough are observed and these should always receive consideration in obscure cases. Arnold's branch of the pneumogastric nerve is accountable for a rare cough connected with irritation of the external auditory canal.* So also chill- * Such a case recently observed by the author was instantly and permanently relieved by the removal of impacted cerumen. The patient had been for several months under the treatment of a quack and, when bankrupt, was told, with engaging delicacy and frank- ness, that his lungs were "all rotted" and his case hopeless. COUGH AND SPUTUM 327 ing of the surface, pressure upon or diseases of the spleen or liver, when asso- ciated with involvement of the diaphragmatic pleura, may be the source of obstinate coughs. In women, chronic disease of the pelvic organs is an occasional cause and such a cough frequently disappears entirely after operation. Hysteric, Dyspeptic and Tobacco Cough. — Other coughs are purely neurotic in origin, such being the obtrusive, forced, hysterical cough and the barking cough of puberty. Dentition cough in infants is apparently purely reflex in character but the so-called "stomach cough" associated ordinarily with chronic gastritis and most frequently observed in drinkers, is no doubt due to the accompanying pharyngitis and the same statement applies to the "smoker's cough" and its associated laryngeal irritation and hyperesthesia. Many cases due to excessive irritability of sensitive turbinate areas are observed, particularly in young people and neurotic individuals, the condi- tions being very similar to those associated with certain asthmatic paroxysms or with hay fever. Direct Sources. — 77 should be remembered that irritation of the lung paren- chyma itself does not cause cough, but unquestionably irritation or inflammation of the bronchial mucous membranes or pleura does. Therefore, in pulmonary disease, acute or chronic, the cough is attributable either to bronchial or pleural irritation. The assumption that any cough is purely reflex or neurotic should be postponed until all other channels have been thoroughly investigated. 11 Adenoids," enlarged tonsils, impacted cerumen, granular pharyngitis, hypertrophy of the lingual tonsil, enlarged turbinates, chronic disease of the accessory sinuses, goiter, chronic heart disease, diseases of the liver, enlarged bronchial glands, aneurysm, mediastinal growths, dorsal caries, occupation, habit, and imitation, are some of the many other potential or possible conditions to be considered aside from affections of the bronchi, lungs, and pleurae. Dry and Moist Cough. — In incipient phthisis and the early stages of bronchial or broncho-pulmonary inflammation the cough is wholly or rela- tively unproductive, i.e., dry. Such a cough may be extremely urgent, paroxysmal, or painful and acute bronchitis, pneumonia, whooping cough, asthma, and pleurisy • furnish the best examples. In their early stages, practically all of the nervous, reflex, or pressure coughs are dry. When pain is present an effort is made to suppress the cough, as is the case especially in. lobar pneumonia and pleurisy. Paroxysmal cough, best exemplified by whooping cough, may be en- countered in many other conditions. Whether due to direct irritation, as in the case of a laryngeal tumor, or to reflex causes, as in impacted cerumen or turgescence of the nasal passages, and particularly in pertussis, the cough paroxysm may be associated with vomiting and even with epistaxis and hemorrhages under the skin. A paroxysmal cough may also result from a gradual, silent, accumulation of secretion and be attended by a profuse and perhaps sudden discharge, as, Smoker's cough. Nasal cough. Bronchial cough. Pleural cough. Source of error. A host of possibilities. Dry cough. Suppressed cough. Many sources. Vomiting, nosebleed, and ecchymoses. Emptying of cavities. 328 MEDICAL DIAGNOSIS Hacking cough. Diminuendo cough. 'Crowing. Toneless cough. Significant variations. Pulmonary' cavities and bronchi- ectases. for example, in bronchiectasis, certain pulmonary cavities, or the rupture of abscesses into the bronchi. Pressure cough due to mediastinal tumors, pericardial effusion and like causes, is not usually paroxysmal but may be most misleadingly so, even to the simulation of asthmatic seizures. The so-called hacking cough is especially common in incipient tuberculosis, but may occur also in acute or chronic irritation or inflammation of the upper air passages. VARIOUS TYPES.— "Barking," "Hollow" and "Brazen" Coughs.— Barking cough, if not neurotic, is usually associated with inflammation of the glottis; a hollow cough with advanced tuberculosis; and ringing, metallic or brazen cough with mediastinal pressure from whatever cause. The author has observed as good examples of the brazen cough in massive pericardial effusion as from its commoner causes, aneurysm and mediastinal growths. In emphysema the cough is peculiar in its prolongation of the individual expirations and the manifest forcing and prolonging of the series diminuendo. The "hoarse cough" of croup and the inspiratory crowing during the paroxysm are but too well known, and a noiseless cough may occur in certain forms of glottic paralysis or a toneless cough in terminal cases of pulmonary disease. The inspiratory whoop may follow various forms of paroxysmal cough, but is occasional and unusual, whereas in established w r hooping cough it is persistent and practically pathognomonic. An Ominous Sign. — Absence or cessation of cough, with persisting physical signs, may indicate profound toxemia, excessive weakness or approaching death and is seen especially in fatal pneumonias of infancy, childhood, and old age. Localized momentary protrusion normally occurs in the apices and upper intercostal spaces during cough. The condition is exaggerated in emphysema and diminished in infiltration of the lung apices. Postural Modifications. — In certain conditions posture markedly modifies the tendency to cough and in bronchiectasis, open pulmonary abscess and certain large phthisical or gangrenous cavities, a severe paroxysm of cough may be induced by a change of position which initiates and facilitates a flow of secretion from the cavity to the bronchi. Such patients may of their own volition assume a posture which, by lowering the head and thorax, drains the cavity by gravity assisted by the cough. THE SPUTUM Definition. — The sputum proper is that content of the air passages obtained by "clearing the throat" or coughing. The term embraces nasal, pharyngeal, laryngeal, bronchial, alveolar and, inevitably, a certain admixture of oral secretion. All sputum save that representing pure pus or blood is mucoid in con- sistence and the general term embraces all similar material derived from fistulous communication with adjacent structures, or destructive processes COIV.II AND SPUTUM 3*9 within the respiratory tract, i.e., perforating abscess, echinococcus cysts, cavities, etc. The Important Factors. — One must observe: (a) Reaction, (b) Color and transparency, (c) Air content, (d) Consistence, (e) Amount. (f) Odor, (g) Albumin content. (//) Microscopic findings. The reaction is alkaline save after certain decomposition processes outside the body. Color. — Aside from misleading tints derived from food or medicines, the color varies, according to its source and composition, from the colorless mucoid or serous sputum to that of pure blood. Slight purulent admixture (muco- purulent sputum) or predominance of pus {purulent) produces various degrees of yellow or greenish yellow. Dust and soot inhalation gives a dingy or grayish tint, and bile pigment or the development of certain germs, may pro- duce a faint or even vivid green. Blood may be pure or represented only by faint pink, light brown or salmon color, iron rust shading, faint yellow's and greens or the thin serous so-called "prune-juice" sputum. True icteric sputum appears only when actual jaundice or perforating hepatic abscess is present, though many blood-containing specimens of unusual tint react to the test for bile pigment. Greenish tints may occur in carcinoma, chloroma and various other conditions, and various occupational sputa are encountered, as in mirror polishers, aniline dye workers and others. Heart Disease Cells. — In disease of the mitral valve with brown sputum peculiar pigment-holding cells are present. In the perforating abscess of amebic dysentery the "anchovy sauce" sputum may be encountered, and in hysteria there is occasionally a viscid or jelly-like sputum exactly like crushed raspberries, which may create much unnecessary alarm.* A similar " raspberry-like " sputum is said to occur in certain cases of tumor of the lungs. Air Content. — Foaminess and low specific gravity measure the air content and all serous sputum is frothy. Cavity sputa dropped in water appear as globules, flattening to coin-like bodies (nummular sputum) as they sink to the bottom and, in general, the greater the pus content the less the amount of contained air, and the smaller the tubes of origin the greater is the air content. hi bronchiectasis and gangrene one finds three distinct layers because of the varying specific gravity of the constituent elements. Consistence. — Pus or serum content determines fluidity, and mucus and fibrin (croupous pneumonia) the viscidity and tenacity of sputum. Macroscopic Appearance. — A proper background for macroscopic ex- amination is readily obtained by laying a piece of glass or a Petri dish * A typical example was encountered by the author at the country place of some old friends whose sympathies and ministrations were in process of bestowal upon a most un- worthy object. An hysterical young female degenerate had entered the grounds and gracefully cast herself down under the bellies of a sedate team of horses. She then at- tempted to simulate coma and convulsions with considerable skill until the doctor arrived. Her "crushed raspberry" sputum had excited even more alarm than her other spurious symptoms. Soot. Blood. Bile. Bizarre forms. Nummular sputum. Fluidity vs. Viscidity. 33° MEDICAL DIAGNOSIS Fibrinous casts. Collecting the sputum. Foul odors. Slight differ- ential value. Fig. 132. — Cursch- mann's spirals, t A, unmagnified. B, mag- nified. over black paper or cloth or employing a special glass plate with half its under-surface black. One may find (a) "Curschmann's spirals," which are not pathognomonic of asthma, but most frequent in that disease. They are refractile, visible to the naked eye and represent probably a bronchiolitic exudation. Though interesting they have no great diagnostic importance'. (b) "Dittrich's plugs" are yellowish- white, mustard-seed sized, foul- smelling aggregations of fatty acid crystals and bac- teria, closely resembling the tonsillar plugs of follicular tonsillitis and are found in decomposition processes (pulmonary gangrene, foul cavities, etc.). (c) Misleading food particles may be encountered w T hich are usually starchy and strike a -blue color with Lugol's solution. (d) Fibrin masses are white and extremely tena- cious and are rendered clearer and bulkier by the addition of acetic acid. They vary in size from the tiniest plugs to casts of the bronchial tubes (croupous pneumonia, fibrinous bronchitis), or the diphtheritic membrane. (e) The Fibrinous Casts. — These show best if shaken up in water. (f) Rarely and especially in old cases of tuberculosis, calcareous plugs or definite casts, often of considerable size are expectorated* or foreign bodies of recent or ancient introduction may appear. All sorts of substances may be introduced by fistulous communication with abscesses, echinococcus cysts, etc., etc. Amount. — Whenever possible the twenty-four hours' sputum should be obtained, and the transparent sputum cups are far better than the metallic and paper cups so generally used. Early stages of inflammation yield scant secretion. The morning is the most productive period in chronic processes though in pulmonary cavity and especially bronchiectasis large amounts may be raised at irregular times, often when assuming a special posture. Advanced pulmonary tuberculosis, bronchorrhea, bronchiectasis, perforating abscesses, pulmonary edema and resolving pneumonia furnish large amounts. Odor. — Ordinarily odorless when first raised, it may be extremely foul in any process attended with decomposition within the lung (bronchiectasis, certain tuberculous cavities, abscess of liver, communicating empyema) and characteristically so in gangrene. Albumin Content. — The albumin content of the sputum constitutes a rough measure of the severity of an inflammation and is said to be absent in simple bronchitis. Possibly some slight value may be attached to a decided percentage as differentiating simple bronchitis from pneumonic processes and from pulmonary tuberculosis. Zenoni's Differential Color Test. — This pretty and simple test for albu- * In a case observed some time ago a large lung stone was ejected after the sudden onset of a protracted and violent coughing seizure and no symptoms of the old disease had been manifest for over twenty years. COUGH AND SPUTUM 331 min and mucin consists in spreading the sputum on a slide, fixing it with alcohol (fifteen minutes) and staining with a half-saturated aqueous solution of safranin. The albumin is stained red and the mucin yellow. MICROSCOPIC FINDINGS.— Staining.— The sputum should first be examined as a flat preparation without staining and then by making a smear, drying in the air and staining for three minutes with Wright's stain, thor- oughly washing, and mounting. Cells. — One may find: (a) Flat pavement cells from the mouth and pharynx. (b) Columnar ciliated cells from the larynx, trachea and bronchi. (c) Mono- or polynuclear cells from the alveoli which may contain (d) Irregular highly retractile masses of myelin, showing concentric layers. (e) Blood-pigment-bearing (heart disease) cells. (/) Hematoidin crystals. (g) Fat. (h) Carbon. (i) Free myelin bodies. (j) Elastic fibers. If present these last structures may be obtained sometimes by merely pressing a cheesy, granular, or especially dense, portion of sputum between two glass slides and using a low-power lens, but a more elaborate procedure is usually required.* Such fibers indicate actual destruc- tion of lung tissue, most frequently advanced tuberculosis or pulmonary abscess, and usually show the alveolar arrangement. Staining is quite unnecessary, the only difficulty being the possible derivation of the fibers from retained food in specimens not properly safeguarded in the process of collection. Owing to the presence of a peculiar ferment, they often are absent in destructive pulmonary gangrene. (k) Leucocytes. Eosinophiles are abundant in asthmatic sputum and neutrophiles in all sputa. These may show phagocytic inclusions of fat, carbon or hematoidin. (I) Erythrocytes. Microscopic blood exists in most sputa associated with severe cough, but macroscopically it is present only in violent paroxysmal cough, accidental hemorrhage and true inflammatory or necrotic processes. Fibrin, if present, may be demonstrated by Weigert's method. (m) Crystals. The rhomboidal crystals of cholesterin indicate emphy- sema or lung abscess, seldom phthisis. The sharp slender fasciculated fatty acid crystals suggest gangrene or advanced tuberculosis, while the colorless, octahedral Char cot-Ley den crystals point to bronchial asthma. Yellow or brown amorphous masses or rhomboidal crystals of hematoidin point to blood retention and ulceration within the alveoli, and leucin and tyrosin may be present in emphysema. (n) Bacteria. Among those occurring in sputum are: tubercle bacilli * Boiling a mixture consisting of equal parts of sputum and 10 per cent. NaOH or KOH, setting aside for twenty-four hours and then examining selected portions of the precipitate is a useful device and search is seldom successful without it. Albumin and mucin. General stain. Significance. Spontaneous disappearance. Emphysema 01 lung abscess. Asthma crystals. Simulators of tubercle bacilli. 332 MEDICAL DIAGNOSIS Animal inoculation. Rapid preliminary examination. Centrifugation. and its simulators, the smegma and timothy bacilli, and, those of pneumonia, anthrax, influenza, typhoid, glanders, plague and leprosy as well as the Friedlander bacillus, micrococcus tetragenous and others". THE TUBERCLE BACILLUS.— The tubercle bacillus is by Jar the most important, and for its determination most careful work and even animal inocu- lation may be necessary. In most instances it is easy to find the germ in the cheesy particles or thicker portions of the specimen, but at other times they must be obtained by centrifugation of the sputum. The bacilli are often readily found in sputum thinned by spontaneous decomposition. To Secure a Concentrated Sediment. — The Antiformin Method. — If the specimen yields none of the acid- and- alcohol-fast tubercle bacilli to the first rapid examination by the Gabbett or Ziehl-Neelsen method, one can procure a concentrated centrifugated sediment by the use of antiformin (a trade mixture of sodium hypochlorite and sodium hydrate solutions), which keeps fairly well and is readily obtainable. Loeffler's Modification of Uhlenhuth's Antiformin Procedure. — (a) Boil, for a period not exceeding fifteen minutes, equal parts of sputum and 50 per cent, antiformin. (b) Make a mixture of 1 part chloroform to 9 parts alcohol. (c) Add 3 ex. of this mixture to 20 ex. of the original boiled mixture of sputum and antiformin. (d) Shake to form a fine emulsion. (e) Put required portions in corked sedimentation tubes and centrifuge for fifteen minutes. The original process destroys all save the acid-fast organisms. The chloroform in the centrifugated mixture holds the tubercle bacilli in a film at its upper margin. (J) The supernatant fluid is decanted and the film and its contained materials is then spread on slides, dried, treated with egg albumin in the usual manner, to insure subsequent secure fixation and is then ready for the usual stain, that most generally used being the Ziehl-Neelsen. The various steps of the staining process beginning with the removal of the centrifuged organisms in the film above the chloroform (stage "e") would be v as follows: Ziehl-Neelsen Method. — (a) Making a thin, even, smear after adding a little egg albumin or, better still, some of the original sputum, in order that subsequent firm fixation may be attained. (b) Drying by gentle heat or passing to and fro through the air. (c) Fixing. — The cover-glass smear is then fixed by passing it deliberately but steadily through an alcohol (or small Bunsen) flame four or five times, or ten or twelve times, if slides be used. (d) Staining. — It is then completely covered with the fuchsin* (acid) * To make this stain, a saturated alcoholic solution of fuchsin or gentian violet is added drop by drop to 5 per cent, solution of carbolic acid until a surface sheen appears. PLATE II. I • ' without detectable cause is almost invariably due to tuberculosis, one hnds many instances of most unfortunate time-loss due to a failure to put this practical knowledge into the form of early diagnosis. Tuberculosis, pulmonary infarct, and syphilis are the three causes chiefly to be considered. Of these the two former are overwhelmingly the more frequent. The term "hemoptysis" should not be applied to blood-streaked or even bloody sputum such as occurs in severe bronchitis, the pneumonias, or passive congestion of the lung. Its use should be limited to the actual hemorrhages of bronchial or pulmonary origin. Aside from the three leading causes mentioned above, one must bear in mind bronchiectasis, pulmonary abscess and gangrene, aneurysm, malignant growths, actinomycosis, aspergillosis, streptothricosis. echinococcus. dis- tomiasis, hemophilia, scurvy and the purpuras. Fluoroscopy. — The skilful use of the fluoroscope and X-ray plate throws much light upon the condition of the lungs in incipient cases and by the former method one often finds a marked limitation of lung movement (''Francis Williams' Sign") as measured by the descent of the diaphragm, quite disproportionate to the amount of lung involved. .Areas of extensive infiltration show as shadows, and cavities of considerable size as bright spots. Litten's sign may be used to test the diaphragmatic movement in the absence of the fluoroscope. Tuberculin. — The subcutaneous use of tuberculin as a diagnostic agent has its many advocates and its few bitter opponents. It is argued that inasmuch as the physical signs produced are due to the production of congestion in tuberculous areas, every dose subjects the patient to unnecessary risks. On the other hand, its advocates claim that the importance of " absolute" diagnosis and the rarity of bad results following its use serve as its justifica- tion. This might readily be admitted if the results obtained were positive for active lesions only, for bad results from diagnostic doses are extremely rare, but '"' absolute" information means usually nothing more than the fact that at some time, somewhere, the patient has been infected and, in the adult Exertion temperature. Important clinical fact Ertremelj valuable. Varying views Extreme frequency of reaction. * The case was not observed in its incipiency though the infiltration was only slightly advanced, but as no temperature was shown during the stage of softening and when the sputum was filled with tubercle bacilli, it is to be presumed that it was absent in the ear lier stages. The patient was a congenitally asthenic girl of 17. 412 MEDICAL DIAGNOSIS Fallible. Routine use unwise. Differential t€6tS. one might " guess" correctly seven times out of ten without even seeing the patient. It does not prove the activity of an infection* The author believes that the routine use of the subcutaneous method is to be condemned and that the methods of Moro and Von Pirquet are adequate. The fact that it is capable of producing a rise of temperature in so many apparently, healthy controlsf and in certain cases of syphilis, and the additional fact that from 60 to 70 per cent, of apparently normal individuals above the age of thirty react, certainly makes its findings less positive than might be wished. Furthermore, the recent attempts to differentiate the reactions quanti- tatively and read into them special diagnostic meaning are not convincing, despite the brilliant work of Wolff-Eisner, Teichman, Ellerman and Erland- sen, and others. J Some of the most striking reactions ever observed by the author have occurred in vigorous individuals wholly unconscious of any health impairment present or past and now enjoying good health after the lapse of years. Preparation of Tuberculin for Subcutaneous Use. — "Alt-tuberculin" may- be had in i-c.c. (1000-mg.) ampules and one uses this content as follows: Using sterile normal salt solution make a dilution of 1 in 10; with 1 c.c. of the 1 in 10 make another in the same manner and so on until four have been prepared. Then 1 c.c. of dilution No. 1 =0.1 = 100 mg. 1 c.c. of dilution No. 2 =0.01 = 10 mg. 1 c.c. of dilution No. 3 = 0.001 = 1 mg. 1 c.c. of dilution No. 4 = 0.0001 = Ko nig. Thus by successive dilutions one may obtain any required lesser fraction of the milligram of old tuberculin. The addition of 0.2 c.c. trikresol for each J-f c - c - °f solution will maintain its sterility or one may use a 0.5 per cent, soluti'on of carbolic acid. The Subcutaneous Tuberculin Test. — In adults Ko to 0.5 mg.of a//-tuber- culin in normal salt solution is first injected according to the condition of the patient. If no reaction occurs, 1 to 2 mg. are injected forty-eight hours later, and still later if the reaction fails 5 or even 10 mg. Reaction Signs. — (a) Fever. (ioo°F. represents the "mild reaction," and io2°+F., the "severe form.") * Chas. E.. Simon gives the following table as illustrating the extraordinary frequency of the reaction: Known pulmonary tuberculosis 90 to 100 per cent., positive. Suspected cases 92.1 per cent., positive. Supposedly normal cases 56.1 per cent., positive. f Robert Koch himself developed a severe general reaction following the injection of 0.25 c.c. of tuberculin in the course of his experiments. % Only the proof of marked superiority of this test, a proof not yet forthcoming, can justify its use in preference to the simple, safe and equally accurate test of von Pirquet.' The author gives the test, nevertheless, because of the existing difference of opinion and its use and attempted justification by some of our ablest medical leaders. DISEASES OF THE LUNGS AND PLEURA 413 (b) General malaise, aching and depression, prostration, sometimes nausea and vomiting. (c) Swelling of regional glands in many instances. (d) Allergic reaction, i.e., redness and swelling at the site of injection. (e) Physical signs may appear, or increase if preexistent, indicating a temporary glowing or lighting up of old foci. Such are harsh breathing, crepitations, or crackles, increase or marked diminution of sputa, etc. Precautions. — Injections should be made only in the forenoon lest an early temperature rise occurring in the night may be overlooked. If fever is present one must await its subsidence over a period of several days. If small doses are used, from ten to sixteen hours may be required before reaction occurs. If the patient has any persistent fever the test is of little value. Pregnancy, heart disease, diabetes, nephritis and laryngeal tuberculosis contraindicate its employment. Modifications of the Tuberculin Test. — Von Pirquet's vaccination test depends upon the fact that hypersensitization of the tissues of an individual affected by an infectious disease (allergie) induces a specific reaction to the toxic substance even in the skin. This is merely an application of the doctrine of anaphylaxis. The Von Pirquet Test. — Any good tuberculin, preferably the alt-tuberculin of Koch, is diluted by adding 1 part of 0.5 per cent, carbolic solution and 2 parts of normal saline solution; the patient's arm is prepared as for ordinary vaccination and three areas are lightly scarified, two through a drop each of the test solution in situ, the other similarly treated with the dilut- ing fluid alone. The test and control punctures may be but slightly apart so as to be covered by the one vaccination shield or they may be on opposite arms. Both should be carefully protected. The test as usually outlined at the present time demands the use of the undiluted old tuberculin. The special " '"impfbohrer" of von Pirquet is not essential. Usually redness and more or less infiltration will appear at the site of the test abrasion within twenty-four to forty-eight hours, but even a vigorous reaction may be delayed for seventy- two hours or even more. No consti- tutional or localizing physical signs appear, and, though occasionally the reacting area appears angry and inflamed, all untoward signs soon subside. In all cases the author tests the degree of infiltration by pinching both the vaccination and control areas between the thumb and forefinger. This enables one to detect reactions in cases yielding little redness. Wolff-Eisner and later Calmette attained the same result by instilling a 0.5 per cent, solution into the conjunctival sac where it was retained for a moment or two and in from twelve to forty-eight hours produced decided congestive or inflammatory signs in affected individuals. Moro prepares an ointment of 50 per cent, strength, rubbing up alt- tuberculin with dehydrated lanolin. A pea-sized portion of this unguent is Focal. Simplicity. Absolutely harmless. Conjunctival test. Moro's test. 414 MEDICAL DIAGNOSIS Relative value of tests. Conclusions. Results essentially those of old test. The "von Pirquet" the most reliable. "Arrest" reactions. Prognosis. Advanced cases. True value of tests. Valuable in exclusion. gently rubbed into the skin of the chest or abdomen over an area of 5 cm., and this surface is left uncovered for from ten to fifteen minutes. Papules in varying number with or without erythema appear within a period varying from a few hours to three days. Moro divides reactions into three grades, viz.: (1) mild; (2) moderately strong; (3) severe. From personal experience with all three tests the author believes the first (von Pirquet) and the last (Moro) to be quite as valuable and far safer than the tuberculin injections hitherto and even now extensively practiced, but as in the case of the older method, they fail to prove in adults much more than the fact that at some time the individual has been infected* The following conclusions represent the author's views as based upon the results of a series of tests undertaken with the three modified methods and a somewhat extensive later experience. (a) The von Pirquet reaction is comparable and probably runs nearly parallel to the old injection test,\ inasmuch as the percentage of reactions closely approxi- mates that obtained by Beck and others using the older method. (b) No fever or physical sign increase is to be observed. (c) The three tests are almost equally valuable, though, in the author's hands, the von Pirquet proved the most reliable of them and should supplement any negative "Moro." The conjunctival test is the least certain and the only one of these three possessing elements of risk. (d) Active-incipient or moderately advanced cases in apparently resistant individuals and those carrying arrested or obsolete lesions react decisively, the last most vigorously and somewhat later in many instances. (e) In known active, progressive, but early cases, the more vigorous the reaction the better would appear to be the prognosis. (J) Advanced cases with low resisting power afford a slight transient reaction or none at all, often to be detected only by careful comparisons of the infiltration produced. (g) As in the case of the subcutaneous test, the positive reactions are so numerous and decided in vigorous non-suspects as to be merely suggestive or reminiscent. (h) The value of the positive test in infants and very young children is con- siderable, and that of the negative test in suspects of all ages can harldy be over- estimated, in that it practically excludes tuberculosis past and present. J Known tuberculous subjects who do not react, almost without exception * The value of negative results of these two tests in infants and very young children is obviously great and the younger the child the greater is the diagnostic significance of the positive test. Infection in children reporting to public clinics is said to reach 35 per cent, between the ages of six and ten. f The author has made demonstrable preponderance of infiltration at the site of vaccina- tion as compared with the control, the test of reaction rather than reddening of the skin alone, which sometimes fails especially in cachectic subjects. J Franz has reported 61 per cent, positives in apparently healthy young recruits. Results obtained in school children as reported by Hamburger and Sluka, Feer, Hillenberg and others show positive reactions in from 40 to 60 per cent. Cohn has reported 100 per cent, positives in fourteen-year-old children of tuberculous parents. DISEASES OF THE LUNGS AND PLEURA 415 present advanced, unmistakable and usually terminal symptoms with marked cachexia. (i) The methods of von Pirquet and Moro are wholly free from danger and cause little discomfort. The extraordinary prevalence of tuberculous infection in man, again may be emphasized by the following tables. Staehelin has admirably summarized the evidence which supports the oft-quoted dictum, u Jedermann hat am ende ein bischen tuberculose" (every one has a little tuberculosis some time).* Xaegeli reports as follows on 500 autopsies. Age Fatal Latent Latent Total infected, T.B. but active inactive per cent. Under 1 yr. O O O O 1-5 yr- 17 O 17 5-9 yr. 25 8 O 33 9-17 yr. 15 15 8 38 18-30 yr. 35 36 24 95 30-40 yr. 47 28 39 94 40-50 yr. 22 23 55 100 50-60 yr. 20 18 62 100 60-70 yr. 9 25 66 100 Over 70 yr. O ^3 77 100 It appears that practically all in this series above the age of seventeen showed previous infection by the tubercle bacillus. There is, of course, a considerable margin of error in such figures and one cannot properly apply the result of work in the dead house of the city clinic directly to the determination of the degree of infection prevailing through- out the population as a whole. Neither can one consider figures derived from the autopsies held upon patients dying in a public clinic as equally applicable to those individuals who enjoy a better environment. Nevertheless they indicate the extraordinary frequency of tuberculous infections in the past, now, happily, lessening. Burchardt reported finding evidences of tuberculosis in 91 per cent, of 1452 autopsies. Many other confirmatory investigations are available and one must conclude that at least 80 per cent, of living individuals above thirty years of age carry tuberculous lesions, for the most part obsolete. (j) The absence of the localizing physical signs of the severer positive reactions of the old subcutaneous injection test is more than compensated for by the lesser risk, the avoidance of confusion due to existing fever or temperature lability on the part of the suspect, the simplicity and the definite results yielded by the allergic tests. * R. Staehelin, "Handbuch der inner e medizin," L. Mohr u. R. Staehelin, ii, p. 465-652. [914, vol. 416 MEDICAL DIAGNOSIS Area of in- volvement exceeds physical signs. Advanced cases. Incipient cases. Value of Litten's test. Frank cases. Misleading color. Often negative. Important data. Hyper- resonance. Comment. — All statistics show the great value of a tuberculin test (von Pirquet especially) in suspected infants and very young children in whom the infection is likely to be, or in infants must necessarily be, recent, but the liability to infection with increasing years progressively diminishes the positive value of the test. (o) Family History. — The family history may throw light upon latent infection, predisposition, or the resistance of the patient, and should be carefully investigated, as regards both incidence and course of cases, in brothers and sisters, parents and collaterals. (p) Past Health Record. — This may be of the utmost significance and importance. Past pleurisy, " winter cough," " inflammation of the lungs" of suspiciously long duration, "spitting of blood," and the like, merit careful investigation. PHYSICAL SIGNS. — A diagnosis must often be made in the absence of positive physical signs, as is evident from the genesis of the disease. Further- more, the X-ray negative will reveal always changes of far greater extent and importance than those elicited by the physical examination of the same case. Inspection. — The physiognomy of advanced tuberculosis is too well known to need a description, the laity recognizing it as readily as the physician. It is merely a composite of emaciation, hectic, exertion-dyspnea, and usually of faulty congenital chest conformation. Incipient cases have no distinctive physiognomy, though an asthenic build is usually present, and anemia may or may not be evident. Unilateral wasting of muscle in the suprascapular region is of much importance. The impairment of chest movement may be imperceptible in the incipient stage, though reduced expansion may be shown by the diaphragm phe- nomenon or the fluoroscope. Advanced cases show marked impairment of chest movement, and often- times localized contraction, abnormal pulsation along the pulmonary-cardiac boundaries and the characteristic, phthisical chest. Some cases present a high color similar to that noted in the mitral disease of young persons and due, apparently, to interference with the pulmonary circulation. Palpation. — Palpation may be wholly negative in the incipient stage, though yielding most exquisite signs in the advanced cases where it reveals lack of expansion, inequality of voice transmission, signs of cavity or marked infiltration (see " Consolidation" and "Cavities"). Percussion. — In the earliest stages percussion may be negative or actually misleading. Any decided inequality in the percussion notes of the two sides, particularly at the apex, should attract attention. It should be remembered that, normally, the note on the left side is less intense but lower pitched than that of the right. Hyperresonance at the apex, especially if unilateral, is a valuable suggestive sign of an incipient process; in the later stage it is of course likely to indicate vicarious emphysema or the presence of cavities. DISEASES OF THE LUNGS AND PLEURA 417 Patches of d nines s may be made out, or extensive areas of infiltration, with or without cavity formation, according to the status of the case. Auscultation. — This is by far the most important procedure. Unilateral diminution of the breath sounds or of voice conduction may be as significant as an increase in their intensity. Harsh breathing and the so-called "cog-wheel" inspiration must be carefully noted and the latter must not be confounded with the inspiration associated with an overacting heart, such a condition being frequently met with in tuber- culous subjects. Undue prolongation of expiration, though it be low-pitched, may be a sign of importance and in advanced cases with marked infiltration and cavity formation the breath sounds are frank and characteristic. Fig. 154. — Various types of cavitation, illustrating some of the various factors affecting physical signs. Rales may be absent for a considerable period in the incipient stage. One often hears only fine sibilant sounds, most significant if detected at the apex even in the absence of other signs, and particularly so if unilateral. Every patient should be made to cough in order to bring out rdles, and deep inspiration following cough may be attended by sibilant, crackling or bubbling rales or by the so-called mucous click, according to the stage of the disease. In advanced cases the rales are of all types as described elsewhere. Comment. — Certain points are absolutely essential to the proper examina- tion and early diagnosis of tuberculous cases. A knowledge of the sounds produced by the various maneuvers in the normal chest is absolutely necessary. Unilateral variations are infinitely more important than bilateral ones in the incipient or early cases. Inasmuch as the disease usually commences at the apex, this region is the most important for the diagnostician. (Both are affected almost coincidently far more often than is generally supposed.) As judged by the physical signs, the earliest recognizable primary lesion is com- monly slightly posterior to the center and about 1 to 1^ inches below the apex. The disease tends to extend both upward and downward along the interlobar fissure and in front along the inner margin of the upper lobe. Unilateral variation. Cog-wheel breathing. Cough maneuver. Know the normal. Apex signs Line of march 4i8 MEDICAL DIAGNOSIS Posterior vs. anterior. X-ray. Height important. Associated ailments. Peculiar area. Great variation. Posterior apex auscultation is usually more productive than anterior auscultation in the early stages of the disease. The important auscultation areas are the apex, anteriorly and posteriorly, the inner lung borders anteriorly, the apex of the axillary space, and the region of the interlobar fissure posteriorly as roughly indicated by the scapular border when the arm is placed upon the opposite shoulder. As previously stated the lungs are usually much more extensively involved than physical signs would indicate, as anyone may prove by the use of the X-ray and this fact no doubt accounts for the errors in prognosis and failure in treatment in cases judged wholly by the physical findings. In fact, the systematic use of fluoroscopy or skiagraphy in these cases has a most chastening effect upon any man who believes himself able to accurately determine the number, position, character and extent of tuberculous lesions by other physical metJiods. Apex Movement. — It is important to employ auscultatory percussion over the apices in order to determine the height at which they stand and the difference in level as between inspiration and expiration. Marked retraction of one apex is an important sign of either an old apex lesion or an active and advancing one, but does not absolutely prove it tuberculous. The diaphragm phenomenon ("Litten's Sign") has already been described. Warning. — Tuberculosis is not the only disease capable of producing ab- normal signs at the apices. PULMONARY INFARCT {Pulmonary Apoplexy, Hemorrhagic Infarct, Pulmonary Embolism) Genesis. — All emboli in the branches of the pulmonary artery originate in the right heart, in thrombotic systemic veins, or from a thrombus in the artery itself, and may be septic or non-septic. The former occur in pyemia, ulcerative endocarditis, septicemia and ex- ceptionally severe acute febrile infections. The latter result from the detach- ment of vegetations from the tricuspid or pulmonary valves, from globose thrombi or polypoid vegetations, from the trabecular of the right auricle, from the chordae tendineae or apex angle, or from a more remote non-septic thrombus. In severe infections associated with marked myocardial toxemia the disengagement of such particles may follow sudden movement of the patient. The result is usually the blocking of a branch of the pulmonary artery which causes a localized pneumonia primarily representing the distribution of the affected vessel and in some instances leading to abscess or gangrene. The areas are usually wedge-shaped with their bases at the periphery and may vary in size from those no larger than a tiny seed to the huge infarcts affecting an entire lobe. SYMPTOMS. — Sometimes Obscure. — Tiny infarcts may be wholly symptomless or produce only slight cough, dyspnea, and perhaps hemoptysis. DISEASES OF THE LUNGS AND PLEURA 419 If branches of moderate size be involved these symptoms are more pronounced or indeed extreme and if the pulmonary trunk itself or its main branches be wholly blocked , rapid dissolution or instant death results. * Frank Cases Easily Recognized. — A sudden onset with such symptoms as are described below, accompanied by the physical signs of circumscribed pneu- monia, pleuro-pneumonia or possibly an acute edema, over an area usually basal or primarily axillary in location, together with the presence of recognized causative factors makes the diagnosis easy. If the embolus be septic the case becomes one of septic pneumonia with pulmonary abscess or gangrene. If the septic element be absent prognosis is favorable as regards the lung condition. Multiple successive small infarctions may occur and their location sometimes may be determined easily, as in a case recently observed, and, in typical cases, the picture presented, viz., sudden localized pain, dyspnea and bloody sputum, is characteristic even though the physical signs be obscure. The middle and lower lobes of the right lung are the regions most affected. It must be remembered that even large pulmonary infarcts may be unattended by bloody sputum. Thrombi of the Pulmonary Branches. — Ribbert maintains that throm- bosis is far more common than has formerly been supposed and that many of the silent infarction areas owe their presence to gradually induced thrombi in the pulmonary branches, rather than to embolus. PULMONARY ABSCESS. — The abscesses may be single or multiple and due to tuberculosis, septicemia, pyemia, septic emboli, lobar and broncho-pneu- monia, malignant endocarditis and indeed to suppurative disease of any organ or structure adjacent or remote. There is usually an associated empyema with embolic-infarction abscesses which are often multiple. Other abscesses may be distinctly localized pri- marily, but tend to extend. Symptoms. — The symptoms are those of sepsis (see " Septicemia" and "Pyemia") and the physical signs may be vague or lacking if the septic focus is central, or simulate an encysted empyema if superficial. Perforation readily occurs (most commonly in a bronchus) and is associated with the sudden appearance of a considerable quantity of purulent sputum which then persists with or without distinct and demonstrable cavity signs. g The sputum is then usually foul, and, in contradistinction to gangrene, contains elastic tissue. At first or at intervals it often shows more or less blood. It will be noted that the symptoms of sepsis apply to all forms; but closed abscess may yield no symptoms whatever or only percussion dulness and compression. Difficulties Seldom Insurmountable. — Despite this fact, in actual practice the author has not found the diagnosis of even closed pulmonary abscess so difficult a matter as one might assume. * It has seemed to the author that otherwise silent blocks in the pulmonary area may account best for many of the extreme abrupt, but transitory periods of urgent dyspnea and precordial oppression so often observed in decompensated cardio- vascular cases. Diagnosis easy, or impossible. The typical case. Multiple lesions. Sudden pain. Dyspnea and hemoptysis. Silent infarcts. Often obscure. Perforation. Foul sputum. Silent cases. 420 MEDICAL DIAGNOSIS The septic temperature is rarely absent and if localized dulness (often showing a central maximum and shading into a circumferential hyperresonance) can be determined, the free use of a clean aspirating needle introduced if possible at the center of maximum dulness point usually makes the diagnosis positive. Fig. 155. — Closed abscess in left lung. The roentgen-ray is often of the utmost value in these cases. In localized and walled-off (encysted) empyemas the symptoms may be precisely the same as closed pulmonary abscess, though the area of percussion dulness or flatness is usually more sharply delimited than is that of abscess. Prognosis. — Embolic abscess is almost invariably fatal and the prognosis is bad in all, though their course may oftentimes be prolonged or recovery achieved through surgical interference. PULMONARY GANGRENE.— The etiologic factors are chiefly those of septic pneumonia and pulmonary abscess. It is a rare complication of diabetes DISEASES OF THE LUNGS AND PLEURA 421 and pneumonia, exceptionally rare in tuberculosis, and varies greatly in extent, being either circumscribed or diffuse and usually but not always affecting the lower lobe. The involved areas are surrounded by consolidated, congested or edematous areas. An associated empyema is common and pleurisy invariable in the peripheral lesions. It shows the same tendency to perforation as does abscess, most commonly into a bronchus, more rarely into the pleura or even the pericardium, esopha- gus, or through the diaphragm. Symptoms. — The only symptoms differentiating the disease from pulmonary abscess or certain excessively foul bronchiectases is the peculiarly horrible odor of the sputum and the usual but not invariable presence of shreds or fragments of lung tissue, characteristically gangrenous and simulated by no other con- dition except certain rare cases of putrid bronchitis with interstitial pneu- monia and pulmonary carcinoma with gangrene. Owing to some peculiar fermentative action, the sputum often contains no elastic tissue, a fact of some importance. Prognosis. — Embolic, malignant, and diabetic cases invariably die; in others the prognosis is unfavorable, but not absolutely hopeless. PULMONARY TUMORS.— Only the malignant variety need be con- sidered. Primary sarcoma is a cmiical curiosity* an3 carcincrma rare, both being usually metastatic. The most common primary focus is of course the mammary gland, less often uterine, gastric, rectal and osseous growths. Carcinoma is the type of growth oftenest encountered and is most common in middle age and in the male. Symptoms. — The disease is often strikingly symptomless for long periods or baffling and indeterminate, the size and location of the growth being the chief factor; obstinate and violent cough may or may not be present. Sputum may be entirely absent or like prune juice or currant jelly, blood-streaked, or even purulent and of gangrenous odor, and contains compound granule cells. Involvement of the pleura may produce severe pain, and the dyspnea usually present in some degree may be strikingly paroxysmal; pressure symptoms may be marked and are often identical with those of aneurysm. Fever is often noted as the disease advances, profuse hemorrhage occasionally occurs and there may be marked displacement of the heart. Secondary growths are usually suggested by the primary lesion, but primary ones are frequently beyond a positive diagnosis. The X-ray may prove valuable in such cases and if the growth be accessible and of considerable size it may yield per- cussion dulness, usually without tubular breathing, and increased fremitus, or, more rarely, if attached to a large bronchus, both phenomena. Cachexia is of relatively slow development in carcinoma of the lung. * In a case of primary sarcoma of the lung observed recently by the author no positive diagnosis could be made during life, though the ailment was suspected by reason of the peculiar but extremely faint shadows shown by the X-ray. The physical signs were in- determinate, the heart signs and pressure symptoms slight but somewhat suggestive of aneurysm and the autopsy showed small disseminated growths, bilateral in distribution though chiefly affecting the left lung. Perforation. Odor diagnostic. Primary rare. Frank or obscure. Pressure symptoms. X-ray. 422 MEDICAL DIAGNOSIS Effusions. mportant point. Important areas. Age. Occupation. Tuberculosis. X-cay. MALIGNANT GROWTHS OF THE PLEURA,.— What is said under the head of malignant growths of the lungs applies here save that the primary signs and symptoms are pleural. Cardiac displacement is usually less marked than in simple effusions, but usually a differential diagnosis depends upon the withdrawal of blood-stained fluid in amount disproportionate to, or without achieving a proper diminution of, the area of flatness. The statement as to the frequency of primary growths of the lung is even more applicable to malignant growths of the pleura, but endothelioma is more frequent in this region than in any other portion of the body. This usually takes the form of multiple nodules with infiltration and thickening of the pleura and in full-developed cases may yield to light percussion a flatness equal to that of the bloody fluid with which it is associated. Primary sarcoma is also encountered in rare instances, and sequential involvement of the lung is the rule. Prognosis. — Death invariably results though only after a period of several months. DISEASES OF THE BRONCHIAL GLANDS.— The most important of these glands lie in the angle of the tracheal bifurcation about the main bronchi. The smaller glands follow the course of the bronchi lying in the interlobular connective tissue. They must chiefly be considered in connec- tion with the ailments of children or adults, as possible sources of secondary enlargement with or without symptoms. It should also be remembered that gangrene of the lung may involve them and that through dusty occupation (inhalation of dust), they may become pigmented and somewhat enlarged. Associated Ailments. — The following diseases may affect them: (a) Severe acute bronchitis, (b) Scarlet fever, measles, whooping cough, typhoid and similar ailments, (c) Broncho- and lobar pneumonia, (d) Pulmonary gangrene, (e) Mediastinal, or, by metastasis, remote, malignant growths. (f) Hodgkin's disease and leukemia (especially the lymphatic form), (g) Pulmonary tuberculosis, (h) Tuberculous or malignant disease of the abdominal or retro-peritoneal structures. The greater number of cases in children are due to tuberculosis, the pri- mary source of infection being either gastrointestinal, tonsillar or bronchial. Symptoms. — Many enlargements are symptomless, in other cases the effects are those of pressure within the mediastinum combined with physical signs chiefly observable in the interscapular region and upper sternum. These signs are usually so indefinite, occurring as they do in areas most un- favorable for percussion or auscultation, that the early diagnosis rests usually upon pressure symptoms, an X-ray picture which is often distinctive, and the knowledge of an adequate cause. (The subject of pressure symptoms is thoroughly discussed under the head of "Aneurysm.") Much stress has been laid upon D'Espine's sign previously described (see page 310) and also that of Eustace Smith which is a venous hum heard over the jugulars and over the sternum just below the level of its notch. To elicit it the head is tipped backward. DISEASES OF THE LUNGS AND PLEURA 423 Neither sign is of much importance and usually both are absent. Pressure symptoms are practically identical in all forms of mediastinal growth or tumor, though the most distressing cases ever observed by the author have been associated with the glandular enlargement of HodgkhVs disease. In some cases a mediastinal new growth yields transmitted pulsation strongly resembling, though seldom accurately simulating, the expansible pulsation of aneurysm. The pulsating dermoid cyst is the new growth most likely to cause this error. If, however, the clinical auscultatory phenomena of aneurysm are demanded as indispensable to a positive diagnosis of that condition no mistake is likely to occur. MEDIASTINAL ABSCESS.— This excessively rare condition may be acute or chronic, and occurs chiefly in the male in connection with traumatism, the acute infectious diseases, pulmonary abscess, gangrene or advanced tuberculosis. It is recognized by the symptoms of sepsis associated with severe radiating substernal pain and marked pressure symptoms. It may rupture and produce a fluctuating tumor in an intercostal space or discharge into the esophagus or trachea. The danger of confounding aneurysm with a pulsating mediastinal abscess is slight save in those cases in which an aneurysm by its continued pressure has produced necrosis and ultimate abscess in some adjacent structure. The use of a. fine hollow needle involves no con- siderable risk and usually establishes the diagnosis. One need never hesi- tate to employ such a procedure if other measures of differentiation fail in so urgent a condition as acute mediastinal abscess. In this connection the cold abscesses usually arising from spinal caries should be borne in mind. The X-ray may be of the utmost value in such cases. CHRONIC INTERSTITIAL PNEUMONIA {Fibroid Phthisis, Pulmonary Cirrhosis). — In spite of years of observation the conditions characterized by extensive fibroid changes remain imperfectly classified. In a broad sense it is best treated under the one heading and we may assume that lobar pneu- monia, broncho-pneumonia, old pleurisies, syphilis, echinococcus cysts and tuberculosis may operate to produce a lesion, the chief characteristic of which is fibrosis. Chronic diffuse interstitial pneumonia is excessively rare as a sequence of acute lobar pneumonia, though a few cases have been described with some accuracy. Chronic broncho- pneumonia is more common, but is usually tuberculous and interstitial pneumonia following pleurisy (pleurogenous) undoubtedly occurs as a result of prolonged compression, it being associated usually with a greatly thickened and adherent pleura. The cases of inter- stitial pneumonia due to continuous dusty occupations (pneumono- coniosis) and the syphilitic tuberculous and echinococcus forms are better understood. Morbid Anatomy. — The process may be lobar (massive) or lobular (peribronchial, broncho-pneumonic, insular). The sound lung is markedly emphysematous and the heart is thus pushed and drawn toward the diseased Pressure. Pulsating dermoid cyst. Rare and obscure. Possible error. Use of hollow needle. Fibrosis. Types. Important signs. 424 MEDICAL DIAGNOSIS Retraction. The heart. Consolidation, Extreme chronicity. lung, pulmonary shrinkage and adhesions being usually marked, though sometimes lacking (e.g., in pneumonoconiosis). The lung itself may be marvelously shrunken and show chronic bronchitis, multiple bronchiectases and perhaps aneurysmal dilatations of the pulmonary artery. The heart is enlarged, its right chambers being especially dilated. The" varied nature of the lesion makes possible wide differences in post- mortem findings. The most extreme cases represent the massive form of the disease, while gummata, apical tuberculous cavities or echinococcus cysts may indicate the specific primary cause as may the peculiar pigmentation of the tissue observed in cases of anthracosis (coal miner's disease) and siderosis (due to metallic particles), chalicosis (grinder's rot, stone cutter's phthisis). Symptoms. — The symptoms accurately follow the morbid anatomy as stated, being those of emphysema, chronic bronchitis, pleural adhesion, bronchiectasis or chronic phthisis, according to the nature and extent of the lesions, combined with physical signs bearing the same relation to causation. The displacement of the heart, retraction and immobility of the thorax on the affected side, scoliosis, and the depressed shoulder are emphasized by comparison with the voluminous opposite side. Symptoms of marked infiltration are usually found, but vary widely with the degree of involvement. The drag exercised by the diseased lung upon the mediastinum and its contained structures reenforced by the thrust of the bulky emphysematous opposite lung may produce an extraordinary displacement of the heart and its great vessels. The disease is not only remarkably chronic but one which permits con- siderable activity for many years or even for a reasonably long lifetime.* PULMONARY SYPHILIS.— There are no characteristic symptoms of this disease which most commonly manifests itself as interstitial pneumonia. It occurs both in congenital, and tertiary acquired, syphilis. The so-called white pneumonia is of no clinical importance, being found only in the lungs of dead babes usually stillborn. The latter process is frequently associated with tuberculosis. In acquired syphilis, gummata, single or multiple, vary- ing in size from a small seed to a hen's egg may be encountered. The physical signs are in no way peculiar to syphilis. Whether there is an actual destruct- ive disease of the lung and true syphilitic phthisis is still debatable. There are certainly rare cases in which softening is associated with caseous gummata and similar cases not infrequently occur in connection with tuberculosis. f The lower lobes are usually sites of election. * One case observed by the author during a period of nearly twenty years has passed through several severe illnesses and has lived to see his two healthy brothers die of acute disease; another case, showing the classical signs of inherited syphilis and every evidence of massive chronic fibrosis, has undergone an appendectomy and nephrotomy and several attacks of influenza. Both men have been almost continuously at work during the whole period. t No one can have failed to encounter cases of undoubted acquired syphilis in which a rapidly advancing proven tuberculous process showed a marked improvement following the use of specific medication. DISEASES OF THE LINOS AX1) PLKURA 425 Differential factors. Resembles tuberculosis. PULMONARY ACTINOMYCOSIS.— In all essential particulars this disease presents the picture of chronic bronchitis, pulmonary tuberculosis, or pulmonary abscess, and its diagnosis almost invariably depends upon the recovery of the specific organism from the sputum. It should be suspected if in such cases tubercle bacilli are absent, the bases chiefly or primarily involved and superficial swellings or brawny inflammations noted. In several cases encountered by the author it has taken the form of " closed" pulmonary abscess revealing its true nature only when explored. ASPERGILLOMYCOSIS — This rare disease is due to the aspergillus fumigatus and has been observed chiefly in those who handle infected flour, meal or grain. The symptoms are essentially those of pulmonary tuber- culosis lacking the tubercle bacilli and the diagnosis can be made only by the discovery of the mycelium. It may also occur as a secondary disease in connection with the various chronic pulmonary ailments and may assume a predominatingly bronchial, nodular, or cavernous form. OIDIOMYCOSIS. — This curious ailment sometimes closely simulates pulmonary tuberculosis. NOCARDIOSIS. — The nocardia are peculiar microorganisms resembling bacteria on the one hand and moulds upon the other. They are branching, thread-like, aerobic, spore-producing bodies, growing readily upon nearly all culture media at ordinary temperatures. They are widely distributed, are found especially on grasses and grains and their point of entrance is usually the pulmonary tract. They produce symptoms and actual pathologic changes closely resemb- ling tuberculosis, the germs of which disease they may closely simulate if fragmented. They are readily distinguished by their behavior on culture material and by their staining properties. The pulmonary symptoms are in themselves identical with those pro- duced by the tubercle bacillus. They do not resist acid and are decolorized by alcohol. These three conditions are dealt with more fully in their appropriate section. PULMONARY DISTOMATOSIS.— ("Lung Fluke disease").— See Paragonimus Westermanni. PULMONARY AND PLEURAL HYDATIDS.— Diagnosis.— So long as hydatid cysts are central and small, few or no symptoms are produced. If they enlarge, and particularly if they reach the pleura, cough and pain may be severe. Fever is usually absent, and dyspnea slight. Physical signs may be baffling, indeterminate, or merely those of consolidation with weakened breath sounds, as in an area of massive pneumonia (blocked bronchi) or a Peculiar cases, closed pulmonary abscess. The superficial (pleural) cases will strongly resemble encysted empyema but are more often like superficial pulmonary abscess in their central intensification of dulness and may reveal a most suggestive friction opposite this point, pleuritic effusion with the usual pressure displacements, weakened breath sounds and diminished fremitus. Symptoms variable. 426 MEDICAL DIAGNOSIS Exploratory puncture. If rupture occurs, the immediate symptoms may be urgent, the watery nature of the fluid is suggestive and characteristic and hooklets and frag- ments of the membrane may be present. Hydatid thrill and superficial rounded tumors may be found. Fowler emphasizes the relative absence of mediastinal pressure symptoms (see " Aneurysm") despite the evidences of a large tumor or exudate. Zapelloni has reported positive results with the " deviation of complement" test in 93 out of 114 operated cases of echinococcus disease. Eosinophilia was present in but 60 per cent. Echinococcus cysts usually involve the right lower lobe and in open pulmonary cases may show the characteristic hooklets in the sputum. DERMOID CYSTS OF THE LUNG.— Dermoid cysts in the lung are of rare occurrence, usually originating in the anterior mediastinum. They offer great difficulties to the diagnostician and may vary in size from that of a small marble to that of a large grapefruit. Occasionally rupture occurs into a bronchus or into the pleural space or the lung itself. In rare instances, through pressure, escape of the fluid may occur into, the pericardial cavity or the great vessels about the heart. Chylous Pleurisy. — A true chylothorax results, rarely, from occlusion or rupture of the thoracic duct or receptaculum chyli, usually as a result of malignant or tuberculous disease. The diagnosis can only be made by the discovery of a pleural effusion and the removal of a portion for examina- tion. Such cases lack any history of acute pleurisy. THE EXAMINATION OF THE HEART 427 EXAMINATION OF HEART AND BLOOD VESSELS THE HEART. — Boundaries Usually Encountered. — The heart lies in the mediastinum between the lungs and presents, when the patient is recum- bent: Fig. 156. — The two dimensions of chief importance in teleroentgenography, viz., Mr. at level of 4th interspace; and Ml. at level of 5th. Both Ml. and Mr., however, should represent the maximal distances from the median line to the heart borders. Fig. 157. — Silhouette of the "sthenic" or "ideal" heart. The single convexity on the left of the diagram represents the right auricle. The four convexities on the right, from above downward are: 1st, the aorta; 2d, the pulmonary artery; 3d, left auricle; 4th, a narrow strip of the left ventricle. This figure would represent the heart outline when the diaphragm is in the neutral position. Compare with the ptotic type of heart shown on the following page. (a) A base at the level of the upper border of the third costal cartilages. (b) A right border formed chiefly by the right auricle, save in the case of the " drop heart," curving from the right base downward to the sixth chondro- sternal articulation and attaining in robust individuals a distance from 3.0 to 4.5 cm. from the midstemal line under the fourth interspace. 428 MEDICAL DIAGNOSIS The total of the right and left transverse heart diameters seldom exceeds 13.5 cm. and may not be greater than 8 or even 7.5 cm. in emaciated con- genially asthenic subjects (see "Drop" Heart). In the latter cases the right border may not pass beyond the right edge of the sternum. (c) A left border, which sweeps outward, downward, and then slightly inward, to a point in the fifth interspace, varying between 5.0 and 9.0 cm. (2% to 3% inches) from the median line, according to the weight and build of the patient and the type of heart. Small hearts. Fig. 158. — The "drop" heart of congenital asthenia and visceroptosis. Normal heart contour and elevation shown by dotted lines. (Schivarz modified.) * Found in a consider- able proportion of the population and in all grades it constitutes a most misleading variant and is responsible for a vast number of missed diagnoses of an existing cardiac en- largement. In persons of the congenital asthenic type, be they fat or thin, the total dimen- sions normally fall short of the measurements ordinarily given as the normal. (d) A lower border connecting the lower extremities of the lines represent- ing the right and left borders. Variations in posture as between the sitting and recumbent position affect the total transverse measurement but slightly. * The position of the auricle in the typical "drop" heart is indicated also by a dotted line. The angles or notches of the left border are exaggerated as compared with the usual roentgenographic picture. Such hearts obviously must be so modified by the effects of valvular diseases and myocardial degenerations as to largely lose their characteristics. Whenever decided visceroptosis is present, whatever the apparent or actual heart lesion, a "drop" heart may be assumed as having existed primarily. THE EXAMINATION OF THE HEART 429 In order that the relatively small size of the average normal heart may be the better appreciated, the author has inserted the tabulation of Dr. Data and Measurements of the Hearts of Soldiers Examined 174 162 164 183 174 170 No. Weight Kg. Height Cm. Age Yrs. Transverse diameter Cm. 1 53 157 21 134 3 54 164 40 12 .0 5 55 158 29 12.8 8 56 56 173 24 27 13.8 12.3 10 11 57 57 160 168 19 24 12.3 12.6 15 16 58 58 168 170 25 .25 11. 4 11 .2 17 59 J 75 19 12.5 "Rule of thumb" inapplicable. II. 3 13-3 13-3 12. 5 10.8 12. 5 11. 8 62 65 177 28 I4.2 64 65 168 20 12.8 66 65 176 21 12.8 68 65 172 27 12.8 69 65 170 23 12.7 72 66 164 27 135 74 66 167 26 12.4 77 67 161 25 14-5 78 67 173 29 14.6 79 67 167 25 13-7 81 67 I7S 23 12.4 82 67 167 26 14.4 430 MEDICAL DIAGNOSIS Alfred E. Cohn of the Rockefeller Institute for Medical Research* very slightly abbreviated Data and Mi .ASUREM.ENTS of the Hearts of Soldiers Examined Transverse Xo. Weight Kg. Height Cm. Age Yrs. diameter Cm. 83 67 175 28 12.4 84 67 168 27 14.0 85 67 169 23 13 2 86 67 170 24 150 87 68 167 49 1.3 5 89 68 171 21 13-4 90 68 175 24 12.8 9i 68 174 iS n. 8 94 1 68 175 26 14.0 97 69 175 42 15-7 100 69 169 26 14.8 101 69 174 3i 13.8 103 69 177 25 11. 8 106 69 172 26 13.6 108 69 180 28 12.3 - III 70 171 30 12.8 113 70 176 29 133 117 70 175 - 11. 8 118 70 175 18 130 119 71 172 22 137 122 71 170 29 14.2 123 71 177 34 13-3 125 71 178 23 12. 1 126 71 172 23 11. 3 127 72 179 24 12.7 129 7 2 174 22 14.O 132 72 174 20 v 12.4 133 72 174 29 14-7 135 72 173 21 12.8 . 137 73 178 21 14. 1 138 74 174 28 14-4 140 74 171 24 13-7 141 74 172 23 12.3 142 74 172 25 130 143 74 178 27 13-3 144 74 186 23 12.7 147 75 173 25 16.O 149 75 165 27 13 .0 150 75 175 30 13-2 154 77 179 28 12.3 155 77 181 30 12.8 157 78 170 28 14.3 158 83 180 2" 14-3 160 S3 179 26 13.8 l6l 86 180 26 13.8 THE EXAMINATION OF THE HEART 431 All transverse measurements given are those of returned soldiers who had been subjected to the privation and exertion incident to active service on the Western Front during the "Great War" just past. Infantrymen were chosen by preference or those whose service entailed an equivalent amount of privation and exertion. All measurements included in this modified table were made in the inspiratory phase by fluoroscopy at a six-foot focal distance. No special criteria other than those mentioned above governed the choice of these men and obviously a considerable number of hearts abnormally enlarged must have been included. Nevertheless the table abundantly supports the contention made originally by the author over a decade ago and set forth in the paragraphs following: Variations in Size of the Heart. — The size of the normal heart varies con- siderably in different persons and its bulk in general corresponds to the osseous and muscular development of the individual, not to his weight, breadth or thick- ness, though height and muscular development combined are important factors. A Source of Gross Error. — A general lack of appreciation of the relatively narrow maximal limits allowable for normal hearts and a disregard of the structural factors necessary to the just application of a maximal allowance of 14 cm., even for robust, mature men, lead, to a multitude of serious errors with relation to minor but not negligible incompensations and enlargements and the existence of serious myocardial disease.^ Forced expiration materially increases the transverse diameter. Many cases of cardiac dilatation of pathologic degree, especially (but by no means exclusively) such as occur in the extremely common, narrow, so-called "drop heart," of the congenitally asthenic individual, are overlooked and neg- lected because of a general adherence to u rule of thumb" measurement and faulty initial concepts. Furthermore, the application of the same rule may result in errors of the grossest type with relation to major dilatations of the small hearts. The Aorta. — From the base of the heart, the aorta sweeps upward and to ! the right, its right border projecting slightly beyond the sternal margin. It then passes backward and toward the left in such a manner as to leave the manubrium resonant under normal conditions. This area assumes great importance in certain cases of aneurysm or enlargement of the thyroid or thymus gland. Mobility of the Heart. — Suspended within the pericardial sac by the great vessels at its base, the heart is movable, responsive to all changes of posture, and laterally displaceable to an astonishing degree in cases of "drop" heart C cor pendulum") or under certain pathologic conditions (ascites, tympanites, pleural effusion, pneumothorax, etc.). Total transverse measurements Neglected at dilatations. Manubrial percussion note. "Corpen- dulum." * Archives of Internal Medicine, May 15, 1920, vol. xxv, No. 2. t Up to the present time the author has encountered no heart exceeding (teleoroent- genographically) 14 cm. in total transverse diameter in the inspiratory phase whose possessor did not show positive evidence of heart disease. This has held true even in the case of men of unusual musculature and athletic tendencies. 43 2 MEDICAL DIAGNOSIS Chiefly rights ventricle and ] auricle. Of utmost value. Relation to Anterior Thoracic Wall. — Anteriorly it presents its right chambers; chiefly the right ventricle to the left of the mid-sternal line, and the right auricle from midsternum to the true right border which it wholly forms. * The left ventricle is normally represented by a mere strip of heart muscle along the left border and the normal left auricle is hardly in evidence. Fig. 159. — "Drop" heart. An extreme example in the adult male, diameter 7.5 cm. Total transverse Cardiac Outline.- — Changes in the shape of the relative cardiac dulness or the radiographic shadow usually indicate enlargement of the heart itself, suggest the individual chambers involved and hence the underlying lesions. As will be seen later, such changed outlines serve as a check upon the diagnosis of valvular lesions and pericardial effusions, and the student must * Save in the " drop " heart and its minor modifications. THE EXAMINATION OF THE HEART 433 never forget that even serious dilatation thus indicated may be unattended by any valvular murmurs. THE HEART VALVES. — The mitral, tricuspid, aortic and pulmonary valves are anatomically located within so small a space that a large stethoscope bell wiU n-early cover them all, but their exact position is of little importance in clinical work. THE CLINICAL VALVULAR AREAS.'— The points of maximum audi- bility arbitrarily fixed for auscultation are: (a) The mitral area which corresponds to the heart apex. (b) The tricuspid area, corresponding to the lower half of the sternum. Fig. 160. — Dilated "drop" heart. (Outlines drawn from original roentgenograms.) Cause of dilatation, over-exertion following an unusually prostrating attack of influenzal bronchitis. Note that breadth of the dilated heart was but 12.1 cm. and after treatment 9 cm. (See also case of D. B. under "Drop" Heart, successive roentgenograms.) (c) The pulmonary area, corresponding to the second left intercostal space at the left sternal edge. (d) The aortic area, corresponding to the second right and third left inter- costal spaces, adjacent to the sternum, the former being most useful in connection with aortic systolic murmurs and aortic second sound accentuation; the latter, in auscultation of diastolic aortic murmurs. In this last lesion one also finds the lower end of the sternum a point of aortic transmission. The Suprasternal Notch. — The use of this area may enable one to hear weak heart sounds not audible over the selective areas mentioned above. INSPECTION FACIES. — No internal ailment presents more external signs to the ob- server than does established heart disease in many instances. In some forms the external signs are relatively prompt in appearance and apparent at a glance. In others they are obscure and relatively late or never appear. The most strikingly objective lesion, over periods embracing many years, 28 Murmurs may be absent. Anatomic position unimportant. Arbitrary auscultation areas. Often strikingly objective. 434 MEDICAL DIAGNOSIS Jerking vessels. is aortic regurgitation, usually associated with pallor and meagerness of face, yet seldom with marked actual anemia. In such cases the jerky throb of the carotid, temporal, or any other superficial artery, may at once strike Capillary pulse. Fig. 161. — "Drop" heart with evidence of slight dilation. Note borders, equidistant from median line. Calcined focus in upper left lung field. A mitral systolic murmur was present in this case. {Dr. Frank S. Bissell.) the eye, and even the head nods rhythmically in some cases or the foot jerks in time with the heart beat if the knees are crossed. In rare instances the eye may catch the rhythmic blushing and paling of the capillary pulse if some skin area becomes congested or even in the lips or nails. One may find jerking vessels and a capillary pulse in thyroid cases, THE EXAMINATION OF THE HEART 435 lacking aortic regurgitation, but possessing overacting hearts and extreme vasomotor relaxation, and the condition of this gland should always be noted, together with the presence or absence of the peculiar stare, actual exophthalmos, or tremor", which may indicate a frank hyperthyroidism. In rare instances the tracheal tug of aortic aneurysm may exist in so marked a degree as to catch the eye, ot pupillary inequality or unilateral flushing or sweating may point to this or some other form of mediastinal tumor and resultant pressure. Facial edema will of course be noted and in cardiac disease will seldom be marked, unless as a part of general edema or when actually due to a com- plicating or primary nephritis. Mitral Stenosis. — Mitral stenosis is cyanotically objective in some in- stances and its outward signs are chiefly those indicative of oxygen deficit and may be closely simulated by advanced mitral regurgitation whether valvular or primarily myocar- dial, or, by certain pulmonary diseases which cause a relative blocking of the lesser circulation and insufficient venti- lation of the blood. In advanced mitral stenosis, espe- cially, and particularly in young women, the rosy cheeks may appear vouchers for good health if the eye fails to note the duskiness which clouds the red and shows especially in the lips and ears. In terminal mitral lesions, especially, the countenance may appear blurred and an orthopneic mitral case, if breath- ing hard and rolling the head listlessly from side to side is almost certainly nearing the portals of the hereafter. All grades of cyanosis must be noted and investigated and, as stated previously, but three forms of extreme cyanosis in walking cases are en- countered: That of the child with congenital heart disease, and advanced emphysema or the red cyanosis of " erythremia" in the adult. In old cases of right heart decompensation of long standing, a subicteric facies is common and underlain by a pallor, contrasting sharply with deeply cyanotic lips. INSPECTION OF THE NECK AND TRUNK.— This should be both direct and tangential, general and local. The most important regions and the conditions to be noted are: i. The valvular areas already described. Important pulsations may often be observed and their character may yield information of value. 2. The manubrium and its neighborhood. Here is found most com- monly the expansile pulsation of aortic aneurysm. Fig. 162. — Peculiar orthopneic variant. Urgent dyspnea associated with listless rolling of the head from side to side. Usually a forerunner of death. "Tracheal tug." Misleading "color." A striking picture. Ambulants. Subicteric facies. \ » X 436 MEDICAL DIAGNOSIS Area and position. Force. "Heaving" vs. "wavy" apex beats. Systolic recession. Extreme type. May deceive the eye. A misleading sign. 3. The area lying between the inner edge of the left scapula and the spinal column, in which the heaving pulsation of an aneurysm of the descend- ing thoracic aorta sometimes appears. 4. The Superior Abdominal Quadrants. — In these we may find: The presence of manifest enlargement, pulsation, or rhythmic displacement of the liver; ascites; epigastric fulness, pulsation or retraction; pulsation of the abdominal aorta. The fulness and rigidity of vessels and the number, nature and time of pulsa- tions in the veins of the neck must be noted. General or localized edema, any evidence of marked sclerosis, local or gen- eral, venous or arterial, should catch the eye. Bulging or deformities of any portion of the thorax together with its form and movements should be carefully investigated. Dyspnea in all its forms from Cheyne-Stokes breathing, BioVs periodic apnea, or an exertion dyspnea, to a mere inability to hold the breath, is of importance and orthopnea is always a serious matter. THE APEX BEAT.— This should be represented normally by a gentle rhythmic uplifting of the fifth interspace over an area not more than an inch in diameter, well within the mid-clavicular line. It is not always present either in health or disease, because of overlying fat, a weak impulse, emphysema or an intervening rib, and the beat is often excess- ive, even in the case of a normal heart, because of temporary excitement, exertion, indigestion, narcotism, psychasthenia, and like conditions. A heart that is the seal of extreme hypertrophy causes a distinct and widespread heaving {uplifting) impulse, and the beat of a badly dilated righ heart is wavy, diffuse and indeterminate. In either case the area of pulsation is greatly increased. Reversed Apex Beat. — In hypertrophy or dilatation of the right heart the right ventricle may wholly form the apex beat, in which event there is visible in the area between the left sternal and parasternal lines, a recession of the third, fourth and fifth or even the second left interspaces, along the region adjacent to the left sternal border, with each systole. In many such cases the left ventricle does reach the wall for a fleeting interval. In cases of extreme right heart dilatation, usually associated with relative tricuspid insufficiency, systolic recession may occur in the fourth and fifth right interspaces and even in the third, though the last is rare. Indeed the combination and coincidence of a visible left ventricular sys- tolic apex beat with a right ventricular retraction is by no means uncommon in cases of mitral stenosis with thin chests and gives a peculiar appearance of undulation. Various Precordial Retractions. — A strongly acting nervous heart and thin chest wall may cause systolic recession (right heart) in the second, third, fourth or fifth left interspace and in the upper portion of the epigastrium, even though the organ shows little or no departure from the normal outline, * The lesser and commoner degrees of hypertrophy do not reveal themselves by a heaving apex beat. THE FA'AMINATION OF THE HEART 437 but in such cases it is often associated with ailments which end to overtax the right heart, such as pulmonary tuberculosis, pulmonary fibrosis and em- physema of the lungs. Congenital asthenia with psychasthenia and subnutrition , hyperthyroidism and profound anemias, are quite competent to produce such visible pulsations in thin chests and especially in those of reduced anteroposterior diameter. In most of these instances an atonic, irritable and overacting "drop" heart is present and the actual apex beat is systolic, diffuse, sharp, and left ven- tricular in origin. Pulsation Adjacent to or Involving the Manubrium.— Swc/j an impulse, if marked and deliberate, always suggests aneurysm of the aortic arch, and pulsa- tion of the manubrium itself is of special significance, because of its association both with aneurysm and certain vascular forms of mediastinal new growths. Systolic Retraction Extending Beyond the True Apex Beat. — This is commonly mistaken for a systolic thrust and leads the unwary to overesti- mate the enlargement of an hypertrophied or dilated heart. It may be caused by the drag of pleuro-pericardial adhesions with or without shrinkage or retraction of the lung itself, but can result when the contraction of any very greatly enlarged heart causes negative pressure areas in the lungs. Solitary systolic pulsation over the second left interspace near the sternum is an exceeding common event as a result of right ventricular overaction. It is also observed early in certain cases of pericarditis and in the rare in- stances of pulmonary regurgitation. Pulsation over the second right interspace is a well-known accompaniment of free and established aortic regurgitation. It is wholly different from the heaving expansile and usually deliberate pulsation of aneurysm of the first portion of the aortic arch. Systolic Retraction in Mediastino-pericarditis. — It is one of the signs of adhesion of the pericardium to the heart itself, when associated with an in- durative mediastinitis or general polyserositis. It causes a systolic drag upon the diaphragm, but to be of diagnostic value in this connection it should involve the posterior interspaces or ensif orm cartilage as well and be unaffected by respiration (Broadbent's sign). Precordial Lifting. — This may occur in great hypertrophy or dilatation or, in minor degrees, even in the case of strongly beating, excited, normal hearts in chests of small anteroposterior diameter. The Position of the Apex Beat. — Abnormalities of position must follow inevitably any decided changes in the cardiac outline or actual displacement of the heart. Displacement of the Apex Beat. — Upward, (a) High position of diaphragm, (b) Tympanites, (c) Ascites, (d) Abdominal growths, (e) In some cases of pericarditis with e fusion {often at nipple level). Upward and to Left. — Effusion into right pleural sac; (a) Liquid, (b) Gaseous. Downward. — (a) Aortic aneurysm, (b) Mediastinal tumor, (c) Senility. Aneurysm. Mediastinal tumor. Broadbent's sign., 438 MEDICAL DIAGNOSIS Important in diagnosis. Often mis- interpreted. Value in diagnosis. Right heart dilatation. Aortic pulsation. Left ventricular* pulsation. Hepatic. (d) Hypertrophy of left ventricle {downward and to the left), (e) Collapse of abdominal viscera. To Right or Left. — (a) Effusion of gas or liquid into pleural sac, i.e., pneu- mothorax, hydrothorax, etc. (b) Unilateral or vicarious emphysema, (c) Pleural adhesion and retracted lung, (e) Marked solid enlargements of lung or of the left lobe of the liver. (/) Respiratory lateral displacements may occasion- ally be visible in right- sided pleural effusion. These are best demonstrated by fluoroscopy, as originally reported by the author. The assumption of the lateral posture results in a corresponding displacement of even the normal heart, but is incredibly exag- gerated in certain cases of "drop" heart {cor pendulum). The apex beat may be invisible by reason of: {a) Interposition of a rib. {b) Fat chest wall, {c) Feeble heart, {d) Emphysema, (e) Edema of chest wall. (/) Pericardial effusion {marked), {g) Pleural effusion, {h) Trans- position of the viscera. ' In this condition the beat is present on the right side. Its area and apparent force may be increased because of : {a) Mere over action, (b) Hypertrophy or dilatation, {c) Retraction of lung. Precordial Bulging.— Aside from the pres- ence of an actual growth this is usually due to three causes, viz.: aortic aneurysm, mas- sive pericardial effusion, or, most commonly, excessive enlargement of the heart. It is most marked in those cases originating in early childhood in which the growing osseous structures have yielded readily to the pressure beneath. One may thereby often approximately fix the date of the heart lesion seen in advanced life. Such a precordial prominence is known as the "precordial boss" or "voussure" (arch). Epigastric Pulsation. — This may be of several types: (i) A systolic reces- sion as timed by the carotid beat, in right heart dilatation (Mackenzie).* (2) A systolic pulsation, as timed by the abdominal aorta, in certain cases of free aortic regurgitation, goiter hearts, anemias, or any case combining an overacting heart with decided vasomotor relaxation. A relaxed abdominal wall makes these pulsations obtrusively manifest. Transmitted aortic pulsation and true aneurysm are always to be considered. The latter is always expansile and usually deliberate. (3) A systolic protrusion in exces- sive left heart hypertrophy. (4) Actual systolic pulsation of the engorged liver as seen in certain cases of tricuspid insufficiency. * Mackenzie found that in one such case a needle, introduced after death, over the maximal area of epigastric pulsation, entered the right ventricle. Fig. 163. — The production 'of the apex beat by the normal heart. (After Staehelin and Ortner.) THE EXAMINATION OF THE HEART 439 PALPATION Palpation serves to confirm and amplify inspection, and to detect thrills associated with valvular lesions or anemia, together with points of tenderness and the general characteristics of tumors of any kind. It is of special value in connection with the expansile pulsation and " diastolic shock" of aneurysm and the apical presystolic thrill and systolic shock of mitral stenosis. No examination of the diseased heart is complete that does not include the palpation of such related organs as the lungs, liver and spleen and determine the presence or absence of ascites in the presence of abdominal distention. Thrills. — A systolic thrill in the second right interspace (aortic area) suggests aortic sclerosis, aneurysm or aortic stenosis. In the second left, if maximal at that point and associated with extreme cyanosis, it points to pulmonary stenosis, usually encountered in congenital lesions. Such thrills are common in exophthalmic goiter. Lacking cyanosis, a diastolic thrill in the second left interspace means aneurysm or aortic regurgitation. A pre- systolic or diastolic apex thrill is almost pathognomonic of mitral stenosis. A systolic apex thrill usually means mitral regurgitation; over the lower sternum or at its left edge, tricuspid regurgitation; and in children or young people, with profound cyanosis it points to congenital defects. The pre- systolic thrill of a tricuspid stenosis is very rarely encountered. PERCUSSION Percussion is often decisive in the differential diagnosis of heart lesions. One usually percusses from the more resonant to the less resonant areas, save in determining the superficial dulness and seeks to determine (a) the deep or relative cardiac dulness; (b) superficial dulness; (c) the resonance of the region of the aortic arch. Abdominal distention and pulmonary hepatic or splenic engorgement are also important factors if the heart is abnormal. The prevalent "flat-finger" percussion must not be used, nor is any method unfailing in results, but by orthopercussion, auscultatory percus- sion, threshold percussion, or a combination of these, it may be very closely approximated in most cases.* The student should accustom himself to the sound of the normal dull tympany of the manubrium sterni, as this is one of the most important regions. He should also carefully note and localize any pain or tenderness attending percussion. Syphilitic periostitis, for example, may be encountered over the sternum and ribs and might prove of the utmost importance in a diagnosis. In many atrophic or degenerated hearts, and in minor dilatation or mere atony, associated with chronic overstrain, tenderness often is marked at the left lower border and perhaps within it. * In skilled hands the correspondence of outlines obtained by such methods of percussion to those obtained by long-focus roentgenograms (teleoroentgenography) or the orthodiagram is usually relatively close, but ivTtertain cases the grossest error occurs. Scope and value. Caution. Aortic. Pulmonary. Mitral. Congenital defects. Never omitted. Cardiac boundaries. Manubrium. Tenderness. 44o MEDICAL DIAGNOSIS Enlargement to the right. Extension to the left. During and following Angina Pectoris major most extensive areas of hyperesthesia may exist and often prove misleading if their maxima are remote- from the heart itself. Superficial Cardiac Area. — The notched inner border of the left lung leaves a portion of the right ventricle uncovered and in such close proximity to the chest as to yield decided percussion dulness over a somewhat triangular space having its base at the left sternal margin from the fourth to the sixth chondro- sternal articulation and its apex at or just within the apexA>eat, the triangle being completed by lines connecting these points. Determination of the Superficial Cardiac Area. — In determining the superficial cardiac area it is best to commence at its known normal center and percuss from that lightly and in radiating lines. Significant Changes in Per- cussion Area. — An increase in the area of superficial dulness may mean: (a) Enlargement of the heart. (b) Retraction of the lung. (c) Pericardial effusion. (d) Pleural adhesions, solidified lung, or new growth. An Important Region. — This area of marked dulness is of great importance inasmuch as its exten- sion to the right indicates clearly displacement of the heart as a whole, enlargement of the right ventricle, or pericardial effusion. A valuable sign differentiating between displacement and en- largement of the right heart is given us by von Oestreich. Fig. 164. — Superficial and deep relative cardiac percussion dulness, flat-finger method. This actually outlines only the exposed area (cross-hatching) and the general profile of the anterior surface of the right and left ventricles. More accurate delineation of the entire cardiac outline is now possible by means of a modern- ized technic, the results closely approximat- ing the roentgenographic outline in most instances ; though gross error is possible. (Repe- tition of figure 92 for added clearness.) If the superficial dulness passes to the right as a straight border or one concave and opening to the right, we may assume that the heart as a whole is displaced or that a greatly enlarged left ventricle is crowding over its fellow of the right side (v. Jagic). If its right percussion boundary is broken by a bulge to the right the change represents right ventricular enlargement. On the other hand, extension of the superficial area to the left alone or to the left and downward indicates left ventricular hypertrophy or dilatation, and if to the left and upward, an added left auricular enlargement. Cases in which decided right and left extension both are encountered are common as the result of combined valvular lesions. In pericardial effusion it may be carried far beyond the right edge of sternum as a parabolic curve, joining hepatic flatness below. THE EXAMINATION OF THE HEART 441 Area of Relative Dulness. — It has been so difficult formerly to accurately outline the normal right heart that many modern diagnosticians still use the flat-finger method and the two arbitrary percussion areas shown in Fig. 163 as representing the normal, and these serve fairly well to determine and measure any variation in the precordial area of ventricular dulness. The orthopercussion method is far more accurate and greatly to be preferred. (See next page.) The most valuable information with relation to the right border lies, as stated, in the extension of the superficial cardiac area to the right beyond the median line as indicating right ventricular dilatation or hypertrophy or pericardial effusion and the determination of an unduly wide extension of relative dulness to the right, as determined by orthoper- cussion, threshold percussion or ausculta- tory percussion, indicating right auricular dilatation.* Value of the Sensation of Resistance. — In the case of the highly trained ob- server, percussion is almost as well carried out on the basis of the resistance felt as on quality and pitch of elicited notes. The direct method of Ebstein is prac- tically a soundless percussion, and in fact, mere thrusting will determine a cardiac or hepatic boundary with considerable ac- curacy and constitutes an excellent drill in concentration of attention. The sense of resistance may be intensified by various forms of plessimeters which also sharply delimit the areas of differing resistance and pitch, or, by the use of the flexed finger in orthopercussion, which is quite as accurate and more convenient. Firmness and equality in pleximeter pressures and plexor strokes over the contrasted areas under percussion is of cardinal importance. The pressure may be varied to suit the conditions and need never be made painful to the patient. An Uncertain Method. — The old flat-finger percussion, still in general use, and most valuable for other purposes, is extremely uncertain and inaccurate in relation to right heart boundaries and the true left heart profile, and should be wholly abandoned in cardiac percussion. Threshold Percussion. — Goldscheider's method of heart percussion demands the lightest percussion stroke audible to the percussor and is at present much used. If a heart border be approached with a stroke so light as to be barely audible to the percussor's ear when applied over the adjacent resonant lung tissue, it should be entirely lost with the shortening of the vibrations induced * Save as stated in the case of "drop" heart. Fig. 165. — Note that in the normal heart the right border is formed by the right auricle. Compare with Fig. 158 ("drop" heart) showing right ventricle forming this border. Working outline. Value of orthopercus- sion. "Tast per- cussion." "Schwellen- werts" percussion. Threshold of audibility. 442 MEDICAL DIAGNOSIS A measure of inaccuracy. by an underlying heart border. -The contrast between "little" and "noth- ing" is sharper than that representing mere differences of degree. // is difficult to carry out in any place not absolutely quiet and, in the author's hands, no more accurate than the combined method next to be mentioned, indeed much less so if the heart dulness passes Jar to the left. It is an excellent method for the expert, but in using it the inexpert are likely to carry borders too far out. The greatest obstacle to its applica- tion lies in the difficulty of maintaining an exact equality in the force of the percussion strokes and the extremely quiet environment necessary to its most effective employment. Fig. i 66.- — The illustration demonstrates the technic to be preferred in delineating outline by percussion. The actual stroke is, as nearly as possible a mere dropping of the wrist varied, as may be necessary, however, by a modulated stroke of bare audibility (threshhold percussion) or the strong stroke sometimes most effective. This may readily be combined with auscultation and constitutes a good method. The need of preserving the vertical direction of the stroke itself is manifest. The upper hands define the true profile boundary; the lower, a false one. Orthopercussion.— As previously stated, in the percussion of a widely ex- tended left heart border in a chest which falls away at the sides before the limit of relative dulness is reached, one must maintain a stroke vertical to the anterior plane of the body rather than to the curving lateral surface of the chest. If this technic is not observed, one carries the border of a "cor bo vis" around the curve of the chest into the axilla. One merely needs to lay off the distance thus obtained upon a centimeter rule to demonstrate the absurdity of this older method. He will find his heart border thus projected into space beyond the left thoracic border, for he will follow the heart too far and elicit the relative dulness of the lateral aspect of the left ventricle (see Fig. 166). THE EXAMINATION OF THE HEART 443 The older tecknic does not meet the modem demand for accuracy, emphasized by the frequent occurrence of great disparities between roentgeno- graph ic outlines and those obtained by the older methods. Methods of Preference. — The author personally prefers to carry out percus- sion with a light yet firm, sustained and clearly audible stroke. The impact of the percussing fingers falls, not upon the base of the flexed terminal phalanx of the pleximeter finger as recommended by Koranyi and Goldscheider, but upon the base of the second phalanx of the middle finger which is flexed at the prox- imal phalangeal joint and with the hyperextended tip applied firmly to the chest.* The more nearly this represents the mere dropping of the hand, with a loose wrist, the more uniform are the strokes. If this method is employed, the" tip of the pleximeter finger should be so firmly applied to the surface of the body as to overextend its terminal phalanx and render the vertical pha- langes as rigid as possible, but need not constitute painful pressure save in exceptional instances. Such percussion seems to check accurately with the "threshold" method, which should always be used secondarily and is preferred by many for right border percussion. One will find usually the former method the more useful and greatly value the sense of resistance and sharp definition which it yields. According to the author's experience almost equally good results may be obtained by lightly tapping the surface with the finger-tips of one hand during auscultation over the heart, at distance, i.e., combining direct percussion and auscultation. No assistant is needed if this last method be used. A proce- dure of still greater accuracy in the author's hands has been the use of ortho- percussion by the method here described combined with auscultation over the heart. Results so obtained seem to check more accurately with fluoro- scopic or plate work than any other. The author personally violates established usage by percussing from within outward until the sudden and decided change of note marks the cross- ing of the frontier. The student should try out the various modern methods and choose that which he finds most suitable to his own needs and most accurate in his own hands. Almost every clinician develops his own preferences and obtains better results by so doing. In the modern clinic many opportunities offer to compare percussion outlines with the chastening orthodiagraphic and teleoroentgenographic findings. He should remember however that when a busy practitioner he cannot always secure such quiet as is necessary to the use of threshold percussion. AUSCULTATION Auscultation aids in determining: (a) The condition of the heart muscle, (b). The competence and condition of its valves, (c) The abnormal increase or decrease of tension present in the aortic and pulmonary circuits, (d) The * This technic is generally credited to Plesch, but has long been used by various clini- cians as an alternative method. Older methods inadequate. Pleximeter finger. A simple method. 444 MEDICAL DIAGNOSIS Of fundamental importance. Avoids blunders. Systolic tone. Diastolic tone. condition of the lungs (congestion, edema, effusions), (e) Abnormalities oj the aortic arch. (/) The presence or absence of murmurs in the tributary veins and arteries, (g) The presence or absence of extracardial sounds of cardiac rhythm, (h) The determination of abnormal sounds of cardiac origin, not the result of primary valvular defects. The first and most important consideration is the quality of the heart sounds in the valvular areas and the carotid arteries. Know and Seek the Normal. — As in the case of the lungs, a common mis- take in the teaching of students lies in the failure to drill them thoroughly in the normal characteristics of, or common variations in, the heart sounds. Students and physicians alike are too often satisfied if no murmur is heard, and do not seek and demand normal heart sounds and accentuation. In no other way can we explain the frequent failures to recognize the serious significance of abnormal quality and accentuation, the decided diminution or almost complete absence of heart sounds, associated with some of the most serious lesions of the heart. The student should possess a thorough knowledge of normal heart tones, permissible variations and normal heart border limitations, and must then primarily seek to determine their presence. Abnormalities exist- ing will thus be emphasized. HEART SOUNDS* The First Sound. — A thorough understanding of the mode of produc- tion, quality and accentuation, of the normal heart sounds is absolutely essential to the intelligent interpretation of heart murmurs. At the Apex the Normal Accentuation is on the First Sound; at the Base on the Second. — Disregarding conflicting theories and fine distinctions, one may say that the essential elements in the production of the first sound are the initial, sudden sharp contraction of the ventricular walls and the coincident closure of the auriculo-ventricular valves. The Second Sound. — The second sound is produced by the simul- taneous closure and tension of the aortic and pulmonary valves immediately following ventricular contraction. Hence this second sound must primarily depend upon the integrity of the valves themselves, and measure the amount of that recoil which is the result- ant of the forces of propulsion and the resistance encountered in the artery. Abnormal Accentuation of the First Sound. — // follows that abnormally increased accentuation of the first sound, as heard in any of the four auscidtation areas, usually indicates an overacting ventricle whether this overaction is tem- porary, and caused by excitement or overexertion, or persistent, and due to mere increase in strength, as in hypertrophy from valvular disease, to excessive radius of contraction of a partly filled ventricle, as in mitral stenosis, or to aortic rigidity or heightened arterial tension, as in arteriosclerosis and interstitial nephritis. Pulmonary and Aortic Accentuation. — The aortic valve being sound, any increase in general arterial tension will produce an accentuation of the aortic * See also "Rationale of Organic Heart Murmurs," page 455. THE EXAMINATION OF THE HEART 445 second sound and similar increased pressure in, or obstruction to, the pulmonary circulation will result in an accentuation of the pulmonary second sound. The degree will depend largely upon the soundness of the valves, the strength of the ventricles and the integrity of the mitral and tricuspid leaflets. The second sound may also be markedly intensified in sclerosis of the first portion of the aorta or pulmonary artery. "The Diastolic Echo." — The "third sound" reported by Barrie in 1893, and again by W. S. Thayer and the late Dr. Geo. Gibson of Edinboro in 1906, is present occasionally in normal individuals; is often extremely faint; and audible over the apex in certain slowly beating hearts when the patient is lying on the left side. It seems to correspond in time to the protodiastolic "h" wave of Hirschf elder as occasionally seen in the venous tracings of the polvgram. It constitutes the protodiastolic element of the "protodiastolic gallop-rhythm" and has long been recognized as occurring in certain cases of mitral stenosis and aortic regurgitation, but though interesting is of slight practical importance. The term "diastolic echo" well describes it, for it immediately follows the second sound and probably corresponds to the termination of the primary rapid rush of blood into the ventricles and preliminary apposition of the auriculo-ventricular valves (Hirschf elder) . Practical Applications. — Much information is afforded in both acute and chronic disease by a study of the variations in accentuation. For example, lobar pneumonia must inevitably be accompanied by marked accentuation of the pulmonary second sound and a dangerous tendency to dilatation of the right ventricle. If this dilatation becomes extreme the \ pulmonary second sound is markedly weakened and if tricuspid regurgitation occurs it may be wholly lost, a sign of the gravest import. The pulmonary congestion incident to mitral stenosis and regurgitation makes accentuation of the pulmonary second sound an important diagnostic feature, and, as in pneumonia, a loss of this accentuation or of the entire sound may be a serious symptom.* Changes in Timbre. — A tone may be weak, short, sharp, muffled or distant, " murmurish" or impure, hollow or ringing, "slamming," "fetal" or metallic. The first sound, as heard al the apex, may be wholly lost or replaced by the murmur in some cases of mitral regurgitation or aortic stenosis. To a less degree, aortic incompetence tends to obscure the second sound alike in the aortic area and in the carotid artery, though in the latter lesion a marked accentuation may be present if a high degree of sclerosis is present in the cusps, or when, in spite of incompetence, the valve segments still swing freely and achieve an imperfect apposition. It is probable that in most instances of diminished intensity some degree of actual aortic stenosis co-exists. In mitral stenosis the aortic second sound is weakened, the mitral first sound * As stated elsewhere a diminution of the pulmonary second sound accentuation in mitral regurgitation may mean a small leak or a powerfully acting left ventricle which keeps the pathway clear. Of slight importance. Probable cause. Pneumonia. Tricuspid leakage. Mitral lesions. Important variants. Modified ist sound and aortic 2d. 446 MEDICAL DIAGNOSIS Lost or ob- scured tones. Multiple factors. A duty often disregarded. Deceptive conditions. at the apex being accentuated and sharp or slamming unless extreme regurgitation co-exists. In aortic regurgitation and stenosis the first sound at the apex is dulled and in combined mitral and tricuspid regurgitation all sounds are greatly diminished. An excessively weak heart may yield relatively loud, sharp, short tones if, as is usually the case, the rhythm is rapid and hurried. A distinctly weakened first sound at the apex, in the absence of emphy- sema or purely external factors interfering with sound conduction, should always suggest cardiac weakness with or without silent leakage, and demands a thorough investigation of the cardiac area and the symptoms presented by the patient, whether these be subjective or objective. "Metallic clacking" is frequent in tachycardial arrhythmias, especially if the stomach be distended by gas. Fetal sounds and a slamming mitral first sound are always pathologic. A ringing, accentuated second aortic tone is often associated with aneurysm of the arch; commonly, with sclerosis of the vessel, high arterial tension and, in many instances, with pure aortic regurgitation. Murmurish Sounds. — The same may be said of persisting "murmurish," impure, unduly sharp and short, or muffled sounds, though due allowance must be made for mere pulse acceleration and disturbances of rhythm. Acute Infections.— In acute infections such as rheumatism, prostrating diphtheria, influenza, scarlet fever, and the like, both during the attack and in and after convalescence, the heart must be carefully watched for signs of serious myocardial or endocardial mischief, such as may be indicated only by subjective weakness or dyspnea, minor dilatation, and a labile pulse. Mere Muffling of Both Sounds. — When this is evident especially at the apex, it may be due to a fat or edematous chest wall, to emphysema, exuda- tive pericarditis, fatty overgrowth, serious myocardial disease, or cardiac displacement. Attention to these changes in quality, intensity and character of the heart sounds are of special importance in connection with early endocarditis, acute or subacute myocarditis and the silent, often abrupt, dilatations and insufficiencies so often encountered in chronic primary myocardial degenerations, atrophy, and in the narrow ptotic hearts of congenitally asthenic individuals. Displaced Heart.— In fibroid phthisis, pleural effusion, mediastinal growths, diaphragmatic hernia or even extreme meteorism or ascites, the. cardiac dis- placement may be suggested by the changed site of audibility of the sounds or murmurs, the whole mediastinum being oftentimes markedly displaced. One can seldom with certainty assign to the individual valves, murmurs heard under conditions of cardiac displacement, as they may disappear wholly or in part when the dislocation is corrected. The pressure of pleuritic effusion and that of ascites or meteorism offer the most frequent examples. In excessively dilated hearts, and especially in such of these as show marked associated arrhythmias, an accurate primary interpretation, differ- entiation and summary of the murmurs, and hence of the individual lesions present, is usually impossible. THE EXAMINATION OF THE HEART 447 A Useful Maneuver. — It is well to become accustomed to the auscultation of the normal heart sounds as heard in the median inferior hollow of the neck u font i cuius gutturis" as one may often test there the legitimacy of the basal heart sounds. Increased Audibility. — Aside from cardiovascular causes already given, this may result if the lung is retracted from the heart, and hence at times Extracardia coincides with a change in the site of maximum audibility, e.g., fibroid lung or 0> j r~ ^ _. r- 3- — -* . Pouse. Pause. E Pause. . Pause. Fig. 2. Fi S .3 Fig. 167. — Division and reduplication of the heart sounds. Upper figure. — Splitting of first sound (blup dwp). Mid- figure. — Division of the first sound apex (lupup dup). Lower figure. — division of second sound (Lub letup). adjacent excavation. Sounds are occasionally transmitted loudly and over wide areas by such pulmonary consolidations or cavities. Reduplication of Heart Sounds. — The normal heart sounds consist of two systolic and two diastolic sounds so blended as to form one systolic and one diastolic tone because of the synchronous closure of the valves of the right and left heart. Under many conditions this synchronism is so interfered with as to produce splitting or actual reduplication of either sound. In true reduplication the elements of the double sound are clear and well- defined though short. In other words, a third sound appears in the cycle. The triple rhythm. 448 MEDICAL DIAGNOSIS Curiously circumscribed. The split sound elements are less clearly separated and sometimes cannot be differentiated from the shortest possible murmur. The phenomenon of reduplication has been compared aptly to the sound produced by the asynchronous closure of double swinging doors. A normal heart, if temporarily overacting, may be the seat of doubling or splitting of the heart sounds, but, in general, it may be said that, hearing an apparent reduplication of the second sound (a presystolic third sound) at the apex only^ Fig. i 68 — Reduplication and division of the heart sounds. Upper figure — Redupli- cation of second sound (lub tlup). Mid-figure. — Presystolic gallop rhythm (lup lup dup). Lower figure. — Proto-diastolic gallop, rhythm (lup lup lup). Gallop rhythm is always a suggestive and serious phenomenon and probably represents in many instances a unilateral block. (See "Heart-block.") and especially if it be associated with diastolic blubbering or a bruit, one may assume that it is due to the presence of mitral stenosis.* If a reduplicated second sound is heard over the aortic area and, perhaps, the whole heart, myocardial degeneration often combined with cardiac overstrain and arterial hypertension is the probable cause. A Split Second Tone. — A split second sound at the base, limited usually to the third left interspace, has been found by the author with especial fre- * Less commonly in regurgitation unless associated with myocarditis of marked degree or arteriosclerosis. THE EXAMINATION OF THE HEART 449 quency in slightly dilated or merely atonic insufficient hearts, usually with a history of past temporary prostration from acute illness or overstrain. It has been present in certain cases of early luetic aortic disease, in the "drop" hearts of persons of the congenitally asthenic type, who so often present the picture of so-called "neurasthenia," and in middle-aged males with minor signs of arteriosclerosis and various grades of dilatation with or without arterial hypertension. It has been associated invariably with a distinct capillary pulse and increased "pulse pressure." An intermittent short diastolic murmur in the third left interspace is occasionally observed which may wholly disappear under treatment, revert from time to time to the original split second sound, or, especially in middle-aged patients, be- come after months or years a persistent, short murmur of aortic regurgi- tations.* Many of these "split-second" cases, with or without "drop" hearts, have been under the observation of the author over long periods. The periods of to-and-fro shifting from the split sound to the actual diastolic bruit some- times observed are most interesting. Fetal Rhythm. — {Embryocardia) . — In this the heart sounds are rapid and equally distant, resembling the actual fetal heart sounds, and the con- dition has been well named " embryocardia " (Stokes-Von Huchard). The expert clinician recognizes its significance and importance, as indicating a marked enfeeblement of the heart muscle associated with excessively rapid con- tractions. Certain cases of auricular flutter, alternation and paroxysmal tachycardia must be placed under this head. Auscultation Areas. — The four primary surface areas for auscultation are: 1. The mitral area {apex). 2. Tricuspid area {lower half of sternum). 3. Pulmonary area {second left intercostal space). 4. Aortic area {second right intercostal space and along the line connecting this point with the third left interspace). As stated previously, these points, all adjacent to the sternum, do not corre- spond to the exact anatomic location of the valves which may be all included in the area of a large stethoscope bell, but represent the region in which the sounds of the respective valves or their associated murmurs are best heard. HEART MURMURS. — Definition. — A heart murmur is an extraneous sound of cardiac site and rhythm tending to obscure, partly or wholly replace, or immediately or laggardly precede or follow, a heart sound. * The author feels that possibly minor aortic insufficiencies, transient or permanent, may be less rare than has been believed and has found no clinical evidence to sustain the theory that a pulmonary insufficiency is responsible for the murmurs, or, that in young in- dividuals, an aortic ring which yields under excessive temporary strain is of necessity per- sistently damaged. Any one familiar with the "drop" heart and its modifications must recognize the special liability of its possessors to cardiac overstrain, especially when such individuals form as they do a considerable proportion of those seeking athletic honors and entering into the more strenuous forms of labor and recreation alike. 29 Ticking rhythm. 45o MEDICAL DIAGNOSIS A reiteration for emphasis. Common Sources of Error. — It should never be forgotten that, as stated, all the extraneous sounds produced by a heart that is overacting, excessively weak or dilated, tumultuously beating, or mechanically dislocated, can seldom be accu- rately interpreted. Under such conditions, existing organic murmurs may be obscured or unplaced in rhythm; or, as more commonly happens, murmurs may Fig. 169. — Usual site of murmur associated with anemia and asthenia. (Sansom.) Fig. 170. — Murmur over conus arteriosus in anemia and myocardial asthenia. be present, purely temporary in character, which may be and often are wrongly regarded and treated as organic. The utter impossibility of accurately differentiating all the murmurs heard over extremely weak and widely dilated or dislocated hearts should be better understood. Transient Murmurs. — Transient dynamic or accidental murmurs and harsh heart sounds, associated with abnormal accentuation, are extremely common. Fig. 171. — Murmur limited to {supra) aortic area in anemic cases. (Eleven per cent, of cases, according to Sansom.) Fig. 172. — Coexisting pulmonary and apex murmurs in anemia. The apex ele- ment must be viewed with suspicion in all such cases of assumed hemic origin. Sansom held such to be true mitral regurgitations. They call for rest, reassurance, the administration of test doses of such drugs as digitalis and the bromides and always for repeated examinations. Postural Modifications. — All patients should be examined, if possible, both when recumbent and when erect, after a rest period, and, if their condition permits, after some brief brisk exercise. THE EXAMINATION OF THE HEART 451 Useful maneuvers. The murmurs of valvular leakage are usually best heard in the recum- bent position, those of narrowing (obstruction) in the erect posture; while sometimes, as in the case of mitral or tricuspid stenosis, a typical presystolic murmur may appear only at the moment when the patient reaches the upright position and then rapidly subside. The diastolic murmur of aortic leakage often may be increased by raising the arms above the head or may require brisk exercise to make it audible. The Intensity of the Murmur. — The stronger the heart and the narrower the affected opening, the louder and higher pitched is the murmur, and, speaking j Loud vs. soft. roughly and broadly, it may be said that the louder the endocarditic murmur the better is the prognosis, inasmuch as it often indicates an hypertrophy of the chamber most affected and most vital to compensation. The general rule previously stated is, of course, a rough one subject to many exceptions, nor would it cover certain excessively loud or even musical murmurs which are often associated with and derive their loudness and peculiar quality from calcareous vegetations. Murmurs must, in any event, take their pitch and timbre in large degree from the form of the orifice and the density, tension, shape or surface irregularities of its margins. Cases with manifest signs of inveterate and extreme cardiovascular disease, but yielding faint murmurs elicited with diffi- culty, or those in which no murmur is present though the heart is manifestly incompetent, are oftentimes of the most serious import, as indicating extreme myocardial exhaustion and at times an excessively large leak. Variations in Timbre. — The greatest possible diversity of timbre is en- countered in murmurs of cardiac origin. " Blowing " of all degrees, " sighing, " "cooing," "gurgling," "whistling," "hissing," "sawing," "grating," "musical," "squeaking," "blubbering," "rolling," "roaring," and "rumbling," are some of the terms quite applicable to the varied sound expressions of cardiac l regurgitations and stenoses quite apart from the "shuffling," "creaking," j "squeaking," "grating" and "rubbing" of pericardial or pleuro-pericardial friction. ASTHENIC AND "HEMIC" MURMURS.— The murmurs associated Related to with decided anemia are systolic in time and soft and blowing in character,* seldom widely transmitted, and usually best heard over the pulmonary area Usual (second left intercostal space). * Rarely they may be loud and harsh as in a case of exsanguination due to acute hemor- rhagic gastric ulcer observed by the author. In this case the murmurs were auto-audible and to be heard when the ear was several inches from the chest. Fig. 173. — Systolic murmur, at apex only, in cases of anemia. All such murmurs justly may be regarded as only in part, if at all due to the physical condition of the blood. They probably represent actual though often transient and atypical mitral regurgitation. Faint murmurs. maximum. 452 MEDICAL DIAGNOSIS Lack of ' transmission. Associated anemia. Cardio- pulmonary murmurs. Papillary muscle insufficiency. They are heard less frequently over the apex, aortic area, etc., and such apex bruits differ from the true murmur of endocarditic mitral regurgitation in the fact that they are usually softer and less clearly defined; are almost invariably associated with a more decided murmur of the same type in the pulmonary area, and have not the same transmission to the axilla and back. They do not, however, differ from many relative and consecutive mitral insufficiencies, either as to quality, or imperfections in transmission. So also, when heard over the aortic area proper (second right intercostal space), they lack the transmission into the carotids and subclavian, charac- teristic of true aortic stenosis. Their association with anemia and disappearance under appropriate treatment further serve to differentiate them in practice from true endo- carditic murmurs, but involves as well factors quite apart from the condition of the blood. Associated dilation is far from uncommon and is itself often attended by apex murmurs of a similar quality in undernourished individuals of the asthenic habitus, even when any marked degree of anemia is lacking. A few cases of diastolic hemic murmurs have been reported.* Adequate Factors. — The author can see no vital objection to the assump- tion that, in marked degrees of anemia with or without associated asthenia, a lowered specific gravity and diminished viscosity of the blood combined with hypotonia, and a rate of flow which may reach five times the normal, may readily produce audible murmurs. On the other hand, it would appear to him that, in the greater number of instances, other associated factors play a large part; for such murmurs often persist after all signs of anemia have disappeared, subsiding only when co- existent general muscular weakness and subnutrition have been overcome. The author believes, therefore, that many of the so-called accidental murmurs heard at the apex or over the superficial cardiac area, now classed as hemic, cardio- pulmonary and the like may be in whole or part murmurs of papillary muscle insufficiency due often to mere temporary heart muscle atonicity. In some instances the yielding of these structures might throw the murmur into the meso- systolic or prediastolic phase (post-systolic) which is precisely the rhythm of 1 ' cardiopulmonary ' ' murmurs. In the anemias of pronounced congenital asthenia the elements of myocardial atony and slight chronic or recurrent dilatation are usually superadded. The great majority of such persisting murmurs of apical site act with respect to audibility as exactly like endocarditic murmurs as they could be expected to do when produced by the insufficiency of structurally normal valves and constitute most valuable signs when occurring in association with subjective symptoms of myocardial inadequacy. They, of course, merely reflect deficiencies pi tonus but these may be associated with myocardial * One case of typical diastolic murmur of aortic localization reported by the author occurred in the terminal stage of pernicious anemia, the autopsy showing a normal valve. He would now regard it as a dilatation of the aortic ring. THE EXAMINATION OF THE HEART 453 degeneration, and if we are not to note these deficiencies we are not to go far in early diagnosis. Furthermore their changes under treatment are exactly what one expects under the foregone assumption and not in the least what would be the case were they cardio-respiratory or cardio-pulmonary. The author does not believe that, in general, murmurs heard over the apex of the heart, even though they lack the quality, transmission, and secondary signs of organic valvular lesions are to be classed as trivial, especially in the case of men and women above thirty or thirty-rive years of age. To admit this is to permit the elimination of an important symptom of minor myocardial insufficiency associated with actual disease. A review of recent literature balanced against a large personal experi- ence with bruits of this type has convinced him of the falsity of any such assumption, whether the murmur heard be directly systolic or post-systolic. It is to be feared that there is a general lack of understanding of the readiness with which, in the tonus deficiencies, the mitral ring or the papillary muscles become incompetent and permit leakage in a structurally sound valve. One is impressed by the apparent lack of appreciation of the extreme readiness with which myocardial tonus is impaired even in health in the vastly greater number of instances temporarily and harmlessly. Any exertion which is excessive for the individual and produces profound fatigue means temporary trifling impairment of tonus. Excessive heat and vitiated warm air affects it in many individuals. Nutritional deficit tends to impair it. Psychic stress, strain and shock, if intense, may be subtly as potent as physical overstrain; and finally, the first effect of toxemia from whatever source upon heart muscle is the reduction of tonicity. One has only to review experimental work done not only upon the heart but upon other hollow muscle organs to realize how exquisitely sensitive such tissue is to such influences. In the diseased or congenitally inadequate hearts, every fresh accession of an existing concealed septic focus; any decided advance in an already seated inflammatory or degenerative process, will affect to a greater or less degree myocardial tonus and consequently the reserve power of that heart. Many or most of these impairments will be temporary and trivial, but from time to time those of a severer grade or greater persistence occur, the existing pathologic process is accelerated, or the primary congenital weak- ness is intensified. As stated previously, the more pronounced systolic hemic murmurs have their maximum at the pulmonary area in nearly every instance and hence simulate in time and -location a murmur of pulmonary stenosis, but the harsh murmur of this rare and almost invariably congenital lesion is wholly dif- ferent in intensity, in its common association with a systolic thrill, intense cyanosis, and other striking and extreme clinical phenomena. Other Forms of Accidental Murmurs. — A cardiorespiratory or cardio- pulmonary murmur is a ''systolic whirling'' heard best during inspiration Impairment of tonus. 454 MEDICAL DIAGNOSIS and in the region of the left lung border, along the lines of the maximum reces- sion due to the systolic contraction and recession of the right ventricle. It is superficial and usually mid-systolic or post-systolic in time and is most likely to be heard when the heart is overacting. If true to type it should be absent in forced expiration over the area of cardiac flatness or move inward in full inspiration and outward in expiration. These murmurs are supposed to be due to the influx of air into interposed lung during right ventricular systolic recession. Their frequency is probably not nearly as great as has been supposed but, undoubtedly, they deserve mention. Pleuro-pericardial Murmurs. — When the apposed layers of the pleura and pericardium become inflamed in the extension of a pleuritis or pericarditis, a murmur may be present which is usually distinctly frictional and superficial in character and heard best usually along the border of the superficial cardiac area. This sometimes endures for a long time after the original disease subsides, usually lacking the quality, and, almost invariably, the transmission, of a val- vular murmur. The murmur corresponds to cardiac rhythm but is dis- tinctly affected by the phases of respiration. It is obvious that the dis- appearance of such a murmur in full inspiration would indicate that contact of the costal pleura and pericardium was responsible for the murmur and that this has been destroyed by the interposition of the inflated lung. Disappearance of the murmur in full expiration would indicate that it arose from contact between the pulmonary (visceral) pleura and pericardium which has been broken by the expiratory recession of the lung. Conversely the appearance or intensification of such a murmur in full expiration indicates inflammation of costal pleura and pericardium and its appearance or intensification in full inspiration points to involvement of the visceral pleura and pericardium. The sign is occasionally one of great importance as indicating a more or less sinister extension of an acute or chronic pericardial or pleural infection or the presence of tuberculosis. Curious Crackles. — Some curious showers of tiny crackling murmurs may be heard rarely along the left edge of the sternum, particularly in connection with advanced and extreme pulmonary emphysema. Mediastinal Emphysema. — The presence of air in this space may be due to external injury, the induced pneumothorax at present so much in vogue, or to ulceration or rupture of any portion of the respiratory tract in direct relationship. There may be subcutaneous or subfascial crepitation, often first observed in the cervical region, or merely crepitation of cardiac rhythm and loss oi heart dulness. Splashing. — If the pericardium contains both air and liquid, churning or splashing sounds of cardiac rhythm may be audible. This may be simulated by sounds produced in large contiguous cavities as in marked gastric distention, pneumothorax and advanced phthisis, but the true murmurs are so bizarre and peculiar as to be practically pathognomonic of the pericardial condition. THE EXAMINATION OF THE HEART 455 THE RATIONALE OF ORGANIC HEART MURMURS.— Varieties.— Organic murmurs may be valvular, arterial, myocardial, pericardial or pleuro- pericardial in origin. The valvular murmurs are of two kinds, namely, the regurgitant and the obstructive; the one being due to a leakage and back flow, the other to a narrowing of the valvular opening, a stenosis. From Upper Extremities.,: IV.C 'N RA. From Trunk and Lower Extremities. To Trunk 4nd Lower Extremities. Fig. 174. — The right and left hearts. S.V.C. Superior vena cava. I.V.C. Inferior vena cava. P. A. Pulmonary artery. P.V. Pulmonary veins. AO. Aorta. The lungs are in the position of a self-cleansing blood filter and purifier, receiving venous blood from the right ventricle and delivering arterial blood to the left auricle. Preliminary Remarks. — For the sake of clearness and vividness of descrip- tion in relation to the production of heart murmurs, no effort to attain a finically technical description is attempted. The student needs to create primarily a simple mental picture such as he may retain and readily reproduce when in contact with the patient. Mode of Production. — The heart must be regarded simply as a double pump in constant action, or, as two double-chambered hearts, firmly united and synchronous in action. It may be represented diagrammatically as two hearts with the lungs between them; the systemic arteries, capillaries, and veins Cardiac pump 45 6 MEDICAL DIAGNOSIS Relation of lungs. Ventilation. Course of blood. Ventricular" contraction. carrying the blood from the left ventricle through the tissues and back to the right auricle, whence it passes to the right ventricle, is driven by it through the lesser (pulmonary) circuit and returned to the auricular reservoir of the left heart, for such is the plan of the circulation. Practical Synchronism. — Pouring constantly into the right and left upper chambers, respectively, comes the blood from both the greater and lesser circulations, led through the lower and upper caval conduits to the right auricle and through the pulmonary veins to its fellow of the left heart. Fig. 175. — The normal heart in \ beginning) systole. The ventricles, filled with blood which they have received from the auricles during diastole, are now contracting and driving their contents through the semilunar valves, just now forced open, into the pulmonary artery and the aorta. The mitral and tricuspid valves have just closed (first sound), shutting off any reflux from the ventricles to the auricles which latter must fill during the period of this ventricular contraction {systole). M.V., mitral valve. T.V., tricuspid valve. A.V., aortic valve. P.V., pulmonary valve. L.A., left auricle. R.A., right auricle. L.V., left ventricle. R.V., right ventricle. V.C.S., superior vena cava. V.C.I., inferior vena cava. AC, aorta. P.V.. pulmonary veins. P. A., pulmonary artery. Into the right auricle the superior and inferior venae cavae pour their dark, impure, venous blood, while to the left auricle the four pulmonary veins bring a constant supply of bright, red. arterial blood that has undergone ventilation and purification in the pulmonary air cells. During the recurring periods of ventricular relaxation (diastole) which follow each ventricular contraction, the blood passes from the auricles into the ventricles through the opened auriculo-ventricular valves; the mitral on the left, the tricuspid on the right. THE EXAMINATION OF THE HEART 457 Systole. — With the initiation oi systole ipresphygmic period) these valves abruptly close (first sound) the inlets to prevent backrlow into the auricles and the blood is forced by the continuing ventricular contraction (systole) along the paths of least resistance, i.e.. through the pulmonary valve and into the pulmonary artery on the right, and through the aortic valve and into the aorta upon the left; these exits remaining fully open during sys- tole, but shutting smartly as the systolic ventricular contraction ends Sa^oTe {second sound). First sound initiates systole. Second sound Fig. 176. — The normal heart in beginning diastole. The ventricular contraction has ceased, the aortic and pulmonary valves, closed (second sound,) , are shutting oft and supporting the blood column; the ventricles are filling from the open mitral and tricuspid orifices above. M.V., mitral valve. T.V., tricuspid valve. A.V., aortic valve. P.V., pulmonary valve. L.A., left auricle. R.A., right auricle. L.V., left ventricle. R.V., Right ventricle. V.C.S., vena cava superior. V.C.I., vena cava inferior. P.Vn. ; pul- monary veins. Blended Sounds. — As both sides of the heart contract simultaneously, or practically so, the sounds produced by each double valvular closure whether of systole (mitral and tricuspid) or diastole (aortic and pulmonary), are ordinarily coincident and blended into one ; ' tone" for each of these phases. The "first sound" obviously corresponds to the initiation of the period of ventricular contraction and the complete closure of the mitral and tricuspid valve; i.e., systole. Its time is practically that of the carotid pulse beat, a fact of much clinical importance. Diastole. — The instant that this systolic contraction is completed the 45§ MEDICAL DIAGNOSIS Auricular contraction. Mental ptetare. aortic and pulmonary gateways close, the emptied ventricles relax, the mitral and tricuspid open. The aortic and pulmonary valves must be shut smartly to prevent backflow into the ventricles from the overfilled and distended great arteries, and thus they produce the "second sound" which initiates "diastole." During this, the period of ventricular relaxation, the blood that has been accumulating in the auricles during ventricular systole pours down through the opened mitral and tricuspid valves to fill the emptied ventricles, ^Systole. Diastole. Tricuspid),,, Tricuspid) Mitral ) aosed Mitral |°P en Aortic ) Aortic \ Puln)onaryj 0pen Pulmonary J Closcd Fig. 177. — Position of the valves of the heart in beginning systole (first sound) and diastole (second sound). and just before the next systole the auricles themselves contract vigorously and ventricular systole almost immediately follows. Presphygmic Period. — The brief interval of time elapsing between the sharp closure of the mitral and tricuspid valves at the onset of systole and the further rise in ventricular pressure, necessary to open the aortic and pulmonary valves against the arterial pressure is called the presphygmic period and varies from 0.07 to 0.09 seconds. Practical Application and Importance of a Mental Image. — For the pur- poses of the auscultator, systole is assumed to be initiated by the first sound and diastole bv the second, and in the mind's eve he sees the evele of events. THE EXAMINATION OF THE HEART 450 Systolic Events. — Thus when hearing the first sound, he sees the ventricles contracting, the mitral and tricuspid valves closed, the aortic and pulmonary valves freely open, the blood surging into the pulmonary artery and aorta, and the auricles refilling from the venous trunks (see Figs. 175 and 177). Diastolic Events. — With the second sound he sees an exact reversal of conditions: the aortic and pulmonary valves tightly closed; the mitral and tricus- pid freely open and the blood rushing through them from the auricles above to the ventricles below (see Figs. 176 and 177). IMPORTANT DEDUCTIONS.—// is obvious that any organic valvular murmur that is coincident with, immediately follows, replaces, or itself modifies, the normal first sound (systolic murmur), must arise either from leakage in the valves which should be absolutely closed and water-tight in this phase (mitral and tricuspid) or from an obstruction in those that should be freely open (aortic and pulmonary). Hence any organic valvular systolic murmur must be due either to mitral or tricuspid regurgitation or to aortic or pulmonary obstruction (stenosis). In diastole the opposite conditions prevail; the mitral and tricuspid valves being open and the aortic and pulmonary valves closed. It is evident that any murmur coincident with, immediately following, modifying, or replacing the second sound I diastolic murmur is due to aortic or pulmonary leakage or to mitral or tricuspid obstruction. Nin-e out of ten murmurs have their origin in the left heart — the hard-working side. Presystolic Murmurs in Mitral or Tricuspid Stenosis. — If the auricles contract as they normally should in presystole this final contraction will increase abruptly the force and rapidity of the flow from auricle to ventricle just before the closure of the auriculo -ventricular valves {first sound) terminates diastole. The diastolic murmur of mitral or tricuspid obstruction will assume therefore a presystolic crescendo intensification. If the auricle is incapable of its normal contraction, the murmur is diastolic purely, lacking all presystolic accentuation or being actually diastolic-diminuendo because the highest speed of the blood stream is attained under the initial intra-auricular pressure, accumulating during systole and highest at the instant the second sound announces the close of the ventricular outlets and the opening of the auriculo -ventricular gateways. In typical cases the 'Tumbling'' or ''thrilling'' crescendo murmur seems to run against and be abruptly terminated by an intensified slamming first sound. AGAINST THE STREAM. — 77 is at once evident that if at any point there is created a serious impediment to the free onward flow of the blood, an increased strain is thereby thrown upon the cardiac mechanism and a tend- ency to passive congestion or stasis in the area whose drainage is thereby impaired is at once established (see Fig. 173). Therefore, if any damming of the flow of pathologic degree is present or any portion of the pumping machinery is defective, the ultimate bad effects will appear chiefly and first in those portions of the heart next nearer the Inevitable conclusion. Systolic murmurs. Diastolic murmurs. Rule of incidence. Auricular systole. Crescendo murmur. Diminuendo murmur. Logical sequence. 460 MEDICAL DIAGNOSIS An extracardial obstruction. Accentuated aortic ad. Heart response. Relative insufficiency. Extremely common. Auricular dilatation. Right ventric- ular response. Accentuated pulmonary 2d sound. Pulmonary stasis. Tricuspid leakage. Systemic stasis. Symptoms often mis- interpreted. venous sources of the blood than is the lesion itself. In short, if one may use an old expression, in the main the bad effects of a cardiac lesion work backward against the blood stream. ILLUSTRATION. — Interstitial nephritis raises systemic arterial blood pressure to an extraordinary degree and the left ventricle responds to the challenge of the narrowed arteries by drawing upon its reserve and increasing the strength of its individual contractions. The blood is then forced so vigorously into the aorta as to make its elastic recoil and the closure of the aortic valve unusually violent. As a result there is an " accentuation of the aortic second sound." Hypertrophy. — Like every other muscle under sustained unusual exercise and overload, the ventricle tends to hypertrophy and to increase its strength; the wear and tear of the aortic valve and the aorta itself is also increased and an unusual and excessive pressure is exerted upon the mitral valve, which alone stands between the overacting ventricle and the weak-muscled left auricle. Secondary Mitral Leakage. — If then the mitral valve becomes the seat of acute inflammation or of sclerosis, if the papillary musculature loses its strength and can no longer stay the leaflets (papillary insufficiency), or, if the heart itself dilates so widely through high pressure, toxemia, and degen- erative changes, and muscle tonus becomes diminished so greatly that the mitral ring which supports the valve yields (relative insufficiency), in any or all of these events mitral leakage occurs. Consecutive Involvement of the Right Heart. — A backflow into the left auri- cle then is established; that chamber is dilated and embarrassed, and the incoming current of blood from the lungs is obstructed . The right ventricle is immediately called upon for increased action in order to relieve the passive congestion of the lungs by an extra drive. The blood is then forced so strongly into the pulmonary artery as to intensify the shock of its valvular closure and produce an " accentua- tion of the pulmonary second sound" The lungs may thus be placed between two fires through the continued back pressure of blood associated with a weak left ventricle, a leaky mitral orifice and weak or fibrillating left auricle in front, and increased pressure from the overacting right ventricle behind. This effect is greatly intensified if the left heart continues to weaken. A persistence of these conditions would tend to cause ultimately a dilatation of the right ventricle with or without a temporary or permanent leakage through the tricuspid valve and a transfer of part of the overload to the great systemic veins. The effects of stasis might be manifested then in the general venous circulation by congestion of the viscera and ultimate edema or general anasarca. Such a complete cycle of pathologic events is common enough in practice though by no means invariable, and usually covers many years in its full course and develops but a part of the complete cycle. Realizing what marked local symptoms may arise from even a slight chronic congestion of the brain, stomach, liver, intestines, kidneys and lungs, one can readily understand how easily in such cases misinterpretation may occur because of the misleading localization of the symptoms and how readily THE EXAMINATION OF THE HEART 461 the true primary and basic cause namely, cardiovascular insufficiency, may be overlooked.* The Causative Factors. — Practically all true valvular murmurs are due either to stenosis or to abnormal patency of one or more of the valvular openings and these conditions result from inflammation of the valves (endo- carditis), chronic sclerosis (arteriosclerosis), from associated secondary or primary myocardial degeneration, actual myocarditis, or from mere toxic or congenital myocardial asthenia (atonicity) which results in insufficiency of the papillary muscle or stretching of the" valvular ring (relative insufficiency). The causative conditions are fully described elsewhere, and a study of these factors makes clear the etiology of the actual lesions. Relative Frequency. — Mitral regurgitation is by far the most common ; mitral stenosis, aortic regurgitation, aortic stenosis and tricuspid regurgita- tion follow in order; the remaining lesions being rare. As to combined lesions, double mitral and double aortic are most common, some placing the latter first in frequency, which is against the author's per- sonal experience, and would vary greatly in different clinics according to the predominant sex and age of the patients. THE DIFFERENTIAL POINTS.— Jo differentiate heart murmurs the fol- lowing points are determined primarily: (a) Time or rhythm, (b) Point of maximum clearness and intensity, (c) The direction and extent of trans- mission, (d) The quality of the abnormal sound, (e) The associated signs, viz., arterial and venous pulsation, the radial pulse, increased area of cardiac dulness, accentuation of heart sounds, cyanosis, edema, etc. RHYTHM. — Organic murmurs occurring with the first sound. (Period of ventricular contraction) : (a) mitral regurgitation; (b) tricuspid regurgitation; (c) aortic stenosis; (d) pulmonary stenosis (rare). Systolic murmurs, nine times in ten, are due either to mitral regurgitation or aortic stenosis or are purely accidental or hemic. Murmurs Heard with the Second Sound. — (Period of ventricular relaxa- tion): (a) aortic regurgitation; (b) pulmonary regurgitation (rare); (c) mitral stenosis; (d) tricuspid stenosis (rare). The mitral and tricuspid stenosis murmurs may be purely diastolic if the auricles are fibrillating or impotent; presystolic, or diastolic with presystolic intensification, if the auricles are capable of contraction just before the first sound occurs. Pure diastolic murmurs maximal at the base are almost invariably due to aortic regurgitation. A presystolic murmur is almost invariably due to mitral stenosis and is maximal at, or, oftener, just within, the apex-beat. To Determine the Rhythm or Time. — This should be positively de- termined by taking the carotid pulse while listening to the murmur. The radial pulse should not be used for this purpose, and in dilatation of the right heart, the apex-beat is far less constantly reliable and clean-cut than the carotid beat which can easily be felt at the anterior border of the sterno- * The patient with a nephritis of the extremely chronic type is likely to be snuffed out by an apoplexy or uremic seizure before he can complete this disastrous cardiac cycle. Endocarditis and sclerosis. Myocardial defects. Double lesions. Systolic murmurs. Diastolic murmurs. Time variable. Pulmonary regurgitation rare. Importantrrule. Use carotid for timing sounds. 462 MEDICAL DIAGNOSIS Meets vital needs. Arterial currents. Capillaries and veins. Arterial pressure. Pathways of least resistance. Sustained flow. Necessity of vasomotor control. mastoid muscle when the head is turned to the side corresponding to the artery palpated. Hypertrophy and Dilatation. — Under their appropriate headings the variation in cardiac outline in the chief pathologic conditions and their in- fluence upon the heart sounds will be fully shown and discussed. "Simple hypertrophy" is usually associated with chronic interstitial nephritis, aortic stenosis or arteriosclerosis, and "simple dilatation" repre- sents a stage of adaptation or actual incompensation in such lesions, or, in some form of myocarditis, myocardial degeneration or congenital asthenia. As a matter of fact the occurrence of hypertrophy without some degree of dilatation is doubted at present by the greater number of experienced pathologists and the so-called "simple dilatation" (lacking hypertrophy) can- not exist in any decided degree without producing decided symptoms subjec- tive or objective together with a limitation of the field of cardiac response. CERTAIN FACTORS BASIC IN THE CONSIDERATION OF THE DISORDERS OF THE HEART AND BLOOD VESSELS What the Heart Must Do. — In conjunction with the vascular mechanism it supplies the initial propulsive impulses and the sustained force necessary to maintain that uninterrupted flow of Hood throughout the systemic and pul- monary vascular circuits, which is indispensable to the physical and chemical exchanges essential to health and indeed to life itself. The Transformer. — In the aorta and pulmonary artery alike, both pres- sure and rapidity of flow are excessive and rhythmically interrupted, but the shock of the expelled blood column is taken up by the elastic arterial walls. In the capillaries, the flow is sufficiently slow and uninterrupted to permit the vital tissue exchanges of waste and repair, and a slowed current and lowered pressure are present with slight modification in the veins. Arteries Auxiliary Hearts. — The sustained arterial pressure necessary to produce a continuous current is dependent upon an adequate initial impulse, a sufficient blood volume, efficient vasomotor control, and normal elasticity of the vessel walls. The great arteries at first yield to the shock of systolic outflow but in their recovery exert a sustaining pressure upon the blood column which, being shut out of the heart during diastole by closed semilunar valves, must of necessity move forward along the vascular pathways of least resistance. Arterial Conservation of Initial Energy. — Obviously the driving force of ventricular contraction is largely conserved and compensated by this primary arterial distention of the aorta and pulmonary artery which serves to main- tain the flow during the entire period of ventricular relaxation. These great vessels constitute a storage plant, rhythmically charged and discharged. The Role of the Vasomotor System. — It is evident also, not only that the capillary flow must be continuous, but that it must be controlled to a degree that will secure the automatic satisfaction of the periodic or even momentary variations in the needs of the body tissues. THE EXAMINATION OF THE HEART 463 Hence quite aside from reflex increase of heart strength, acceleration of primary outflow and rise in pressure, tissue needs are met by a slowing or quickening of the peripheral stream and a coincident local increase or decrease in intravascular pressure through automatically regulated dilatation or contraction of the capillary channels. Speed of the Blood Stream. — In the great arteries the normal flow varies between 200 and 400 mm. per second as contrasted with a capillary flow of but 0.6 to 0.8 mm. per second. In the normal individual the body circuit is completed in about fifty-five seconds requiring about 55 heart beats. In strenous physical effort the time required is but four and one-half seconds and in marked anemia, with lowered specific gravity and decreased blood viscosity, the circuit consumes but thirteen and one-half seconds, the required beats being reduced to 23 (C. Hirsch). In erythremia, on the other hand, increased erythrocytes and a heightened viscosity are associated oftentimes with a doubling of the total blood content of the body, heightened arterial pressure, cardiac overaction, and vasomotor constriction, and the resultant slowing of the circulation becomes an important factor. Extreme Vasodilatation. — This may obtain in disease to a degree which actually threatens the life of the individual, such indeed as would be the dila- tation if the medullary center were paralyzed, as in certain cases of sudden death from diphtheria, or if the splanchnic nerves were divided. Excessive Vasoconstriction. — Conversely, vasoconstriction may become so extreme through direct overstimulation of the vasomotor centers in the medulla or the action of circulating toxins (uremia), as not only to raise arte- rial pressure to a dangerous degree, but also, when exerted locally, to cause actual gangrene of the part affected, as in Raynaud's disease, in which there is extreme vasomotor constriction alternating with excessive local vasomotor dilatation. Conflict of Opposing Forces. — In certain ailments, as in aortic regurgita- tion, there is a compensatory effort on the part of the body tissues to neutralize the effect of the unsupported blood column (at the aortic outlet) and modify the necessarily excessive strength of the primary flow by means of a persistent mild vasodilatation. In a case of interstitial nephritis the resulting tendency to adverse toxemic vasoconstriction is further aggravated by a coincident impetus given to arteriosclerotic changes. This not only weakens the heart, but, by im- peding conservative vasodilator action, produces a decided impairment of body nutrition. The vasomotor center itself not only may become markedly irritable or weakened through the toxins of disease or the imperfect blood supply it receives in certain cases of incompensation, but is extremely susceptible also to adverse psychic influences.* The Heart's Capacity for Work. — The miraculous perfection of this com- plete, wholly automatic, hydraulic plant is shown by the fact that each day's work of the normal heart is equal to 20,000 kilogr ammeters (Zuntz), viz., the power * The Dastre-Morat Law. — Dilatation of the splanchnic vessels is accompanied usually by contraction of the surface vessels. Rate of flow. Great arteries. Capillaries. Physical exertion. Complete circuit. Anemia. Erythremia. A. cause of death. Uremia. " Raynaud's disease." Compensatory vasodilatation. Super- imposed nephritis. Daily task. 464 MEDICAL DIAGNOSIS Life's work. Dependent upon chemical processes. sufficient to raise 20,000 kilos of water to the height of 1 meter. In a lifetime of sixty years it pumps 2,800,000,000 liters of blood (Plesch). Varied Demands. — The output of the heart must be such as will satisfy the extremes represented by absolute rest on the one hand and the most violent exertion on the other, and this means that the normal heart must be able to meet instantly and adequately at least a thirteenf old increased demand. One of the earliest, most important, and least recognized symptoms of insuffi- ciency is an inability on the part of the individual to meet hitherto well-borne variations in the demand upon his heart strength without conscious effort or actual discomfort. The daily work hitherto done easily becomes a burden. Metabolism in Insufficiency. — It is evident that any decided interference with efficient circulation must affect the supplies of nutrient material and oxygen which in health are steadily and continuously carried by the blood to the chemically active tissues, no less than the proper combustion and com- plete disposal of the waste products of body metabolism which are removed through various channels in like manner and by the same mechanism. Acceptance of Myogenic Theory. — No attempt will be made to set forth in detail the claims .of the neurogenic and myogenic theories relating to the con- traction of the heart. The latter, for the most part, stands upon a firm experimental basis, so admirably serves diagnosis and therapy alike as to have immeasurably advanced the proper clinical conception and management of cardiac derangements, and is accepted by most physiologists. WHAT THE NORMAL HEART MUST POSSESS MYOGENIC THEORY.— The heart cells must possess: (a) The power to generate stimuli to contraction, i.e., "stimulus production." {b) The ability to receive stimuli, i.e., "excitability." (c) The power to respond to stimuli by contraction, i.e., "contractility." (d) Conductivity. (e) The power to maintain continuously a le sser but vastly important tonic contraction or muscle tonus apart from periods of active contraction, i.e., tonicity. Stimulus Production. — The myogenic theory also assumes that the highly specialized heart muscle cells when normal, properly nourished, and free from disturbing extracardial influences, can elaborate and maintain rhythmic chemical exchanges which stimulate the muscle fibers to a constant maintenance of proper tonus and efficient rhythmic contraction (rhythmicity) . Explosions of Energy. — Irritability remaining constant, temporary exhaus- tion attending each systole is complete, but is rapidly repaired during diastole, and, in health, stimulus production and irritability constantly readjust themselves to adequate recurrent rhythmic discharge. Refractory Stage. — By reason of its rhythmically recurring exhaustion, the heart muscle is wholly unresponsive to stimulation during the period of its actual contraction, i.e., it loses its excitability {refractory stage). The prompt restoration of excitability and contractility, as seen in health, depends'upon THE EXAMINATION OF THE HEART 465 a proper maintenance of the balanced chemical exchanges necessary to the renewal of the cell activity. Rhythmicity. — The rhythmicity of those explosions of energy which give rise to the normal heart beat depends upon the generation of periodic stimuli apparently determined by the rhythmic chemical interaction of inorganic salts of potassium, calcium and sodium and their ion-proteid combinations present in the blood in certain definite proportions (balanced solution). In such combinations the substitution of one ion for another can change the physical properties of the " ion-proteid " compound and it is assumed that the quality of recurring irritability (recharge of the exhausted cell) indis- pensable to contraction is thus explained. The theory of Gaskell which assumes a rhythmic alternation of assimila- tion and dissimilation (anabolic and katabolic processes) would seem well suited to this assumption. Restoring the Heart Beat Post-mortem.— By proper perfusion with Ringer's solution,* H. E. Hering restored and maintained for three and one- quarter hours the heart beat of a man eleven hours dead and Kuliabko obtained contraction of the heart of a dog five days dead. Adequate rest periods must be had between the recurrent discharges or neither stimulus production nor contractility of normal degree can be retained. Therefore, the work of the normal heart is dependent upon a series of rhythmic explosions and these in turn are contingent upon the maintenance of an efficient balanced metabolism. From the foregoing it is clear that the possession of a certain degree of ana- tomic integrity of the heart muscle is a paramount necessity and that the matters of nutrition and proper conduction are alike vitally important. Efficient Contraction. — A point or points of maximum irritability, free conductivity and definite open channels of conduction are essential to efficient and orderly contraction. As Hirsch well says, "the heart muscle is a homogeneous plasma mass with nuclei," a veritable aggregation of specialized cells. Its fibers freely anasto- mosing, are naked, wholly lack the connective tissue sheath of the skeletal muscle, and conduct almost as freely as nerve fibers. Thus every facility exists for rapid and harmonious stimulus transmission and coordinated response. It has been clearly, and apparently conclusively, shown by Wm. His, Jr., that the embryonic heart can act by virtue of its own intrinsic powers of conduction before its ganglion cells are demonstrable. This does not prove that a function possessed in embryonic tissue may remain dominant after the nervous mechanism develops but is a strong link in a long chain of evidence. Gaskell's Bridge.— (Bundle of His). — The apparent barrier to the full acceptance of the theory of the heart's potential automatism was represented by the anatomic break evident in the separation of the auricles from the * Ringer's solution is an artificial blood serum containing sodium, calcium and potassium chloride and sodium bicarbonate. 30 Chemical exchanges. Modern miracles. Fiber conduction. Heart fibers naked. Free inter- conduction. Automatism. 4 66 MEDICAL DIAGNOSIS Purkinje fibers. Increased "a-c interval. Partial block. Ventricular rhythm. Adams-Stokes syndrome. Sino-auricular node. Position. ventricles by the auriculo-ventricular septum, a non-muscular structure, but this gap has been bridged by Gaskell of Cambridge and Wm. His, Jr., who have shown that the interruption of normal stimuli passing from auricle to ventricle is not accomplished by cutting the nerve bundles, but rather the "bundle of His." Gaskell foreshadowed and foretold,* and Stanley Kent and Wm. His, Jr., proved, for the human heart, that the apparent barrier between auricle and ventricle was bridged by a bundle of peculiarly modified muscle fibers ("auri- culo-" or " atrio- ventricular bundle"). Auriculo-ventricular Bundle. — Tawara described clearly the course of these fibers, whose point of origin forms the so-called auriculo-ventricular node of AschofT and Tawara at the posterior right border of the base of the auricular septum, and showed that the bundle represented an aggregation of the Purkinje fibers which ramify to every part of the ventricles. Heart Block. — Any disease process or the administration of any drug tending to obstruct the free passage of impulses through this bundle must at least increase the time interval normally existing between auricular and ventricular contraction {conduction period) as expressed clinically by that separating the jugular wave (a) from the carotid wave (c) of the polygram. If the block interposed is still more decided, certain auricular contractions will fail to carry through and both delays (prolonged a-c interval) and elisions of the "c" wave ("dropped" ventricular contractions) will appear on the record, and show a rhythmic ventricular disregard and pretermission of fixed groups of auricular beats. The auricle may beat two, three, four or more times to each beat of the ventricle. Complete Block. — This may reach a point where entire dissociation of auricle and ventricle is present and the two chambers beat quite independently, each of the other, the latter developing a slow deliberate rhythm of about 30 beats to the minute, while the auricle pursues its own rate which may be two, three, or four times that of the ventricle. It is in such cases of heart block that periods may occur when the over-deliberate, and oftentimes weakened ventricle fails to send sufficient blood to the brain, thus causing convulsive seizures. It may cease for short periods, moreover, to beat at all, in which case syncopal attacks may occur and thus round out the classical "Adams-Stokes syndrome." The Pace Maker of the Heart. — Whence come the rhythmic impulses which induce coordinate contraction of the auricles and ventricles? There is a normal point of maximum irritability represented by a network of specialized muscle cells richly supplied with nerves and imbedded in the upper anterior end of the sulcus terminalis, which sulcus runs from the in- ferior vena cava to the junction of the superior vena cava with the right auricular appendix. *W. H. Gaskell of Cambridge University, England, actually demonstrated both myogenic conduction and heart block in the frog and tortoise in the year 1883. THE EXAMINATION OF THE HEART 467 This is the sino-auriciilar node of Keith and Flack which, from its station in the wall of the right auricle at the mouth of the superior vena cava, normally initiates each contraction of the heart. Fig. 178. — " GaskelPs Bridge," "His 1 Bundle." Interior of the right atrium and ven- tricle. The atrio-ventricular bundle dissected out. {Morris- Jackson.) i, Aortic arch. 2, Vena cava superior. 3, Right pulmonary artery. 4, Right superior pulmonary vein. 5, Right atrium. 6, Right inferior pulmonary vein. 7, Crista termi- nalis. 8, Cut anterior tricuspid cusp. 9, Fossa ovalis. 10, Valvula sinus coronarii. n, Valvula venae cavae. 12, Vena cava inferior. 13, Left common carotid artery. 14, Innominate artery. 15, Reflexion of pericardium. 16, Pulmonary artery. 17, Ascend- ing aorta. 18, Left pulmonary valve. 19, Conus arteriosus. 20, Crista supraventricu- laris. 21, Papillary muscle of conus. 22, Atrioventricular (His) bundle. 23, Medial tricuspid cusp, partially removed. 24, Anterior papillary muscle. 25, Part of posterior mitral cusp. 26, Posterior papillary muscle. Sinus oode. 468 MEDICAL DIAGNOSIS Course of impulses. Normal con- duction time. Thence the wave of impulse spreads over the auricular walls, causing auricular contraction, then crosses the bridge of Gaskell (bundle of His, Jr.) to the papillary muscles and walls of the ventricles, which begin to con- tract from o.i 2-0.18 of a second later (normal a-c interval of the venous tracing). Fig. 179. — "GaskelTs Bridge," "His' Bundle." Left ventricle and part of the atrium. (The aorta is opened through the medial cusp of the mitral valve. The plainly visible left limb of the atrio-ventricular bundle has been accentuated.) {Morris- Jackson.) 1, Pulmonary artery. 2, Right auricle. 3, Right aortic valve. 4, Anterior mitral cusp. 5, Atrioventricular bundle. 6, Anterior papillary muscle. 7, Cut wall of left atrium. 8, Membranous ventricular septum. 9, Left atrium, io, Part of posterior mitral cusp. 11, Vena cava inferior. 12, Coronary sinus. 13, Posterior papillary muscle. 14, Fine mesh work of columna carnae at apex. Right vs. Left Auricle. — As might be expected from the position of the pace maker, the beginning of right auricular contraction actually precedes that of its fellow, the left auricle, by 0.01 to 0.03 second but clinically their contraction may be considered as simultaneous. THE EXAMINATION OF THE HEART 469 Extrasystoles. — In certain pathologic conditions the heart may develop abnormally placed areas of irritability which initiate imperfect beats dis- turbing normal rhythm though usually leaving the rate unaffected. The Strength of Extrasystoles. — Given equal stimuli, the strength of any extrasystole is mainly dependent upon the time elapsing since the initial contraction of the beat preceding it, i.e., upon the duration of the antecedent rest period. Stimulus Conduction. — As stated previously, conduction by the muscle fibers themselves, while a trifle less perfect than that of systemic nerves, is re- markably good. It is greater in the contractile fibers of the auricle and ventricle than in the auriculo-ventricular bundle and, as in the case of other functions of heart muscle, is momentarily exhausted by each systolic contraction. Tonus. — A s in the case of all other muscles a certain degree of muscle tonus is normally well maintained and during life complete relaxation never occurs in the normal myocardium. The Neurogenic Theory. — This hypothesis assumes that the intrinsic stimulus to contraction originates in the ganglion cells adjacent to the sinus node or in those of the interauricular septum. Thence it is supposed to be transmitted by axones to the "sinus node" (of Keith and Flack), the auriculo- ventricular node ("node of Tawara"), the "bundle of His" (His-Tawara system), or directly to the muscles. Independence of the Heart. — It is obviously possible that the two sys- tems may prove to be interdependent or simultaneously active, but it is certain that the heart muscle itself is perfectly capable of automatic rhythmic activity wholly apart from the nervous system. The Influence of the Vagus and Sympathetic Cardiac Nerves. — The vagus and the sympathetic nerve fibers are physiologic antagonists with relation to heart action. Normally tonic vagus influence exists and manifests itself chiefly in the maintenance of a normal rate. When abnormal vagus excitation occurs, the rate of heart beat is slowed, and the interval between the auricular and ventricular contractions ("conduction time, a-c interval") is increased. Certain auricular contractions may fail to excite the ventricular contraction of the heart or either or both auricle and ventricle may stop temporarily. These constitute examples of partial or complete vagus heart block (delayed and interrupted conduction in the His bundle), such as may be seen in digi- talis poisoning or in the toxemias of infections.* It would seem that the direct action of the vagus is exerted upon the sinus * Whether the older conception of "conduction time," which assumed that impulses to ventricular contraction were passed through the auricular tissues, was correct may be doubted. It would appear that strictly speaking the "a-v interval" represents the fraction of time intervening between an auricular and a ventricular response to individual and separate stimuli from the sinus node. The ventricular impulse passes through the auricular-ventricular node, the His bundle, and the two branches of the His-Tawara system. The distinction is of slight importance in this elementary discussion. Premature contractions. Auriculo- ventricular node. Physiologic antagonists. Vagus block. 47° MEDICAL DIAGNOSIS Action^ of sympathetic. Effect of atropin. Reinforcing spirals. Marvelous regulation. Cardiac response. Cardiac endurance. node (node of Keith and Flack) and that it is left vagus stimulation which chiefly affects the conduction time. Conversely, stimulation of the sympathetic tends to increase the rate of the heart beat, shorten the conduction time and increase contractility and irritability. In health, these accelerator nerves constantly exert a tonic influence opposed to that of the vagus. Common Causes of Vagus Overstimulation. — Aside from poisoning by digitalis, strophanthus, aconite, etc., vagus overaction may occur in varying degree in dyspnea and cyanosis (lack of oxygen and excess of C0 2 ), in tobacco poisoning, in cerebral compression, and in arterial hypertension. On the other hand, vagus influence is diminished or suspended under full doses of atropin and this fact is utilized in the differentiation of the slow pulse of vagus overstimulation from that due to organic disease. Vagus overeffects may be easily obtained by deep thumb pressure over the right carotid at the middle or lower third of the neck, but the maneuver is not wholly safe. To what an extent the diseased heart can escape the normally balanced influences of the accelerator and cardio-inhibitory nerves and run amuck through sheer disorganization of its own automatism and intrinsic rhyth- micity, is shown later in our discussion of the " arrhythmias " associated with organic disease. Remarkable Anatomic Structure of Heart. — The arrangement of the muscle fibers of the heart is peculiarly adapted to coordination in that the ventricular musculature constitutes two spirals (Mall) each consisting of two layers running at right angles to each other. One of these spirals passes from the tricuspid area to the apex of the right ventricle, the other from the aortic and mitral orifices to the apex of the left ventricle, each being connected to the other by twisted strands running from the papillary muscles of one ven- tricle to those of the other. Coordination of Function. — This is indispensable to the normal heart action and in addition to a marvelous correlation of functions we find a certain automatically regulated sequence of stimulation and contraction which permits selective muscular activity on the part of different portions of the heart. Thus a given stimulus being received, the sequence and degree of the resulting contraction is exactly that necessary to the economic and efficient contrib- utive action of each part of the heart. An understanding of this beautiful mechanism enables us to comprehend more readily the newer nomenclature of heart disorders, and the mechanics and modern interpretation both of disturbances of rhythm and of actual cardiac insufficiency. Possibilities of Cardiac Reserve. — Extraordinary possibilities of emergency response to effort are possessed by all normal hearts and affect both rate and force of contraction. Much cardiovascular overwork may be borne for long periods without producing symptoms, and actual insufficiency can be present for years without obtrusive manifestations. BLOOD PRESSURE 471 Fundamental requisites. Determining Factors in Cardiac Insufficiency. — 77 is the degree of impair- ment or exhaustion of the reserve force, the sudden or gradual narrow-lug of the vital point. field of response, which determines cardiac insufficiency, one or all of the heart functions being affected. Therapeutic Objective. — Our object in treatment is to amplify, restore, or rehabilitate impaired reserve, and the main object of diagnosis is to detect To maintain early, and, so far as possible, measure the degree of, its impairment. BLOOD PRESSURE Factors Basic in its Determination and Interpretation ADAPTIVE CARDIOVASCULAR AUTOMATISM.— In order that a state of perfect body health may be maintained without undue and ultimately damaging strain upon the heart and blood vessels, it is necessary that the heart, that automatic generator of energy in the cardiovascular power plant, be itself measurably perfect as regards its controlling mechanism, and possessed of the attributes necessary to the generation of adequate horse- power and its economic delivery to the storage plant represented by the aorta and its main arterial service lines. Transformation and Conservation. — It is also requisite that the turbulent intermittent outrush of blood from the ventricles into the aorta should be so controlled automatically as to replace the primary jerky intermittency and rhythmic variations in the velocity of the blood stream by conditions of relative uniformity and constancy of flow, and such gradual reduction of speed, as best suits the needs of the tissues fed and drained by the capillary deltas. Selective Adaptation and Distribution. — There must also be a selective adaptation of the local rate of flow and actual blood supply to the ever-vary- ing demands of body metabolism. Obviously there is equal need of a relatively constant capillary blood pressure, varying only as may be neces- sary to meet the demands of tissue metabolism by means of a frictionless automatism. A Marvelous Mechanism. — The anatomic structure of the arterial sys- tem is beautifully adapted to these purposes, and the exquisitely balanced and adjusted control exercised by the vasomotor system in health adjusts to a large degree the speed of the capillary current and the local supply of blood without any special demand upon the heart for decided changes in rate, rhythm, force or output. Systolic and Diastolic Pressure in the Aorta. — Inasmuch as the systolic pressure and energy transmitted from the heart to the aorta far exceed primarily the amount needed to move the blood column onward, these must be husbanded in order that blood flow may be steadily maintained during the entire diastolic period. One per cent, is the amount of pressure energy immediately applied to support the forward movement of the blood column. Ninety-five per cent, is expended in distending the elastic arterial walls and thus becomes potential pressure-energy, the gradual release of which during 472 MEDICAL DIAGNOSIS Adjusts to tissue needs. diastole serves to keep the column of blood moving steadily onward without permitting a descent of pressure below that representing the minimum ("diastolic pressure") of the preceding diastole. Pulse Pressure. — Hence both systolic and diastolic pressure levels are maintained in the arteries, the former (systolic blood-pressure) representing the maximal level for the cycle, and becoming lowered as potential energy is converted into kinetic drive for the blood column. The difference between these two levels ("pulse pressure") of pressure energy represents under absolutely normal conditions the reinforcement, rhythmically dispatched to the arterial system by the heart through its recurring systolic con- tractions. Regulation of Rate of Flow. — Both initial current velocity and initial blood pressure, as demonstrable in the larger arteries, would be disastrously excessive both in the lesser and least arteries and in the capillary spaces if the primary rate of flow was maintained through- out. Therefore, as we have seen, the rate of flow which in the large arteries varies from 200 to 400 mm. per second becomes reduced to 0.6 to 0.8 mm. in the untroubled waveless capillary lakes (C. Hirsch). Blood Pressure in the Small Arteries and in the Veins. — The systolic blood pressure, which in the aorta is about 150 and in the brachial may average 125 mm. of mercury, is reduced to the diastolic level of constant pressure (60 to 70) in the lesser arteries. In the capillary deltas it varies from 45 to 15 mm. of mercury and, in the veins, is reduced to a maximum of 20 in the superficial venous channels and 10 to 15 in the subpapillary venous plexuses (C. L. Wiggers). DETERMINATION OF BLOOD PRESSURE.— Preliminary Considera- tions. — It is evident that in clinical work we are chiefly concerned with the cir- cumferential pressure exerted by the blood column upon the walls of the brachial artery during systole and at the end of diastole, together with the difference be- tween these two which is u pulse pressure" Fundamental Factors. — furthermore, that variations in arterial pressure are dependent chiefly upon the volume and energy of ventricular systolic dis- charge, its rate, and the resistance offered by the lesser arteries and capillary field. It must not be considered the measure of the heart strength, which is but one factor. Importance of Pulse-pressure. — In health the average * 'pulse pressure" varies between 35 and 50 mm. and this and the diastolic pressure are actu- ally far more important in a diagnostic sense than the systolic pressure. Fig. 180. — Gartner's tonom- eter. One of the first blood- pressure instruments applied widely to clinical uses. It is used still occasionally for com- parison of peripheral with brachial blood pressures. BLOOD PRESSURE 473 A diastolic pressure reaching or exceeding ioo mm. Hg. is almost in- variably pathologic. It should represent normally about 70 per cent, of the systolic reading. Simple Device. — Fortunately for the clinician, blood pressure may now be measured quickly and with sufficient exactitude by simple and relatively inexpensive instruments nearly all of which depend upon the same general principles, viz., the translation of the pressure required to obliterate the arterial pulse, into the height of a mercury column in a manometer tube. Fig. 181. — One of the several forms of pocket sphygmomanometers of the aneroid type. Convenient, compact and portable, but needing standardization from time to time. Fig. 182. — New Nicholson Princo sphygmomanometer. Small, portable and accurate. (Courtesy of Precision Thermometer and Instrument Co., Phila.) The portable instruments now available are, for the most part, sufficiently accurate for ordinary clinical work, but systolic blood pressure readings which depend upon the usual and least accurate method of determination, i.e., the first palpable return of a radial pulsation after obliterative compres- sion, involve an underestimate of from 5 to 15 mm. of mercury. The Older Technic of Blood-pressure Determinations. — The hollow armlet, applied midway between shoulder and elbow, is inflated by the hand bulb until the radial pulse is lost, then by the outlet thumb-screw the pres- sure is lowered until the pulse return is just perceptible. As the pressure is equal in all parts of the closed system, the height of the mercury column in the manometer tube is an exact index, and the reading represents the" maxi- mum" or "systolic" pressure. Systolic,|»dias- tolic and ; "pulse" pressures. 474 MEDICAL DIAGNOSIS "Diastolic" or "minimum" pressure is determined by noting for ten to twelve pulsations the increasing amplitude of the pulse wave registered by the mercury column as the pressure is reduced in 5- mm. series. The point representing the base line of the maximum excursion is the index of diastolic pressure. Below that is a limited pressure area of equal amplitudes. The "mean" pressure represents the average of systolic and diastolic readings and the "pulse pressure" or "pulse amplitude" represents, as has been stated, the difference between the systolic and diastolic readings. Pulse pressure is usually about one-fourth the systolic pressure and runs between 35 and 50 mm. Eg., as Pulse pressure variations. Sources of error. Sclerosis. Sex and attitude. Auscultation method. stated above. A pulse pressure which falls below 25 or exceeds 60 is almost certainly pathologic. Diastolic readings run normally about 25 to 40 below the systolic; in low tension, varying from 50 to 80 mm. ; and in aortic regurgitation ; 150 mm. or more. An excessively rapid, persistently irregular or unequal pulse makes palpatory diastolic pressure determination impossible. In every case the arm band should be closely adjusted, the arm supported at the heart level and the same position taken for a series of tests. The limit of error in calcareous arteries is but 10 or even e mm. and is negligible or easily esti- mated. The same figures respec- tively represent the difference between females and males and the standing and sitting posture. The limits of error in respect to the state of contraction or relaxation of the arterial wall itself are probably considerable and quite beyond accurate determination. Muscular movement and the presence of edema alike introduce a variable element of misinterpretation. An error of 20 mm. Hg. may result from the use of an improper rubber tube and old tubes should be replaced frequently by new ones. Koratkow's Method. — This simple, clinically accurate, and recommended method consists merely in auscultating over the brachial artery below the point of constriction, the sounds produced during the obliteration of the brachial pulse by the arm band of any of the ordinary instruments. The use of a special arm band carrying a stethoscope is a matter of increased Fig. 183. — The illustration shows the Pilling bracelet-stethoscope, an ingenious, useful, yet dispensable device. It is less con- venient but wholly possible to use the binaural stethoscope of any type alone. (See Fig. 184.) BLOOD PRESSURE 475 convenience but is not a necessity. The sounds heard over the brachial artery as the obliterating pressure is gradually released are divisible in five phases of audibility, viz: First Phase. — Systolic Pressure Level. — A clear thumping sound, which must be translated into the reading of the manometer scale at the exact time of its occurrence represents systolic pressure. This sound remains clear and distinct usually until the mercury column has dropped 15 mm. and represents the first projection of blood into an empty artery. Second Phase. — The clearness of tone of the first phase becomes a blending of multiple eddy murmurs and this blurred picture lasts until an ad- ditional recession of about 20 mm. of mercury has occurred. Third Phase. — A sharp sound appears and grows progressively more distinct and louder dur- ing a recession of about 25 mm. of the mercury in the manometer column. Fourth Phase. — Dias- tolic Pressure Level. — This represents the abrupt muffling of the tone of the preceding (third) phase and lasts for only a short period represented by a reces- sion of about 5 mm. of mercury. The scale reading of the manometer at the exact time of the appearance of this dull muffled sound is taken as representing the diastolic pressure. Fifth Phase.— This is merely the period initiating entire loss of sounds and by Koratkow and others was considered formerly as representing the diastolic pressure point. The use of the fourth phase is probably the more accurate and certainly the more generally applicable method inasmuch as complete disappearance of sounds may not occur in aortic regurgitation or in certain cases of exoph- thalmic goiter. Normal Readings. — The normal systolic pressure readings according to A clear sound. Fig. 184. — The auscultation method. (A 7 orris.) Confused multiple bruits. Reappearance and intensifi- cation of clear tone. Abrupt muffling of tone. 476 MEDICAL DIAGNOSIS Effect of excitement. A great need. Faulty figures, Results in practice. Janeway are: for young adults, ioo to 130; older adults 100 to 145; children 90 to no; infants under two years, 75 to 90.* Age. — The following table is that of L. Gordon, and represents the results of an extensive study of the relation of age in normal children to systolic blood-pressure. Years Mm. Hg. Under one 71.0 One 73 . o Two 79 . 3 Three 81.0 Four 83 . o Five 86 . 5 Six • 88.5 Seven 85.0 Eight 93 . o Nine 100 . o Ten 95 . o Eleven 104 . o Twelve 105 . o Excitement may cause a rise of 40 mm. or more and physical effort a slight increase or, if extreme or of an unusual nature and abrupt, a rise of 30-60 mm. may occur. Accustomed effort of the same grade may cause a rise of only 10 mm. or less. The rise of pressure under exercise and excitement alike is predominantly systolic, and, in the case of the former, pressure may actually fall if the individual is in good training and the effort is not one of an abrupt, violent, nature (high jump, throwing the hammer, 100 yard dash). Experience teaches us that a persistent pressure of 130 or more in the young adult is a suspicious finding, and that even in middle age a systolic pressure of 150 is almost certainly pathologic, f We need greatly a large series of " normal" readings based upon the auscultatory method and upon cases thoroughly and completely investigated with respect to the presence of incipient disease and the structural types encountered. The variations in the figures at present available are too great to represent wholly normal departures. The reported average systolic reading of 1 50 mm. at age sixty for example, to which about 10 mm. must be added to allow for the constant error in- herent in the palpatory method, must have involved the inclusion of maximal readings so high as to raise serious doubts concerning the legitimacy of the figures. The mortality reports of life insurance companies show the fallacy inherent in the application of the word "normal" to any such figures. * The author feels that the lower figures for adults are to be accepted only with decided reservation inasmuch as he has usually found them only in association with more or less profound subnutrition or circulatory depression. Low readings are especially common in tuberculosis even during the incipient stage. t The average normal for the sixth decade is 138 mm. Hg. Maximum obtained in large group 150 mm. Hg. BLOOD PRESSURE 477 Important Statistical Data. — /. W. Fisher has recently published a most valuable article reporting the average systolic pressures obtained as the result °f x 9>339 readings representing that number of accepted candidates for life insurance. Fig. 185. — The UskoflE sphygmotonometer. This instrument simultaneously records blood pressure in millimeters of mercury, together with the brachial pulse at varying pressures, and one other tracing (jugular, carotid, apex beat, etc.). (Courtesy, A. H. Thomas Co.) The following table shows that even those who had attained the later years of the sixth decade of life showed an average systolic blood pressure slightly under 135 mm. of mercury. Dr. J. W. Fisher's Table Ages Number Average blood pressure 15-20 281 119.85 21-25 785 122.76 26-30 791 123.65 31-35 689 123.74 36-40 2,111 126.96 41-45 6,740 128.56 46-50 4,471 130.57 51-55 2,371 132.13 56-60 I, IOO I34-78 total 10.310 tcR r>T On 525 applicants accepted in earlier years who showed an average sys- tolic pressure of 152.58 mm., the Northwestern Life Insurance Company 47 8 MEDICAL DIAGNOSIS Excessive mortality. Important temporary i ncrease. suffered an excess mortality exceeding by over 30 per cent, the general average of that company. On another group of 1970 lives showing an average sys- tolic pressure of 161.44 mm. representing the rejected risks, followed only in part and under great difficulties, the mortality rate was almost two and one- half times greater than the general average of the company. Yet, of this group, at the time of examination, 1082 showed no other impair- ment than this relatively high systolic pressure and the individuals composing this subgroup, and showing but the single blemish (B. P. 161.44 »»• Hg.), yielded an excess mortality more than double that properly to be expected* The experience of Dr. Fisher and other medical directors in relation to life insurance corresponds accurately with the clinical observations of the author extending over a period of several years. Faught's Formula. — Faught suggests that one may determine approxi- mately the normal limit of blood pressure (palpatory) for any age by assum- ing 120 mm. Hg. as the normal for the male adult of twenty years, and adding 1 mm. for each two years of added age. An arbitrary deduction of 10 mm. Hg. is made at all ages in the case of women. ABNORMALLY HIGH PRESSURE.— In chronic interstitial nephritis the elements of arteriosclerosis, high peripheral resistance from toxic hyper- tonus of the blood vessels and increased heart energy bring about high systolic readings (160 to 300 or even higher) and a markedly high diastolic level. In both " acute nephritis" and "the chronic parenchymatous lesion," the pressure is usually decidedly raised though seldom to the same degree as in the chronic interstitial save during uremic seizures. It may be sig- nificantly high in acute nephritis before edema is manifest and attain and maintain a high level throughout the acute stage. In amyloid kidney the pressure is not raised, but is usually abnormally or even extremely low. In abnormal nervous excitement temporary high pressure may be observed and this may be very decided in victims of preexisting chronic hypertension. In secondary myocarditis with associated splanchnic spastic crises, lead poisoning, gout and actual or impending cerebral hemorrhage, relatively high readings are present. Cerebral Arterial Crises. — Fleeting aphasia, vertigo and syncope, asso- ciated with decided hypertension, have been observed frequently by the author. Less often an actual transient hemiplegia has occurred and in most instances this has proven a prelude to an actual apoplectic "stroke." Lead Poisoning. — The chief characteristics of the arterial hypertension of lead poisoning are high systolic and relatively low diastolic pressure resulting in increased pulse pressure with a low diastolic level. This is in rather decided contrast to the high diastolic and systolic levels of interstitial nephritis. The distinction is lost, however, if, as so often happens in chronic plumbism, renal involvement develops. Marked exacerbations of pressure occur, es- pecially in cases of encephalopathy, and apparently are associated with a * "The Value of Blood-pressure Readings in Examinations for Life Insurance," J. W. Fisher, M. D., Lancet- Clinic, Cincinnati, No. 7, vol. cxiii, Feb. 15, 1915. BLOOD PRESSURE 479 vascular spasm, usually visibly reflected in the condition of the retinal arteries. Four-fifths of the workers in lead show high arterial pressure, even in the absence of other symptoms of plumbism (Norris and others). Bradycardia is commonly observed (55 per cent.). Excessively high (250-300 mm.) sys- tolic readings in cases showing tremor and obscure cerebral symptoms in renal disease should always suggest the possibility of lead encephalopathy Transient stupor or coma, fleeting delirium or transient or persistent delu- sions, maniacal excitement, hysteroid manifestations and epileptiform seiz- ures are some of the symptoms encountered and uremia may be closely simulated. In impending uremic seizures a rise in pressure to 300 has been several times observed by the author. The pressure may recede sharply but is likely to remain high until a balance is again attained or the fatal issue approaches. A reading of 420 mm. with recovery has been reported in puerperal eclampsia. In general arteriosclerosis alone it is unlikely that pressure readings of over 170 are often observed and these only in exceptional instances. On the other hand, in well-marked instances a distinctly low pressure may be found and it is probable that our former views with relation to the matter must be greatly modified. In aortic regurgitation the " pulse pressure" is unusually high (60 to 120+) because of the high systolic and extremely low diastolic pressure character- High pulse istic of that lesion, and is largely due to increased capillary flowage, to the left ventricular hypertrophy, and the unsustained blood column.* In middle-aged individuals carrying this lesion the systolic pressure may run from 170 to 230, with diastolic readings of 30 to 60 respectively. The highest systolic-diastolic readings with relatively lower pulse pressures are seen in cases showing more or less renal involvement and arteriosclerosis. In free regurgitation with a large, powerfully contracting ventricle, one may obtain systolic readings of 230 mm. or more with a diastolic of 30 mm. The pulse pressure in aortic leakage is of some value in determining the freedom of regurgitation. An abnormally high variation between the arterial tension in the arm and the leg (60-160 mm.) exists in pure and fully com- pensated cases. Intracranial Pressure. — High Tension. — This form may be due to meningi- Brain center tis, tumor, thrombosis, meningeal hemorrhage, and the like and produces asphyxia, high pressure through brain center anemia and a reflex extreme vasomotor Misleading constriction of the cerebral vessels which in its turn excites the heart to power- ful contraction. (Apoplexy is usually included in this group, but is more likely to follow a long-sustained hypertension than to initiate it.) In con- Coma. ditions of coma this may be most confusing and lead to an erroneous diagnosis * Wiggers believes that the element of vasodilatation plays little if any part. From a purely clinical standpoint one would strongly affirm the constant presence of moderate vasodilatation, meeting in some degree the demand of the tissues for a more stable capillary flow. hypertension. 480 MEDICAL DIAGNOSIS Epileptic seizures. An exception. Splanchnic crises and lightning pains. Increased viscosity and blood volume. Often overlooked. An asphyxial phenomenon. A vicious circle. Shock and hemorrhage. of uremia. Some epileptic seizures are also temporarily most misleading because of attendant hypertension, but the pressure falls promptly to normal or oftentimes below normal as soon as the attack subsides, unless it be of 1 the Jacksonian type in which event it may behave as do other forms of increased intracranial pressure. Locomotor Ataxia. — Splanchnic spastic crises and lightning pains may produce transitory high arterial pressure and in this, as in intermittent claudi- cation, vasoconstriction seems to be the fundamental cause. Angina Pectoris. — In most instances, according to the author's experience, this is associated with a sharp or even maximal rise in pressure oftentimes followed by a sudden drop to or below the antecedent pressure and this hypertension is most extreme in cases complicated by interstitial nephritis. The Adams-Stokes syndrome may or may not be associated with high arterial tension but the readings during the severe seizures with feeble or absent systole are, of course, reduced to an approximate zero. Erythremia {Chronic Splenomegalic Polycythemia). — Many cases show a blood pressure much above the normal. In two, observed by the author, the pressure variations resembled those of an interstitial nephritis. One showed marked. arteriosclerosis, the other none. In these cases both viscosity and total blood volume are greatly increased. The Heightened Pressure of Stasis. — This is a form of contributory hypertension extremely common and unfortunately often overlooked, disregarded or misinterpreted. It occurs most typically in cases of interstitial nephritis and mitral dis- ease with a weakening or failing myocardium and is due to an asphyxial irrita- tion of the centers and resulting vasoconstriction associated with an overload of carbon dioxide in the blood. In such cases an acidosis is usually present which greatly reduces the tolerance of the respiratory center to CO2 and may thus produce dyspnea without marked pulmonary stasis. The fact that digitalis and rest are the best remedies shows that the immediate indication is increased heart strength and blood flow. Although an asphyxial phenomenon no extreme signs of stasis, such as deep cyanosis , need be present. Inasmuch as it is the center itself which is chiefly affected, under a carbon dioxide blood overload, the vessels contract and the heart coincidently slows and loses tonus, thus increasing the overload and estab- lishing a vicious circle. In diphtheria the blood pressure may be of the utmost importance in relation to the not infrequent deadly combination of acute dilatation and the splanchnic paralysis of central origin. It should certainly be watched care- fully in such cases for it is unlikely that either condition is unheralded by significant blood-pressure variation in the way of hypotension. Abnormally Low Pressure. — The conditions giving the lowest readings are toxic paralysis of the vasomotor center, shock, collapse, visceral perforation, and concealed hemorrhage. BLOOD PRESSURE 481 The lowest recorded persistent low reading followed by recovery is 50 mm. Hg. (Xeu). In visible hemorrhage attended by nervous excitement, fear, and appre- hension the pressure may be raised though if actual exsanguination be in- duced it will be low. The acute infectious diseases, pleurisy with effusion, cholera, dysentery and severe diarrheas, anemias and cachexias and the terminal stages of all diseases usually show low pressure. Acute Infections with Persistent Hypotension. — The low pressure is probably due to vasomotor relaxation from toxemia of the centers together with, or without, profound myocardial weakness, and sudden death may occur from either one or from both causes. Death may result from mere emotion or slight exertion in such toxic cases. The degree of the hypotension manifest in all severe cases of diphtheria measures roughly the grade of toxemia, but in laryngeal cases an "asphyxial" higher level is present until the obstruction is relieved by tracheotomy or intubation. A sudden drop in blood pressure is an ominous sign, and a progres- sive lowering of the level during the second week of the disease is of grave significance. A similar but less extreme hypotension occurs in dysentery. Cholera. — Systolic readings of 60 mm. are reported as occurring during the algid stage and 70-75 is a relatively common reading. As stated by Dr. G. W. Norris in his admirable book* dealing with blood- pressure the response of a lowered systolic level to saline transfusions and epinephrin constitutes "a satisfactory criterion" of the amount required. Pneumonia. — The late Dr. Geo. Gibson of Edinboro first stated that a pressure persistently and decidedly below normal in pneumonia was "of evil omen," and that a decided drop "bodes disaster." He proposed the follow- ing formula: When the arterial pressure expressed in millimeters of mercury falls below the number of heart beats per minute the fact is of evil augury. This may be accepted as a rough clinical rule vitiated somewhat by the fact that high pressure may have existed before the attack of pneumonia; that cases showing absolute or relative high tension or a normal level not infrequently prove fatal; and that many factors affecting the pulse rate stand quite apart from blood-pressure variations. Howell states that a study of the four auscultatory phases is useful and believes that clear sounds and regularity of rhythm are of good augury, and that persistence of the relatively impermanent second phase is of especially good import. One must not overlook, however, the right heart and the car- dinal prognostic value of pulmonary accentuation and grade of cyanosis. Bronchial Asthma. — This condition is nearly always associated with de- cided hypertension, which in cardiorenal cases may be extreme. Hypertension occurring in the bronchial form doubtless is accounted for * "Blood Pressure. Its Clinical Applications." Lea and Febiger, 1916. 3iJ Toxemic centers. May be a danger signal. A useful criterion. Fallible but useful. 482 MEDICAL DIAGNOSIS by the fright and distress attending the attack together with the asphyxial element. It is said to be low in the misleading cardiac form, but this has not been true of the few instances enountered by the author in which readings were obtained. Pneumothorax. — Conflicting reports only are available with relation to blood pressures in this condition. Obviously much depends upon the mode of onset, the degree of intra- thoracic pressure, the question of a preexistent tuberculosis and the stage of the process. Those of sudden onset are associated doubtless with an abrupt drop in arterial tension and those showing marked dyspnea and cyanosis should show a moderate psychic and asphyxial rise in pressure. Tuberculosis. — Active tuberculosis wherever seated is associated with moderate hypotension in most instances and one must extend this statement to cover many obsolete and inactive cases. Many, if not most of the latter, fall under the head of "chronic congenital asthenia" elsewhere described. Chronic Universal Congenital Asthenia. — This more or less visceroptotic functionally unstable, structurally deficient, and non-resistant group yields many instances of hypotension. The high percentage of obsolete or latent tuberculous foci revealed by the roentgen ray and tuberculin tests in these supersusceptible yet resistant individuals renders it difficult to determine whether or not they may be con- sidered as a group apart with relation to hypotension. Lowered Splanchnic Tonus. — In the hypotonias of congenital asthenia in its subnutritional form one assumes a loss of splanchnic tonus similar, but less in degree, to that present in shock. In many instances there appears to be a generalized lack of vascular tonus associated with the peculiar relative atonicity of the myocardium of the "drop"- or modified "drop "-heart characteristic of these cases. Syphi]is.-^-H ypotension is the rule probably in the more active earlier stages of syphilis, which, in its later phases, constitutes a not uncommon etiologic factor in hypertension. Pericardial Effusion. — The effect of a large exudate is to produce low tension and a small pulse pressure, and the degree of reduction, or better its persistent lowering, is one of the bad signs of this condition. Normally the pericardium tends to limit or prevent excessive dilatation and reenforce especially the weaker right heart and the left auricle. When the sac is excessively distended by an effusion the right auricle is compressed and cannot receive and pass on the proper amount of blood to the embarrassed ventricles. Deficient blood supply and insufficient activity of the heart as a whole contribute largely to the production of ypotension. Aortic Aneurysm. — No striking diagnostic points are elici table with refer- ence to this lesion. The associated conditions determine the pressure varia- tions for the most part. BLOOD PRESSURE 483 Dr. R. Edwin Morris reports, moreover, that decided unilateral pulse and blood pressure differences are common in individuals lacking any sign of aneurysm, marked arteriosclerosis or cervical rib. Chronic Alcoholism. — In delirium tremens hypotension is marked during the stage of active delirium. In cases of chronic alcoholism presenting vague symptoms, psychasthenic and otherwise, a curiously constant rise of systolic pressure (20-70 mm.) occurs and endures for several days. The systolic pressure remains relatively high. Raff has found the phenomenon of considerable differential value.* Morphinism. — The blood pressure in the morphin habitues of the better grades of society or those of any class who are relatively well nourished are said to show high pressures which are strikingly reduced by the free catharsis now universally used prior to withdrawal of the drug. Norris properly points out the fact, however, that the patients of this type admitted to the public clinics are usually in a state of semistarvation, pro- found cachexia and hypotension. Anesthesia. — Ether. — The primary sharp and oftentimes excessive in- crease in arterial tension due to excessive stimulation of the psychic sphere and the struggles of a resisting patient may be a source of great danger in cases of aortic aneurysm, antecedent hypertension and myocardial weakness of any type. During full anesthesia the blood pressure is maintained usually at about the normal level by stimulation of the respiratory centers, some- times so excessive as to cause temporary suspension of the breathing. Arrest of respiration in the stage of full anesthesia is the result of par- alysis of the centers. The combination of oxygen and ether produces a considerable rise in blood pressure throughout the anesthesia. Chloroform anesthesia is characterized by an early fall in pressure increas- ing pari passu wdth the deepening of the state of unconsciousness, and in fatal cases continuing its descent until death. It is asserted at present that this is wholly due to the persistent cardiac depression characteristic of the drug, but it would seem unlikely that this is the last word, and probable that peripheral vasodilatation plays a consider- able part. Not only progressive myocardial weakness, but also an increasing dilatation are present in lethal cases. The early temporary arrest of heart action often encountered is a respira- tory reflex inhibitory effect which may prove fatal in cases of myocardial degeneration or inflammation. Nitrous oxid slows the pulse and raises blood pressure. This anesthetic is somewhat dangerous in cases of decided chronic arterial hypertension. Ethyl chlorid exerts an effect wholly comparable to chloroform, but in a greatly lessened degree. Typhoid fever is characteristically a disease associated with persistent * Dr. Karl Raff, Deutsche Archiv. f. klinische Medizin, vol. cxii, p. 209. A suggestive finding. Public patients. Surgically ] important Caution. 484 MEDICAL DIAGNOSIS Low tension. Importantsign. Important data. and progressively increasing hypotension though this usually does not reach extreme figures (95 mm.). Sudden drops are ominous. The advantage of routine observations is especially marked in relation to hemorrhage and perforation where a sharp and sudden drop may indicate hemorrhage, and a decided secondary rise (within from two to four hours) point to developing peritonitis from perforation or to renal involvement. Malaria. — In malarial cachexia the blood pressure usually is low. Scarlet Fever. — Hypotension or normal pressure are usually present. A decided rise in blood pressure is of great importance as suggesting the coming of a complicating nephritis, for it may precede by several days the onset of frank signs or even the albuminuria. On the other hand, albuminuria may occur without such an ascent of pressure, and may be merely that of toxemia of the lesser grades. Norris emphasizes the following facts with relation to hypotension in acute infectious diseases. They may be summarized as follows: 1. Hypotension occurs in practically all febrile infections, being especially marked in certain forms. 2. In so-called sthenic fevers the fall of pressure is trifling. 3. In asthenic fevers arterial hypotension is pronounced and death in many cases is attributable to vasomotor failure quite as much as to a failing myocardium. 4. Toxemia rather than fever determines the degree of hypotension. 5. Degeneration or disturbed function of the adrenal glands occurs in some febrile infectious conditions, notably in diphtheria. 6. Decrease of pulse pressure usually represents a systolic fall and is a bad symptom; well sustained pulse pressure, a favorable sign. 7. Practically any acute infection may produce cardiovascular damage. 8. A convalescent patient should not be permitted to leave his bed so long as there is a marked difference between the pulse rates in the erect as compared with the recumbent posture. 9. Minor degrees of physical exertion in unfit convalescents may cause a fall of 30 or 40 mm. Hg. systolic pressure. 10. Arbitrary standards cannot be set forth in figures. The essential prognostic factors relate to the course of the blood pressure, diastolic and sys- tolic, upward or downward, and to the lability or stability of arterial tension. Hypotension Attending the Sudden Relief of Abdominal Pressure.— The danger from shock which is associated with the too rapid removal of preexist- ing abdominal pressure is well known. In the withdrawal of fluid from the abdominal cavity, a decided temporary hypotension is induced which is much less marked if the flow is gradual and constriction of the abdomen maintained throughout. Pleural Effusion. — A large pleural effusion whether transudate or exudate causes a rise in blood pressure; its removal, a fall coincident with its with- drawal, and to a degree measurably corresponding to the relief of intratho- racic pressure afforded, but dropping temporarily below the level of arterial tension normal or habitual for the individual. The dangers attending the BLOOD PRESSURE 485 A common error. withdrawal of exudates too rapidly or the yet greater one dependent upon undue irritation of the pleura are well known. The fall in blood pressure during thoracentesis (20 mm.+) is more rapid in the case of chronic than in recent or acute effusions and the only fatal a instance observed by the author occurred in the case of a patient suffering from a multiple serositis, whose chest had been aspirated again and again with impunity. Vertigo is a symptom to be regarded and shallow rapid inspiration may precede syncope. In the case of both paracentesis abdominalis and thoracentesis the lack of efficient preliminary local anesthesia, an unnecessary f ussiness, and the unwise assembling and parade of instruments, greatly intensifies the tendency to syncopal seizures. Both operations are ordinarily trifling in their nature and the patient should be spared mental perturbation so far as possible. Abdominal Colics. — Practically every form of severe abdominal pain of this character may be associated with moderate rise in pressure. An ex- 1 cessive ascent in cases of preexisting arterial hypertension has been observed by the author several times in cases of angina pectoris with abdominal pain maxima, and this statement also applies to Pal's " splanchnic crises," possibly misnamed, certainly too often diagnosed. Blood-pressure Determinations in Pregnancy. — Significant and even critical arterial hypertension may precede the appearance of albumin in the urine. No pregnant woman should be allowed to go through delivery without receiving the benefit of repeated blood-pressure determinations especially More im- 1 - 7 1 1 " 1 1 « i- • r • i • 1 1 Portant than during the later months, these being of infinitely greater importance than the urinalysis, examination of the urine. Any case which shows readings distinctly above I normal should be carefully watched and if the rise is progressive as well as persistent and reaches or exceeds 145 or 150 mm. it constitutes a danger signal. In cases of pregnancy associated with marked hypertension the rupture of the membranes is followed by a drop of from 60 to 90 mm. of mercury, a rebound of nearly as great an amplitude, a further and second recession following actual delivery, a second rebound, and then and thereafter a gradual return to normal occupying from three to seven days (Anders and Boston). Acute heart lesions, with profound weakness, show decided low pressure unless a marked asphyxia of the centers is present. Points of Importance. — A low systolic coexisting with a high diastolic pres- sure (100+) may prove of great significance in the early stages of an inter- stitial nephritis and is often present in the terminal stages of cardiorenal dis- ease when the myocardial reserve is near to exhaustion. A high systolic and normal diastolic pressure may result from purely temporary conditions such as emotional upsets or excessive exertion in an untrained individual. A high systolic and extremely low diastolic pressure almost invariably means aortic regurgitation even though the murmur be absent. If very marked it A curious sequence. 486 MEDICAL DIAGNOSIS will be associated probably with Duroziez's sign in the femorals and a well- marked Corrigan pulse. If true aortic stenosis exists, this will be modified and the pulse pressure reduced, but usually retains its chief characteristics. Ac- cording to the author's limited observations, frank exophthalmic goiter usu- ally shows a similar but less marked pressure curve. A low systolic and diastolic pressure in ambulant patients usually repre- sents residual cardiovascular effects of past acute illness and in any event strongly suggests lack of cardiovascular reserve. Of late the value of this finding as an indication of cardiovascular depres- sion or actual myocardial weakness has been emphasized by the clinical experience of the author and the check afforded by the teleoroentgenogram, electrocardiogram and polygram. It is encountered with especial frequency in individuals of the congenital asthenic habitus carrying concealed septic foci. Its occurrence in terminal cases of heart disease and especially in post hypertension cases with failing hearts is well known and the author encounters a decided drop in blood pressure frequently in individuals who are experi- encing a definite impairment of what was previously an adequate com- pensatory reserve. In heart cases with a clear history of physical overstrain an initial low blood pressure may be seen to heighten daily under treatment. In cases of chronic arterial hypertension a pressure of 175-185 with a diastolic pressure above 100 appears to be well borne for years (author's personal observation), but pressures of 190-200+ convey a threat, and those of 220+ mean that the sword overhead is suspended by a hair. In this connection the author ventures to assert his utter disbelief in the widely accepted doctrine of the conservative effects of decidedly high blood pres- sure in cardiorenal cases. In nearly all of the non-terminal cases carrying a blood pressure of 200 plus, in which, fortuitously or otherwise, a drop to 160-175 mm. Hg. has occurred, this event has been associated with immediate and decided better- ment, not only with respect to myocardial reserve, but also in a number of instances, decided shrinkage in the cardiac outline. This does not justify the use of an over-radical and depleting therapy, prove that a moderately increased blood pressure is never of good augury, or that excessive abrupt falls in pressure may not sometimes be ominous, but it suggests the danger inherent in the prevalent attitude. The point has been emphasized in a certain small group of cases in which by a happy chance the author found intermittent hypertension before any albumin appeared in the urine. In several of these individuals the adaptive changes in the heart itself were interrupted by hypertensive periods which definitely increased certain minor decompensatory phenomena. In cardiorenal cases high blood pressure would appear to be primarily and chiefly a toxemic manifestation. Those particularly affected were of the congenital asthenic type, but the same phenomena have been observed in others. THE RADIAL PULSE 487 Chief Clinical Significance of High Diastolic Pressure. — As a matter of practical application a decided and persistent hypertension with a high or relatively high diastolic level means chronic nephritis, until another cause is proven or rendered a reasonable assumption. This statement holds good regardless of the absence of the classical urinary findings at the time that hypertension is become manifest. In other words, chronic Bright's disease with or without albumin and casts, but seldom without evidences of impaired renal permeability, is so commonly the cause as to place all other claimants among the "possibilities" only. In the group described in the preceding paragraphs periods of impermea- bility coincided with intervals of increased arterial tension. Blood-pressure Estimations in the Arrhythmias. — As stated previously, the difficulties encountered in taking 'the blood pressure when certain forms of irregularity are present may be insurmountable with respect to diastolic pressures. This is true of all arrhythmias in which inequality of force plays a part, i.e., auricular fibrillation, alternation, extrasystolic irregularities, etc. In such cases one can only determine the "highest" and "lowest" pressures at which the systolic sound is heard by the auscultatory method or, less accurately, record the levels by the palpatory method. With respect to the auscultatory method, this means merely the taking of the reading at the maximal pressure at which the first sound is heard and then slowly and carefully lowering and raising it until the sound of every systolic wave is heard. A count of the beats per minute then audible at the brachial should be made during several minutes and compared with a similar count made by direct auscultation over the heart. In both extrasystolic irregularity and fibrillation certain ventricular contractions may fail to open the aortic valves.* Pulse Deficit. — Such comparison of the number of beats reaching the radial or brachial artery with that of the heart itself as determined by auscul- tation direct is a matter of considerable interest and some importance. Venous Pressure. — The venous pressure may be roughly estimated by Oliver's method which consists in allowing the arm to hang downward so as to distend the veins, noting the height at which venous collapse occurs when the extended arm is raised. Normally the fulness is lost }^ inch above the level of the heart apex. Each additional inch represents a venous pressure equal to 2 mm. of mercury (1.985). Other methods of measuring venous pressure involve more trouble, time and apparatus than the information gained is worth to the clinician. * James and Hart obtain an "average" systolic pressure in such cases by making a systolic pressure record for each 10-mm. reduction of pressure, counting the systolic beats per minute for each level while an assistant counts the beats as heard over the heart itself during the same period. The systolic beats heard per minute over the artery at each level is multiplied by the reading obtained at that level and the sum of the products is divided by the number of apex-beats per minute. 4 88 MEDICAL DIAGNOSIS High figures are often present in marked systemic stasis such as occurs in right heart decompensation from whatever cause. THE RADIAL PULSE "TAKING" THE PULSE.— Relative Value of Methods.— In general clinical value, instrumental methods cannot compare with pulse-taking by the old method. The palpable beat of the radial pulse represents normally the sudden systolic increase of arterial tension and it is felt only when the artery is partially compressed against some rigid supporting tissue. Pulse Palpation. — Whenever possible the pulse should be taken casually, while talking of other matters, and due allowance made for the nervousness incident to examination and the effect of any antecedent physical exertion or excitement. In children, especially, accurate determination of the actual rate is often impossible unless the youngster is asleep. The Importance of Correct Technic— A correct technic is of the utmost importance and the patient's arms should be similarly placed, in a position free from restraint, flexion, or muscular compression of the vessels. The pulse should be taken simultaneously in the two radials, the pulp, not the ex- treme tip, of three fingers (mid-, fore- and ring-finger) being applied lightly over the artery at the wrist. (There is no better proof of bad training than the gingerly one-finger-tip approach sometimes observed.) Position of Arm. — Faulty position of the patient's arm and hand may greatly modify any pulse. The forearm should be slightly flexed, the wrist thrown slightly backward and a trifle supinated. Points to be Determined. — (i) The "size" of the artery. (2) Pulse rate or frequency. (3) Rhythm. (4) Uniformity of strength. (5) Synchronism and equality of the right and left radial pulses. (6) The force required to obliterate them (tension). (7) Abnormal thickening of the artery (arterio- sclerosis). (8) Correspondence of radial rate and rhythm to the auscultatory findings. (9) Peculiar variations in the character and quality of the beats. When the physician's fingers are applied to the artery the first four points ("size" "rate," "rhythm" and "force") are determined almost unconsciously and instantaneously, the vessel being lightly rolled under the finger to get its size, which for the most part represents its "tonus" or state of contraction and not the force or efficiency of the beat. Pressure is then made with the upper finger until the pulse is lost to the lower, the force exerted being a rough and unreliable, yet extremely useful, measure of arterial tension. The artery, thus emptied, is rolled under the lower finger to detect any thick- ening of its walls (arteriosclerosis) and any vessel that can thus be felt as a distinct tube when collapsed is sclerotic and hence abnormal. Such vessels may be just palpable as a tube, definitely thickened, distinctly rigid, furrowed transversely and rigid, or carry multiple tiny plaques or beads of deposited lime salts. THE RADIAL PULSE 489 Determining the Rate. — It is ordinarily sufficient to count the pulse for thirty seconds and multiply by 2 to get the rate per minute, but in severe ail- ments or if any abnormalities in rhythm, quality, or force be present, it should be taken for at least one minute, and, if excessively rapid, it may be necessary to count each second or third beat only and apply the proper multiplier. Not infrequently, especially in myocardial degeneration, coronary sclerosis and certain valvular lesions, some systoles are premature and inefficient {extra- systoles), and though readily auscultated, may yield no pulse wave or a very feeble one. In such cases nurses' pulse records are often worthless with respect to actual cardiac beats. Nurses should be instructed with relation to the com- moner types of intermission and irregularity. The Recurrent Pulse. — This is one which cannot be cut off by the pressure of the upper ringer because of an unusually free communication and recurrent flow from the palmar arch. The difficulty may be surmounted by making obliterative pressure with the lower ringer and carrying out the usual pro- cedure above, or by compressing the ulnar artery. Unilateral Variations. — A student frequently jumps at faulty and far- fetched conclusions if he finds an unilateral weakening or absence of the pulse. Either finding may or may not indicate deficient heart strength, but is ordinarily due to an abnormal course of the radial artery, or, more rarely, to actual blocking of the vessel, to aortic aneurysm, cervical rib, or to pressure of new growths. The findings must be always checked by comparing the larger arteries, such as the brachials of the two sides. In aneurysm of the ascending portion of the arch involving the innominate, the right radial and carotid may be affected ; in aneurysm of the descending aorta, the left radial; or a delayed pulse may accompany aneurysm of the trans- verse portion. Direct sac pressure upon arteries abnormally constricted, deformed arterial openings, or the complete or partial conversion of inter- mittent into what may appear to be a continuous weakened pressure by the aneurysmal sac, make many variations possible, aside from those caused by adhesions due to associated perianeurysmal inflammation in certain cases. Too much reliance should not be placed upon this as a sign of aneurysm, as it is often lacking or without exact significance. In obscure chronic cases in which pain is present in the lower extremities upon exertion, whether cramp-like, rheumatoid or paroxysmal, the arterial pulse should be taken in the dorsalis pedis and posterior tibial arteries. Such pain is often due to obliterative arteriosclerosis and vasomotor spasm (intermittent claudication) or may be associated with Raynaud's disease and always demands a careful examination of the heart and kidneys. A full, bounding pulse is frequently mistaken for arterial hypertension because of faulty technic. Arterial hypertension may be detected by the finger in many instances, but correct determination requires the use of special instruments.* * No excuse remains at the present day for dependence upon the fingers for the estima- tion of blood pressure. Most humiliating errors are sure to occur if the unaided senses are employed Proper methods. Useful device. Lost beats. Vitiated records. Often trivial. Sometimes important. Important inferences. Importance great. A common error. 49° MEDICAL DIAGNOSIS Fingers may fail one. Rate readily affected. Erect posture. Important sign. Danger signal. Persistent rapidity. Infancy. Childhood. Maturity. Tachycardia. Auscultation is of course often necessary to reveal the true rate and rhythm of the heart beat and in certain cases of paroxysmal tachycardia pulsus, alternans, or auricular flutter, instrumental determination alone yields strictly accurate results. PULSE FREQUENCY.— Exertion and Attitude.— Aside from mental excitement, the digestive process and bodily exertion, which latter includes even the changing of the posture in bed or evacuation of the bladder or bowels, the position of the body affects the pulse rate. In the erect posture the rate is from 10 to 15 beats faster than in recum- bency. (This variation was formerly believed to be due to rise in arterial tension, a theory exploded by the fact that the sphygmomanometer shows but trifling variations in systolic pressure and that often downward. Increased intra-abdominal pressure is undoubtedly a factor in many postural changes.) The significance of an abnormally great increase of rate upon slight, unusual exertion, unattended iy excitement, is very great inasmuch as it clearly indicates cardiac weakness and a limitation of the field of response (reserve). In cases of profound cardiac weakness such a maneuver frequently develops coincidently a suggestive subjective or objective dyspnea or substernal or epigas- tric distress. Congenitally asthenic individuals with their narrow hanging ("drop") hearts show a remarkably labile heart action during periods of nutritional depression especially if, as so often happens, the atonic myocardium is actually dilated. Alcohol, tobacco, the coal-tar products, arsenic and other toxic sub- stances used in excess, may occasion a persistent lability and increase in rate, and cachexias, hyperthyroidism and especially incipient tuberculosis should also receive attention in this connection. Age. — The average normal rates are for the first year of life from 130 to 140; gradually dropping from the first to the fourth year to 105 or no, and so diminishing until at the fifteenth or sixteenth year it reaches from 75 to 80 beats per minute. During middle age and up to sixty years frequency is slightly diminished, sometimes increasing somewhat beyond that age. Sex, — Women show a rate which averages 5 to 8 beats faster than men, and it is slightly slower in tall than in short persons. - Fever with Increased Pulse Rate.- — Any decided persistent increase in pulse rate, lacking obvious cause, demands the use of the clinical thermome- ter and we find that, as a rule, the rate increases from 8 to 10 beats per minute for each degree Fahrenheit above the normal, and further that the behavior of the pulse in fever is of both diagnostic and prognostic importance.* In general an increase in the rate out of correspondence with the rule given suggests profound toxemia or diminished resistance to the disease and 'con- stitutes a danger signal. In those few diseases in which the pulse rate should be lower than the rule, excessive rapidity has still greater significance. In fever a relatively rapid rate is of far less significance in the child than in the adult. * See "Fever." THE RADIAL PULSE 4QI Slow Pulse. — High temperature and relatively slow pulse are observed espe- cially in tubercular meningitis, typhoid fever, and lobar pneumonia as well as in febrile ailments associated with some of tie organic causes of slow heart, such as coronary sclerosis, myocarditis, aortic stenosis and especially u heart block." Rapid Pulse. — A rapid pulse occurs in many non-febrile ailments, most markedly in exophthalmic goiter, and may be decided in the decompensatory stages of mitral stenosis and insufficiency, myocarditis, aortic insufficiency, acute endocarditis, pericarditis, and the pressure displacements of the heart. Paroxysmal tachycardia, alternation, auricular flutter and delirium cordis furnish striking examples of the special types of rapid pulse. An excessively weak, thready, rapid "running" pulse associated with marked evidence of cardiac weakness is a forerunner of death in certain diseases and may represent auricular flutter or alternation. Tachycardia. — {"Swift Heart"). — Mere excessive rapidity is known as tachycardia, and as used alone this term should be strictly limited to the pulse free from irregularity, intermittency, inequality or paroxysmal rapidity. Scarlatina and Tuberculosis. — In children an excessively accelerated pulse may suggest the onset of scarlatina before the appearance of the rash, and in incipient pulmonary tuberculosis a labile and persistently overrapid pulse is one of the most constant of the early signs. Various Factors. — In nearly all cachectic states weakness, acceleration and lability are present and it is an important confirmatory sign in severe shock and collapse. Aside from these must be considered sexual psychas- thenia, the overuse of snuff or tobacco (often associated with palpitation or sinus arrhythmia), physical and mental overstrain, and idiosyncrasy. Palpitation. — The term tachycardia covers most of the cases commonly described as " palpitation,' ' the heart action being in such cases quite normal save for a rapidity which seldom exceeds 170 beats per minute (Mackenzie), and showing no abnormalities of origin or transmission, when subjected to analysis with instruments of precision, unless it be an occasional extrasystole. In such cases the attack subsides gradually and excitement, radical changes of posture, and physical exercise markedly affect the rate. Bradycardia. — (Slow Heart). — Pulse below 60. A slow regular pulse may be congenital and physiologic, but most of those thus described have subsequently been proven to be due to heart block, chronic toxemia or or- ganic disease of the heart or brain, the latter being associated with increased intracranial pressures. Indeed any regular pulse under 50 usually indicates "heart block," i.e., blocking of certain of the impulses normally passing from auricle to ventricle through the "bundle of His" or in cases of extremely low rate, a complete block and dissociation of auricle and ventricle. The lesser degrees of slowing may be met with as toxic effects of various drugs, in aortic stenosis, chronic myocarditis, coronary disease, cerebral hemorrhage or tumor, meningitis, epilepsy, general paralysis of the insane, melancholia, mania, myxedema, pituitary disorders, jaundice, uremia, exhausting disease and sometimes in acute ailments, especially diphtheria Relative slowness. An ominous symptom. Seldom physiologic Significance of excessive slowness. Often partial "heart block-.' Many and varied con- ditions. 492 MEDICAL DIAGNOSIS Danger signal in which, no doubt, undeclared myocarditis and heart block are chiefly accountable. Abrupt Transition to Bradycardia. — As regards its occurrence in acute infections during either the active stage or convalescence, the rule may be laid down that any sudden and decided drop below the normal or usual rate, unless associated with crisis, is quite as much, if not more, suggestive of danger and need of special watchfulness and care as would be excessive rapidity. Toxemia, intracranial pressure and actual disease of the myocardium or bundle of His are therefore chiefly to be considered as its causes. Slowing of the heart may occur in connection with rapidly induced arterial hypertension. This fact is strikingly illustrated at times in cases of acute nephritis or the onset of uremia. Sinus Arrhythmias. — In sinus arrhythmia there is irregular spacing of the beats and by instrumental methods one discovers that this irregularity arises chiefly from a shortening of the diastole rather than of both the phases of the heart's cycle. With excessive increase of rate this irregularity disappears, with slowing it may reappear. Such sinus irregularity is recognized by a labile periodically shifting pulse rate, quickening with inspiration and slowing with expiration, but showing no inequalities of force in the individual beats. The variation in the diastolic periods is determined readily in many instances by auscultation, when difficult to recognize in the pulse (Mackenzie). As a matter of fact if one applies the finest and most careful measure- ments to electrocardiographic records some variation in the spacing between the diastolic periods can be detected in almost every record. By ordinary clinical methods these are not determinable nor is the matter one of importance. Syncopal attacks occur occasionally in this form o! tachycardial irregularity. The condition may persist for years but is rarely encountered after the age of 30. Quite recently in the case of a youth showing a frank myocardial decom- pensation with septic tonsils and an ethmoiditis, sinus arrhythmia alternated with short periods of fibrillation. It is usually of slight significance, but one cannot follow James Mackensie in regarding its (frequent) presence after an acute illness as evidence that the heart has escaped infection. It may be assumed, however, that the toxemia has affected the myo- ardium but slightly and may thus constitute indirect evidence of no serious amage. Either simple tachycardial "palpitation" or " sinus irregularity" may be the source of much discomfort and quite unnecessary alarm. Unfortunately the most serious forms of pulse irregularity may give rise to a similar condition and the reader should refer to " extrasystolic irregu- larity," " fibrillation, " "flutter," and "paroxysmal tachycardia" as de- scribed in the succeeding section. THE RADIAL PULSE 493 Serious error may result either from an overestimation of the gravity of a simple tachycardia or sinus irregularity, or careless disregard of the fact that "palpitation" arises also from some of the most serious cardiovascular conditions. In simple palpitation fear of death is readily excited by the curious sub- jective manifestations of precordial, "bumping," "thumping," and "turning over," of the heart, but the curious inward conviction of impending death sometimes experienced even in miniature replicas of angina pectoris is seldom present. IRREGULARITY AND INTERMITTENCY.— These conditions are de- scribed fully under the "arrhythmias." Irregularity includes variation in volume and strength as well as in wave intervals, though the former are better described by the term "unequal" By intermittency is meant the apparent or actual omission of beats. The stethoscope and more fully the polygraph or electrocardiograph show that intermittency may be due either to premature and inefficient extra- systoles or the " dropped," systoles of partial heart block (" pulsus deficiens "). " True pulse intermittency" therefore, would apply only to the phases of recurrence of inefficient or dropped beats, which result in the transient, persistent or irregularly recurrent actual elimination of pulse waves in the arteries. Fig. i 86. — Pulsus Irregularis Perpetuus. Two radial tracings taken during auricular fibrillation. Note extreme irregularity in time and force alike. (Drawn from the original tracing of Parsons-Smith.) If an extr asystole is of sufficient vigor to cause a lesser beat in the arteries there is established during the period of recurrence what might be termed a regular irregularity and inequality with respect to the phases in which it occurs. For the usual type of extrasystolic irregularity, as it is reflected in the pulse, the term "interrupted pulse" would apply more aptly. The fundamental cause (extrasystoles of the heart) may therefore be expressed by either an intermittent or irregular radial pulse. In the absence of definite clinical findings their significance is far more serious in middle-aged, or elderly people than in the young and both varia- tions admit of subdivisions. (See pp. 546 and 549.) "Pulsus deficiens. "Pulsus intermittens. Significance. --- :_z: :. -.: : :-.:-:■ ?:s ::::: . — '"<:..':■ exc e ss iv e frequency [as in "delirium cordis" due to I mmj he transient, variable, persistent or periodic n:_ii i :r::i; :~ :::ei rr:i:r= lie in re: e en -leu ie~ :niiri:.e :y -_le polygraph, or, double or triple beats may occur with a prolonged pause be- i-eei lie Lis: :ei. ::' lie r::.:: Hi lie nei: 5_::ee:li.: :ei: ;:.'::.: una) {pulsus trigeminus), in extrasystolk hregularitv, or, the norma atkm due to deep inspiiation may be so exaggerated as to make the radial puke weak or imperceptible daring inspiiation {pulsus paradoxus)* "Tie ?irii:n: Pulse " — 1m .5 n :s: ilei-enl;. ::=.ervei n ei:eee:ve :i:iii: -Miizesi e = :e::ily : issiiii.ei —111 :!•= ::_: live irrssure = _:! is t :::::: : : ; : 7:.. if -ill nt :.:.:..: m. iiii-i: :: iii_:iii: :.:. : _.:i:. 7 zie iirii:.- :: lir.-re^ .mien :: '::::•'-'•' s:e-:>ii Tie eiiezi; . -;..;• nfe:ez:e :i ii; :i. : : ii litre ensii z:r :n :::.::i::::::.:::::. iir:_lii::- _:/ir i :e5i_-i::r. inr :: r:7i: ' 7.:.f :: z±'ii-iii: zzLiitz in i n lie :: res-en :e : inreniii. leir: iis-tis-e :ii- PuisiiS 7ni_s — Tne nit: in le::e: s: 7i:.i:t5 lie ili-il-lle :: :i:::i: 7 = 7:: :: 1 ~i- :: 1 _iik .: ■: : : si:- rise mi ill Tie fzrner - - :: i:rii: Ins-imiieriry n: .i::e: : " 7 -_ .— :: i::e:. : f :.e: : .-.. ; .:: ^111 17:::.:.: iir:ii r ~i :: ti _i_i :e:i.e Mi- ll- :sis h; 1- THE RADIAL PUISE 495 Monneret's Pulse. — The sieved, soft. Iz-zz^d pulse so often observed in the ::ie~;i :: ;i_r.i::e is s:rie:iries river. '.iis sneni r ii:e :i : u: -.emir.:'.: r/ ".'.- ?_.se - .-: r. -..-:,.-: : .:. v:.:::..:.: Puis is : r_s - - : .r \ "i::e:. ii -.er.s.:r. : .: r.:: srr.ii iii. ~iry Dicrotic Poise. — A re::ii ::'!:— :-* ±e bei: my zf.ei be :ei: rn:re :: iess iir.i- :ily --ir: r:::-e: ::rSS-:e iii iiiiii:es ::iiiiriy :-:-:- ei- iiisii:i :: ::rerri ei:iy -:ei ii :; — "r_ : i i fee: i~i lie ;yii:ii sii.e :u: :f:ei f:ni in ::ie: se e:e ::::::::.:: einiisiir. b.s-e.i.s.es :: i:.:-i sorts, and, very rarely, in apparent health after severe exercise. Tie iimiry 7 _i = r — .. : .' ; ':: ; •■'•■■ /•/;:.. :v :;/:.":-;. ;;,i ;.;',/*', It is a rhythmic blushing and paling which may be observed over iiinam- !| Hi::: i : : lie 1 ire :-:. 11 : r. ~ lining Izz: : :t: = ire : v: lies: eirs e:: by reiienbig lie siii :y ::.:- 1:1 iir i ziiss siie :r eve- lie rir ::' i z : : i - : ni«:i lie riie ::* lie ib-s iis :iyiir :srllli:dr_z b:rier is reiiiiy :■: ... lie ;t ... ■'. ir:erie^ :y :-e s "jrri lien liy eiubei ii lie -•: ::' lie ::i:.ii.im 5 : :: - It is a valuable confirmatory sips, of aortic insufficiency but may also be :::{'■:■ i :-; -:::c : :.; ';:>::■; :::■:•:■'. :;; : ;.:";:i 1:;'; ; ; ;.>/;:/ :';■-■'.: :-:-:z:-. ::.-/: ://>.:". ;-:•";: '::::...; :;:""-;:; :-:•; ;::,.;-: : ; :'"";;" ; ;:;f.;. Its associations are essentially those of the '"pulsus cder" and it is MMsiir-iiiy ::scr."ri in r t r 5 : r. s iiiireniy in r::i ieiin Tie lime: :•: de-bleb •liysiiiiri: iirilbiry : ■ -t instE seei :y lie iiii:: ms s:eiviiy iiziiiisiei since 115 iisiivery ::' lie fii: im: i sin: semi -:n: — iii 11 irei ::' iibmry iirmei :: lie liiri iei: mersime rsiiiiy :eiresei:s miiiei: i::i: ieiiire 11: ::e:e:es :y i Linger :: simer re:::: lie appearance of a distinct diastolic aortic murmur. i: ::::.; .11:.::: irrireiiy ::; ; .i::.: lie me:. : m mry reiixi- 1:1 : :t -i : :::e ::' ei: :.: y ::' rirrei: ie:essi:y : : r : : me e: : rr :r : r t:t:: ..:e ~: :: in :re ririiliriets ire linrrririe :: i mi5£ei iy;r:- * - ~ : : ir~. Tie Buirre in Pnise Terrnin:i:ry. — Tie :e:n is i :e- :: i:rr .nes "^ien men sniiri lie rnis-e mrre :it utt:: :in — e miens i: ~. iii li lit reniemeirs :: :r5ri::r ryui: i: : _r 5err:e I: ins i rinre ii lie :ini: ievenieie ::' r-re free i::::: :er_:rvn:i ~.:r. ::s surr = :.: :e: :.. ::: ::. :ie ±:.z-: 496 MEDICAL DIAGNOSIS Indurative mediastinitis Rare phe- nomenon Rare form. Instances might be multiplied if one were to quote from the works of the older clinicians and the aptness of many of the descriptive terms together with their multiplicity, is good evidence of the possibilities inherent in the tactus eruditus as applied to pulse-taking. VENOUS PULSATIONS "Diastolic Jugular Venous Collapse." — This is now regarded as a weak, unsustained, positive venous pulse, but the collapse is particularly marked in "adhesive mediastino-pericarditis" and is rendered more striking by the diastolic recovery of the chest wall, which has been dragged down by the ventricular systole of a greatly enlarged and adherent heart, associated with diastolic intrathoracic suction (Friedreich). Positive Penetrating Venous Pulse. — Very rarely and usually in associa- tion with the "capillary pulse'' a wave may be observed in the terminal venules. Compression causes central obliteration of this pulsation but does not affect the peripheral portion. Visible Respiratory Venous Phenomena. — The swelling of the veins of the neck during violent muscular straining or sustaining a musical note is common form, familar to every one and it is seen in all forms of severe dyspnea, whether temporary or permanent. In chronic conditions the overdistension may become permanent and, occasionally, the usual inspiratory diminution and expiratory fullness is reversed, in which case indurative mediastinitis, chronic pericarditis, aneurysm, or any form of mediastinal tumor is suggested. If forced expiratory movements, with the mouth and nose closed, show overfilling of the cervical veins upon one side as compared with the other, intrathoracic venous compression is suggested. Carotid vs. Jugular Pulsation. — Students often find difficulty in distinguish- ing between venous and carotid pulsation; the former covers a wider area, is undulatory and collapsing in character, and obliterative pressure upon the carotid does not affect it. Proper Posture. — The patient should be in the dorsal position with the head raised, supported by a pillow and turned well to the right, when in about 75 to So per cent, of all cases the pulse will be visible. If distention of the veins prevents visible venous pulsation the head and shoulders must be elevated until the pressure is modified sufficiently, if this be possible. Much maneuvering and many shifts of position may be necessary to secure results and these should be carried out with the least possible effort or psychic disturbance on the part of the patient. Very little exertion or excitement, for example, may suffice to remove an extrasystolic irregularity or other interesting subsidiary findings. INSTRUMENTAL METHODS The True Value of Instrumental Methods of genuine Facilitate Research. — The use of the fascinating and delicate instrument clinical value. . ...... .. . .. . ,. . , ,,ri of precision in the investigation ot cardiovascular disturbances has bee THE SPHYGMOGRAPH 497 of incalculable value in advancing our knowledge of cardiac physiology and in the clinical field the newer methods have clarified many obscure conditions and added much of real value to the resources of the clinician. The author feels strongly that with respect to the electrocardiograph we may hope that present achievement, remarkable as it is, represents but a part of its capabilities as an aid to clinical research. He now regards it as of very great value in detecting conditions of genuine importance with relation to both diagnosis and treatment such as cannot be demonstrated without its aid. Necessary Training. — It is proper and necessary that every earnest student of medicine should know the instruments and, so far as possible, the methods of modern cardiac research, fascinating alike to eye and mind. If possible he should be accustomed to their use so far as to enable him to translate readily the simpler forms of the graphic records which they yield, or, if time and opportunity offer, become sufficiently expert to take up research along this most fascinating and attractive line or even use them clinically to his advantage and that of his patients. Their value, especially in the early diagnosis of myocardial lesions, is extremely great and it is to be regretted that as yet neither the electro- cardiograph nor even that simpler instrument, the polygraph, can be utilized widely by the general practitioner. Simpler Methods Usually Adequate. — He should realize nevertheless that the major part of the clinically important circulatory phenomena registered by modern recording instruments may be recognized and interpreted by the simpler means of ordinary clinical technic, if this be founded upon an adequate knowledge of modern cardiac physiology and pathology. Useful but'not essential. Fig. 187. — Marey's sphygmograph. Now nearly obsolete, because of its slight value and the far greater usefulness of polygraphic tracings. It was never a satisfactory instru- ment. Fig. 188. — Ideal radial sphyg- mogram. b.c, percussion up- stroke; b.c.d., percussion wave; d.e.f., tidal wave; g., dicrotic wave. Without desiring to lead his readers to overvalue instrumental methods or to obscure the far more vital and practical aspects of clinical technic by a needless elaboration of graphic procedures, the author feels that a brief and simple reference to the chief of certain instrumental methods properly may be attempted. The Sphygmograph and Sphygmogram. — The sphygmograph, of itself and apart from its combination with other recording apparatus, is an instru- 32 49 8 MEDICAL DIAGNOSIS Replaced by polygraph. ment of some slight value in connection with pulse-taking, yielding, in certain directions only, more important information than may be derived from touch and making, if desired, a permanent record, but the relation of time lost to information gained and the large elements of error inherent in the technic make impossible its general adoption in private practice. It has now been almost wholly superseded by the polygraph which has been elaborated to an extraordinary degree and has thrown a flood of light upon the genesis of cardiac irregularities and the pathologic phenomena of the heart cycle. The arterial pulse tracing represents the systolic and disastolic variations of intra-arterial pressure as registered by the expansion, retraction, short- ening and elongation of the elastic artery. In the case of rigid arteries the vessel itself may also move as a whole, as in the case of tortuous sclerosed temporals or brachials under high pressure or associated with aortic regurgitation. The rhythmic change of size and position of the artery itself is very slight normally, but sufficient to impart to the tambour of a delicate recording instrument the tidal wave of pressure generated by each systole which reflects to a remarkable degree certain important events of the cardiac cycle. The analysis of all sphygmo graphic tracings depends upon a thorough understanding of that oj the normal pulse. In this we recognize an anacrotic or ascending limb which at its summit or apex becomes the katacrotic or descending limb, the latter being divided into two chief waves, the higher being tidal or predicrotic, the lower the recoil or dicrotic wave. Between these two elevations on the descending limb is a hollow representing the aortic closure. The apex height shows the maximum excursion, the two secondary elevations on the descending limb the reactive contractions of the artery. These phases will be readily recognized in the ideal radial tracing shown on Fig. 188. THE POLYGRAPH. (Sphygmocardio graph) Principles Underlying Its Mechanism. — All of the simpler instruments depend upon the same general principles. A clockwork mechanism or small motor is employed, by means of which a roll of specially cut paper is passed at any required speed under a stylus or pen attached to a lever operated by delicate tambours, which, through rubber tube connection with the jugular and radial terminals (E and C), transmit and record the impulses. Some form of time marker graduated to two-fifths of a second should also be included, and several of the instruments are capable of registering three tracings of different origin simultaneously. The spring lever type of recorder may be used for the radial and a special receiver over the heart itself. The simultaneous records of greatest use and value are those of the venous and carotid pulse and to obtain these the patient is placed in the dorsal THE POLYGRAPH AND POLYGRAM 499 position, with the head slightly flexed, turned to the right* and resting upon a small pillow and should retain the posture for several minutes before record-taking is attempted. If the venous pulsations are not evident in the jugular fossa because of overdistension of the veins, it may be necessary for the patient to sit up before they can become manifest. In some cases of phlebosclerosis or extreme venous pressure no proper record is obtainable. Technic. — Ordinarily the venous pulse is evident and the proper receiver is placed over the jugular bulb in the interval between the two heads of the Jugular bulb. Fig. i 88. — Mackenzie ink polygraph. This instrument records two simultaneous tracings only, i.e., radial pulse and one other, such as carotid, jugular, apex beat, etc., the great advantage being the avoidance of smoked paper and the convenience and permanency of the ink tracings which may be continued almost to any length from the long roll of paper supplied with the instrument. The instrument need not be attached to the patient's wrist and by many is preferred because of this feature. The clock work operates at varied and controlled rates, permitting the taking of protracted records at different speeds. The original instrument was invaluable, but Dr. R. Edwin Morris has improved greatly the con- trol of the paper strip, increased the ease and accuracy of tambour attachment and adjust- ment, and, furthermore, has made possible a delicate, independent and accurate control of the pens, through various ingenious devices.* sterno-mastoid, just above the right clavicle, and such light pressure is permitted as is just sufficient to secure exact contact and exclude the air. The proper receiver is then placed firmly over the carotid which is easily palpable just at the inner edge of the sterno-mastoid when the head is in I proper position for the venous tracing, i.e., turned to the right. tracings!" The tracing of the venous pulse of course represents right auricle effects but tracings representing the left auricle may be taken by introducing into tracings. * See "Modification of Mackenzie Ink Polygraph." R. Edwin Morris, Teaching Fellow, Medical School, University of Minnesota. Jour. A. M. A., June 17, 19 16, vol. bxvi, p. 1922. f Almost all patients instinctively turn the head to the left unless watched and checked. 5oo MEDICAL DIAGNOSIS the esophagus to the distance required, a stomach tube capped by a rubber bag and connected externally to a suitable tambour and writing lever. This method is ingenious but not of much practical use in clinical work by reason of the nausea and retching usually induced. Crehore registers both heart sounds and the events of the cardiac cycle by means of an ingenious apparatus termed the micrograph. It is valuable in cardiac research but too elaborate and time-consuming for clinical use. Fig. 190.— Portable polygraph, with continuous roll (20 meters) of smoked paper. This instrument consists of an accurate clock movement imparting two speeds to the paper, a time marker recording in one-fifth seconds and three recording tambours, each of which may receive impulses from three different parts of the body for simultaneous tracing. The in- strument thus answers the purpose of a kymograph and is valuable for many purposes because of its extreme portability. The same instrument is furnished with a mercurial syphgmomanometer indicating blood pressure and a cuff writing attachment. In this arrangement of the instrument one of the tambours must of necessity be used for recording the tracings of the brachial pulse under various pressures, while the other two tambours may be used to record any other two tracings such as the radial, jugular or carotid pulse, apex beat, respiratory movements, etc., under an accurately determinable blood pressure as read in a manometer. The pressure applied to the cuff is transmitted to the manometer and, at the same time, to the writing tambour by means of a rubber bulb enclosed within a glass bulb, or Erlanger capsule. {Courtesy A. H. Thomas Co.) There are many other special devices of extreme ingenuity and varying usefulness but none of them demand a full description here. The Interpretation of Venous Tracings. — A venous tracing remains a thing of mystery until the simple technic of correlating simultaneous records of different forms and sources is explained. Having fitted the receivers to the proper areas for receiving and recording simultaneously venous and carotid tracings, one first tries the excursions of the levers which should be at least 5 mm. for the venous tracings. The position of the two recording points initiating the record should then be distinctly indicated upon the paper by exaggerated sweeps of the pens and the record taken by running a series of short tracings. The measurements THE POLYGRAPH AND POLYGRAM 501 accessary to the marking and interpretation are facilitated by the use of short runs. The longer the record the greater the opportunity for error. (See Figs. 192 and 193.) The purpose of the venous tracing is chiefly to establish the presence and normal relation of the three chief oscillations, i.e., waves "a," "c," and "v." Their place in the tracing may be definitely established by comparison with the carotid tracing in the light of their known relationship to the ca- rotid curves and, of both, to the phenomena constituting the heart cycle. ( • -k| >^H 5r cK^jl r *i^JB ,--# am/a ^jiBi SB s&i »i?ii Fig. 191. — Jaquet sphygmocardiograph. In this instrument one tracing must always be that from the radial artery, over which the instrument is fixed in place, either by means of a cuff as in the older forms, or by means of an arm rest. In the single tambour type, therefore, two simultaneous tracings are made in addition to the chronograph record, i.e., the radial pulse from the pelote attached to the instrument and one other tracing through the single tambour, which may be taken from the jugular, carotid, apex beat, respira- tory movements, etc. In the double tambour type two tracings may be made simulta- neously in addition to that from the radial pulse and the chronograph record. The double tambour type is the most widely used form of Jaquet instrument. Both types are pro- vided with two speeds so that tracings may be greatly magnified by the use of a high speed. The illustration shows the double tambour type with cardiograph attachment in position for recording apex beat and one receiving tambour free to take either jugular or carotid. Jaquet sphygmotonograph. By means of a tonograph attachment to the double tam- bour type of sphygmocardiograph, Prof. Jaquet has provided a means of recording the blood pressure from the brachial artery, under increasing and diminishing pressure, simul- taneously with the tracing from the radial pulse. The brachial pulse tracing may be read in millimeters of mercury by means of a calibrating table accompanying each instrument. By such a comparison of the more or less variable venous tracings, often obscured by wholly fortuitous notches or wavelets, with an arterial record of relative stability of character, one may readily locate its important events in most instances. It is necessary to establish the coincidence of the "c" wave of the venous tracing with the initial rise of the primary wave of the carotid tracing; for a vertical drawn f-rom this latter must intersect the venous "c" :o2 MEDICAL DIAGX F: , 192. — Use of dividers in measuring up on the polygram. (-4 ) First step. ugulax patee. wave which in its own initial rise marks the onset of ventricular systole, but just precedes the actual systolic thrust in the large arte One has, therefore, only to measure on the carotid tracing the distance from the (previously marked) starting or finishing point oj the carotid lever to the starting point of a pri- mary carotid warn, and then lay off ex- actly that distance : the (previously marked) starting point of the venous pulse lever, and he will cut the li c' r wave of the venous trc which should commence its rise just before that of the former. The corresponding point on a radial tracing is attained by an additional allowance of one-tenth second on the an: tracing for transmission. Therefore' exactly the same initial procedure is adopted save that the distance from the starting point of the radial lever to the starting point of a radial wave is laid off and moved to the left one-tenth second of distance as per time marker. One has then attained the same point with relation to the venous "c" wave as in the former example. (See Figs. 192 and 193.) In the author's practice little use is made of the carotid tracing. The "a" wave summit of initial auricular systole precedes the s ::e summit by somewhat less than one-fifth of a second. The "v" wave of protodiastole normally is about two-fifths of a second later than : . THE AURICULAR VENOUS PULSE.— The instru- mental study of the cardiac venous pulse, as distinct from the respirator)- oscillations, which occur in active breathing, has added greatly to precision in clinical diagnosis and the so-called "jugular wave" gives most valuable information as to the action of the auricles with relation to the other events of the cardiac cycle. General Sig- nificance. — The carotid and the venc us pulsations are quite distinct in form and char- acteristic 5 One ; reflects primarily i the systolic contraction of the left inferior, or pumping chamber, the other chiefly represents the effect of presystolic contraction of the automatic pumping reservoir of the right heart (right auricle). -Use : : fividas in measuring up on the polygram. E St: :nd step. THE POLYGRAPH AND POLYGRAM 503 Of the two, the venous pulsation is infinitely the more valuable in instru- mental readings. One most easily recognizes the former by its thrust; the latter, by its collapse. The venous pulse when normal and visible over or near the jugular fossa appears to be a phantom double wave; the first element ("a" wave Presystolic * *3," W8. VC of the polygram) is presystolic as timed by the heart sounds or apex-beat and its collapse immediately precedes the commencement of the carotid pulse. Fig. 194. — Site of election for the application of the receiver used for jugular tracings is indicated by the circle, and overlies the jugular bulb. It will be noted that the veins are shown in black wherever accessible. {After Keith, modified.) The second element, "c" wave, or secondary rise, immediately follows The systoi it, just preceding the thrust of the carotid beat. Events of the Venous Pulse Cycle. — This double pulsation so often visible, in the jugular fossa, higher along the course of the vein, or, in the supracla- vicular fossa over the external jugular, is found to be triple actually, when recorded by the polygraph. The first ("a" auricular) {atrial) wave is, as stated, unquestionably the result or the auricular presystolic contraction, being due either to a return wave to the jugular bulb or to the sudden check interposed by the auricular systole to the venous current. It is absent, therefore, in auricular fibrilla- tion, or auricular paralysis from excessive persistent distention. Nodal extrasystoles occur when the impulse to contraction arises (probably) in the auriculo-ventricular node, not in the sino-auricular node, its proper normal point of origin. A triple pulsa- tion. Genesis of "a" wave. Presphygmic wave. :: - 1LEDICAL DIAGN APEX TRACING CAROTID TRACING RADIAL PULSE TRACING iiilS JQIRICOUK SVSIOIE CLOSmC OUSIOJEi W' HD CD nranutaoK OPENING OF SOIILUKJWS I 'C^SCEKTOFCJWDTlDPytJa: } _. BASCEMTOFIWDUILPtlLSt '_ ojosukeofjmk§i0- aeorvone^iAsiSBi£ YtimjnilJlR V7HVE5 nra vr-:r::-iir : :z::tisti i~: ;:rs; -; :=:: ii>zz*z'=i: :: "C = O7- — ive ii-:e~: nlezof "R." D* =Ta :-.-!:_;: :: -:■: I i-f 7 :::•: :.:: per rf : : : : ~ 1 t iz.z e~i :■: z .z ::: : :-:: ;•-«::_ z ---- zZiLZZ 5_:.t::fi :: :i.e .::: :~ :5:::zi: :•: : ;_ i- e t:::::u- ; r_: s; i::_: :■:•-- lives -:::ii 11: ::_:: :: z'zt i::n. ~: : ::::s:::::i: ^rreri :e :. THE POLYGRAPH AND POLYGRAM .">^0 As a result the ventricular contraction may practically coincide with or actually precede that of the auricles and in consequence a large wave embracing both "a" and "c" may result. Such concurrent or fused waves, a-c, merely show on a tracing as interruptions and variants of the dominant rhythms followed by the '"'com- pensatory pause." The second wave u c" is now known to be a Presphygmic venous wave independent of the carotid beat, starting probably early in the presphygmic period.* present even though the carotid be ligated and aorta held away, and instrumentalb demon- strable in both esophageal and hepatic venous tracings. Indeed its form in the tracing, as obtained with sufficiently light pressure, is entirely diflerent from that of the arterial wave. Its beginning probably represents the time of Genesis of the closure of the tricuspid valve and it precedes the actual carotid pulse by the presphygmic inter- val, i.e., the time elapsing between such tricuspid closure and the forcible systolic opening of the pulmonary valve. t A studv of this wave in extrasvstolic frustrated The wave of . ' . , , * , valvular contractions, i.e., such nasty, weak, and prema- closure, ture contractions as are incapable of opening the Diagram drawn aortic and pulmonary valves though the tricuspid close, shows the truth of this Fig. 196 from actual tracings showing anc j m i tra l mav the variations in records of . the auricular type of venous hypothesis. pulse._ The upper phlebo- -phe third or "v" wave is practicallv svnchro- gram is normal. The lowest . , , ' . " shows the effect of free tri- nous with the second sound 01 the heart, i.e., with cuspid regurgitation. _ Xote closure of the pulmonarvand aortic valves, opening the gradual increase ot wave . . .. %■»■*_•• u v" at expense of the de- oi the tricuspid and mitral and the beginning ot pression "x." (1) The be- diastole.! ginning of auricular svstole. .. .. . (3) The appearance of the Between the "a and the "v waves is. ot pulse in the carotid. (5) The course, a drop in the tracing due to the emptv- closure ol the semilunar. . . . . * valves. (6) The opening of mg ot the veins which accompanies auricular the tricuspid valves. (After diastole which mav be denominated the "x" John Hay. . depression. After the height of auricular systole is attained a drop in jugular venous * It is probable, however, as von Jagic says, that in practice, the carotid pulse is often included in the tracing of this second wave through technical error. t Minute interval of time (0.07 to 0.085 sec.) elapsing between the closure of the mitral and tricuspid valves and the opening of the aortic and pulmonary exits in systole. It is more properly termed the ventricular isometric period. t A second "v" wave (v") is recognizable in polygraphic tracings, but as yet has been assigned no clinical significance. Proto -diastolic "v" wave. 506 MEDICAL DIAGNOSIS pressure results which is reflected on the polygram by the "x" depression interrupted by the "c" wave. Any encroachment upon the "x" depression by the "v" wave indicates a tendency to venous stasis and more rapid and perhaps excessive filling of the auricles. Any of the various pulmonary and cardiac conditions embarrassing the right heart and resulting in venous stasis would tend to cause a widening of the "v" wave at the expense of the "x" depression or " phase." Summary. — The "a" element of the jugular wave corresponds to the beginning of auricular systole in its rise; to the close of auricular systole in its fall and immediately precedes the first heart sound. The "c" element of the jugular wave in its beginning marks the closure of the tricuspid valve and the initiation of ventricular systole. It coincides with the first sound of the heart and just anticipates the carotid thrust. The "v" wave crest very nearly marks the beginning of diastole and coincides with the opening of the tricuspid and mitral valves, the closure of the pulmonary and aortic and the second sound of the heart. See Fig. 194. Registration of the Venous Waves. — It is evident that if the venous pulse events and those of the carotid or radial are registered simultaneously in graphic form, one may draw conclusions of great value with regard to irregularities and conduction, as well as heart strength. Lack of balance between the venous and arterial circulations and variations in heart strength are often clearly shown. Scope of Methods. — Such registration is now readily obtained by means of any one of several polygraphs and, in fact, the heart sounds and the direct action of the auricle as well as the electric "action currents" of the heart, can also be graphically represented by means of special instruments of precision. Decided Limitations. — Special training is necessary to accurate results with such instruments and this fact and the time consumed in the necessary procedures will confine such work largely to the research laboratory, teaching hospital and, possibly, the consulting room of the specialist. MARKING AND INTERPRETATION OF THE POLYGRAM Systematic Procedure Indispensable. — It is absolutely necessary to proceed in a systematic and orderly manner in the marking and interpreta- tion of a polygram. (See Figs. 192, 193, p. 502.) Technic of Marking. — The only instrument necessary to the marking is a pair of needle-pointed dividers. Inasmuch as these are permanent records, mark the name, date, and special circumstances surrounding the taking of the record, i.e., whether following exercise, special medication, accident or injury, association with painful seizures, syncopal attacks, etc. Also mark the radial and jugular tracings, indicating the side used. It matters little what particular system is adopted. The one in use in the author's clinic is outlined below and has proven fairly satisfactory. MARKING AND INTERPRETATION OF THE POLYGRAM 507 i. Determine the " c" wave from the radial record by measuring the distance from the beginning point to the first point of rise of any radial thrust. Lay off this same distance on the venous record from its beginning point. That wave occurring J-fo of a second earlier is the venous "c" wave of that corresponding heart cycle. Mark the "c" wave in at least six consecutive heart cycles, in the same manner. (See page 502 for details.) 2. Determine the "a" wave. This is the definite wave preceding the "c" wave normally by ^ of a second or less. 3. Determine the "v" waves. These are normally the only remaining waves of importance and lie approximately midway between the "c" wave and the "a" wave of the following heart cycle. 4. Determine the nature of extrasystoles if they occur. (Detailed descrip- tion to be given later.) 5. If the "a" wave is absent look first for the presence of fibrillation and, if found, label the fibrillatory waves "f," "f," "1" 6. Determine the rhythm. With the presence of extrasystoles or fibrilla- tion the arrhythmia itself is apparent at a glance. To determine sinus arrhythmia measure the distance between the tops of any two radial thrusts and make comparison with several other similar intervals. A variation in these intervals, in a record otherwise normal, indicates sinus arrhythmia in its varying degrees. The pulse rate is markedly affected by respiration, being increased by full inspiration, and decreased by full expiration. It is wholly abolished by vigorous exercise. Fig. 197. — This record shows an extrasystole of auricular origin at a'-c'. There is no compensatory pause. In this patient the conduction of the premature stimulus is unduly delayed, the a'-c' interval being almost two-fifths of a second. The diagram shows the relative incidence of the systoles of the auricles and ventricles. {After John Hay.) 7. Determine the "a-c" interval. Lay off the distance from the beginning of the "a" wave to the beginning of the "c" wave. Compare this with the time-record. The normal does not exceed 0.20 sec. 8. Determine the rate. The time is recorded by the " marker" in fifths of^a second. Fifteen spaces on the time-record is equivalent therefore to 3 seconds. From the top of one of the radial thrusts lay off a 3-second interval (15 spaces on the time-record) and count the radial thrusts during that period; then lay off another consecutive distance of 3 seconds and continue the count. The result is the number of heart cycles in a 6-second ;o8 MEDICAL DIAGNOSIS interval as recorded by the time-marker. Multiplying this by 10 gives the rate per minute. Special Conditions. — Extrasystoles. — Extrasystoles may be (i) auricular, (2) ventricular, or (3) nodal. Sinus arrhythmia has already been dealt with. 7M. Fig. 19S. — In this record an extrasystole. originating in the ventricle has occurred before the normal systole of the auricle a\. Xote that in this case there is no ventricular systole resulting from the auricular systole «i, the a-v bundle apparently refused to con- duct the stimulus. Xote absence of K v" wave immediately after extrasystole. The downstrokes in the upper space "As" of the diagram indicate auricular waves "a" in the jugular pulse: the downstrokes in the lower space w vs" indicate the carotid waves • - c" in the jugular tracing, the slanting lines connecting them give the "a-c* 1 interval. {After John Hay.) 1. Auricular extrasystoles show a premature contraction of the li'hole heart indicated on the record by an abnormally early occurrence in diastole As <1-C V* T s i; v^: Fig. 199. — Simultaneous records of radial and jugular pulses. Three extrasystoles are recorded at "o." "p" and "o" in the radial tracing. The rhythm of the auricle is regular but the ventricle contracts prematurely as is obvious from the radial tracing. The post-extrasystolic pause is fully compensatory and lasts three and-a-half fifths of a second. "a" = auricular wave, "'a:" = the auricular wave associated with the extrasystole. The diagram represents the events in the latter two-thirds of the above record. (After John Haw) of the "a" and "c" waves, with a corresponding early appearance of the radial thrust. This is followed by a lengthened diastolic interval represent- ing less than two heart cycles in duration as measured on the radial record. MARKING AND INTERPRETATION" OF THE POLYGRAM 509 j. Ventricular extrasystoles are premature contractions originating in the ventricle and show (a) unaltered auricular rhythm, (b) a premature systole S To7 V4 Fig. 200. — Simultaneous records of the jugular and radial pulses. Shows four nodal extrasystoles. The diagram gives the sequence of events as shown in the jugular tracing. Note (1) that both auricle and ventricle contract prematurely; (2) that there is a full com- pensatory pause: (3) that the wave "v" is greatlv diminished after the extrasvstoles. r John Hay.) of the ventricles either preceding that of the auricles or simultaneous with it, and (c) complete compensatory pause, i.e., equal to two heart cycles. T? a ^ Fig. 201. — Shows three irregular periods due to extrasystoles. At "A ,J a nodal extra systole; during "B" a ventricular extrasystole; and at "C" an auricular extrasysto le (After Mackenzie.) A record in this case would show the regular occurrence of "a" wanes and an abnormally early "c" wave appearing either before or coincidently Fig. 202. — Radial and jugular tracing from a patient suffering from auricular fibrilla- tion. Xote 1 the absence of ""a " waves in jugular tracing; (2) the presence of fibrillatory waves ('fff : 3 the lack of rhvthm of radial thrusts. The slow radial rate is due to digitalis. (After John Hay.) with the "a" wave. In the latter case the "c" wave cannot be differentiated from the "a" but its location is determined bv the usual method. 5io MEDICAL DIAGNOSIS It is to be noted that in ventricular extrasystoles the "a" waves do not occur prematurely and the so-called " compensatory pause" following is equal to two complete heart cycles. Note. — Extrasystoles of ventricular origin in rare instances occur as interpolated beats between two normally spaced ventricular contractions each of which represents a response to normal auricular stimulation. 3. Nodal extr asystole is indicated by the premature and simultaneous contraction of both auricles and ventricles. This is followed by a com- pensatory pause equal to two full heart cycles (called complete compensatory pause). This is indicated on the venous record by an exaggerated wave resulting from and in time measurement representing the simultaneous occurrence and merging of the "a" and "c" waves. C v" ev £r <~ v c~ V ^ V RJ TtR. Rafc= 63 9ZZI Mt.fl.H. Fig. 203. — Mr. A. H. (A) Polygraphic record taken in case of fibrillation in a young adult at beginning of hospital regime. (B) Record in same case 54 days later showing practically normal rhythm at radial, marked improvement in myocardial tone and strength as indicated by the height of the radial. The general absence of "a" waves in the jugular record shows that fibrillation still exists, but an occasional wave in the normal position of the "a" wave is found. R.R. = right radial. R.J. = right jugular. Fibrillation. — Fibrillation is characterized by a total irregularity in rate, force and rhythm of the radial pulse, the absence of "a" waves in the venous tracings, and the occurrence of multiple coarse or fine undulations (fibrillatory waves). Label fibrillatory waves "f," "f," etc. In this condition many impulses are so weak as not to be registered on MARKING AND INTERPRETATION OF THE POLYGRAM 5" the radial record and even less would be detected by palpation of pulse. The more rapid the heart the greater the "pulse deficit." (See page 551.) Block. — Block may be (1) complete or (2) partial. In complete block there is complete dissociation between the "a" and "c" waves together with a slow rate in the radial record. Os 1 jZ-v\ y > k \ V3 Fig. 204. — Increased depression of conductivity producing an arrhythmia. The "a" wave occurs perfectly regularly. Note that the "a-v" bundle requires the whole time of two auricular systoles to recover its conducting power. When this length of time is cur- tailed as in the middle of the record the "a-c" interval A 1 is at once lengthened. The diagram represents the condition present in the above record. The downstrokes in the upper compartment As representing auricular systoles, occur with perfect regularity, with one exception every other systole is blocked. Note the lengthening of the "a-c" interval when two consecutive stimuli pass down the "a-v" bundle. The downstrokes in the compartment Vs represent systoles of the ventircles. (After John Hay.) In this condition the complete block existing in the conducting fibres compels the ventricles to adopt their own slow, deliberate rhythm, causing the occurrence in the venous record of correspondingly few "c" waves. The conduction through the auricles being unimpeded, they respond freely to the 4 J"u«» * Qs Vs H3 Fig. 205. — The record above shows a sudden halving of the pulse frequency. There is no depression of conductivity. The "a-c" interval is normal throughout. Depression of excitability is shown by the refusal of the ventricle to respond to a stimulus normally conducted. The diagram represents the events shown in the jugular record. (After John Hay.) stimuli arising in the pacemaker (sino-auricular node). The result is a preponderance of "a" waves over "c" waves in the venous record varying in degree with the ventricular rate. An auricular rate of 70 might accom- pany a ventricular rate of 40, for example. The lowest ventricular rate 12 MEDICAL DIAGNOSIS reported to date is one beat every 57 seconds, observed shortly before death. In partial block some of the auricular contractions cause corresponding ventricular contractions. There is found a predominance of "a" waves again, but every so often at definite intervals, there is found an "a" wave which has its normal position in relation to the "c" wave. For example, in 2:1 block every other "a" wave is in its proper relation to the "c" wave with the extra "a" wave midwav between these two. Here the auricles are »■ t f >->• r £da 4 a a & c § 4 q a.a a a_<. a< 2 «. Fig. 206. — Tracing showing auricular flutter ' Auricular rate = 24c. Ventricular rate = 60. As ave due to systole of auricle. itr :: 4 : 1. [After John Hay.) 1 block there are two extra waves, all of the "a" waves beating twice as fast as the ventricles. In •"a" waves between two normally placed '"a being the same distance apart. Auricular Flutter. — This is a condition of extremely rapid, rhythmic auricular contractions associated usually with a partial block, and occasion- ally with alternation of the pulse. An associated block may give rise to a 2:1. 5:1. 4:1. or in rare instances, even 6:1 ratio between the recorded auricular *p^Jtyj& *»«.-.* Fig. 207. — Polygraphic curve showing a sinus irregularity during a period of suspended respiration. The arterial curve resembles those found in partial A—V block; the venous curse shows that the auricle participates in the irregularity. The diagram shows the events of the heart upon the hypo thesis of " sino-auricular" block. See Sir:o-auricular Block " — in Electrocardiographic S e : :i o. {After Thomas Ltj. is . and ventricular waves. This condition is accurately determinable only by instrumental methods. (See page 555. Paroxysmal Tachycardia. — This is a condition characterized by a sudden outburst of rapid action of the whole heart and its abrupt termination after a duration of minutes, hours or days. It is usually, if not always, initiated by extrasystoles of auricular origin. Rarely, it is said that these cases are ventricular in origin, v^ee page 559.) MARKING AND INTERPRETATION OF THE POLYGRAM Rhythm. — A record is either rhythmic or arrhythmic. Arrhythmic records are by far the more common and the larger per cent, of these are due to the simple, and relatively unimportant, sinus arrhythmia. Of the arrhythmias due to extrasystoles. the ventricular type constitute the largest per cent. The Venous Record. — The examination and interpretation of the venous record is very important for it reveals some of the earliest signs of myocardial insufficiency. ■n and Character. — Normally the venous record is small and narrow, with its various components small but clear-cut and distinct. A wide exaggerated record with large, disproportioned components is significant of an abnormal condition of the cardiovascular system. In order to deter- mine the condition present, the 'a." "c" and "v" waves must each be examined as to form. size, and general characteristics. —Normally the •"a"' wave is a small rounded wave, smaller than the **c" wave and just preceding it. Its absence suggests fibrillation. Note whether the "a" wave is larger than the "c" wave. If not larger all the time, is it larger than the "c" wave part of the time? Is it a wide, broad w:- ■^aJ>al Fig. :: ; — S imultaneous records of the jugular and radial pulses. In the jugular pulse there is a marked lengthening in r. interval. The distance between the downstrokes i and 3 represents more than two-fifths of a second. This indicates delay in the passage of the stimulus from the right auricle to the ventricle. {After Eerrirgham.) -'_-" Interval. — Normally the "a-c" interval is 0.20 sec. as measured by the polygraph. Any interval greater than 0.20 sec. indicates delayed conduction. Among the conditions found to be associated with delayed conduction are the following: acute and chronic myocarditis, myo- cardial degeneration, decided or profound toxemia, myocardial insiiinciencies resulting from overexertion, acute infectious diseases, etc. The determination of the u a-c" interval is important at all times but especially so when digitalis is being administered, for the sudden develop- ment of delayed conduction under this circumstance usually means over- digitalization. The author's experience with the polygraph and electrocardiograph during the past two years have served to convince him that too little stress is laid upon the importance of minor degrees of delayed conduction such as. do not reach the grade of even partial block, and believes that it constitutes a finding of definite clinical significance and one that demands 33 514 MEDICAL DIAGNOSIS in many instances the most careful and discriminating therapeutic management. This is particularly true of the cases arising in the chronic heart lesions as contrasted with those in which some active and potent infection is demonstrable. In cases of actual heart block, contrary to the usual belief, digitalis may act most favorably in ameliorating the condition provided that other signs of myocardial insufficiency are present in the case. In administering digitalis, however, the author exercises the greatest care not to produce the so-called full physiologic effect, finding that in many instances when this is done a definite weakening of the myocardium becomes manifest. In cases of block especial care is needed, but in his opinion the rule applies to nearly all decompensated cases. The object of digitalis administration in such cases is to aid in removing whatever insufficiency may be present inasmuch as this seems to be a decided factor both in per- sisting delayed conduction, partial block, and complete block alike. "c" Wave. — The "c" wave is usually called the carotid wave. It is a venous wave however quite independent of the carotid heat which it pre- cedes by the "presphygmic interval" (see page 505). Normally it is larger than the "a" wave and is followed by a fairly sharp drop and then by the <<-.>> v" Wave. — There is usually one, and sometimes there are two, "v" waves. An exaggerated "v"-i suggests a tricuspid insufficiency. The Radial Record. — In general the height of the radial thrusts indicates the condition of the myocardium. A good myocardium gives a good radial thrust. Before the interpretation of the height of the radial thrust can be made, however, one must know that the instrument was working properly and that the adjustment to the radial artery was accurately made. This is especially important in cases of weak myocardial strength which frequently give a practically flat radial record. One exception to the above statement is in the case of the "drop" type of heart, for, even with a good myocardium, this heart gives a relatively small radial thrust. Normal tracings show a nearly vertical upstroke of moderate amplitude, moderately sharp apex and a gradual descent, the tidal wave being small, the dicrotic wave low but well marked. Abnormal Tracings. — (a) Broad Apex. This indicates sustained tension and a strongly acting deliberate heart, as in interstitial nephritis, aortic stenosis and aneurysm, or, merely too great pressure on the artery by the pad. (b) An unduly long sharp apex indicates low or unsustained tension^and is especially marked in aortic regurgitation. (c) A short upstroke indicates small volume, as in mitral regurgitation, aneurysm, aortic stenosis, and arteriosclerosis. (d) A long upstroke means free peripheral circulation, sharp systole, or, in general, unsustained pressure. Aortic regurgitation furnishes a typical example. MARKING AND INTERPRETATION OF THE POLYGRAM 515 (e) Excessive obliquity of the upstrokes points to slow filling of the artery and is especially noticed in aortic stenosis, mitral stenosis or regurgitation, arteriosclerosis, aneurysm or a weakened myocardium. (J) A vertical upstroke indicates large blood volumes and quick systole whether strong or weak and is exemplified by aortic regurgitation. (g) A marked tidal wave suggests high tension or actual obstruction as in aortic stenosis or in arteriosclerosis with a strong cardiac impulse. Qt) A diminished tidal wave indicates cardiac weakness, or strength with relaxed peripheral circulation, as in mitral or aortic regurgitation. (i) A marked dicrotic wave points to low tension or to high tension with cardiac weakness. It is best marked in the pulse of typhoid fever. Mr. M*D . • • ■ "V a* ~ y GZZ #$££ ,Zh«. Jw« Jay* R«t*^ 4° F?a^*y v Fig. 211. -Pulsus Alternans. Every alternate wave is small, each pulse'period is of full duration. (After John Hay.) methods, it is a great aid in diagnosis. Its value does not stop here, how- ever, for if employed frequently thereafter it gives much valuable infor- mation as to the progress of the case and the results of medication. It can be of inestimable value in hospital and house cases where the elaborate and efficient office instruments are not available. When used in this way it very frequently gives the first hint that the patient is not doing as well as he is believed to be doing and gives the opportunity of changing the existing regime of the patient before any real harm is done, hours or even days before the ordinary clinical methods reveal the threatening trouble. THE ELECTROCARDIOGRAPH 517 THE ELECTROCARDIOGRAPH Basic Principles. — Whenever a portion of muscular tissue takes on activ- ity it becomes electrically negative with relation to the resting portion. The differences of electric potential thus created (electromotive force) can be measured by the "string galvanometer" when one electrode overlies the active portion and the other the passive area. Plate/LAdjustabieSlit w ^Cylindrical Lens Time Marker Water Bath Condenser -800 Fig. 212 Arc HO _*<_80-— -Essential parts of electrocardiograph, as shown below. Fig. 213. — Cambridge electrocardiograph. Simpler and less expensive instruments are much to be desired and those shown are undoubtedly satisfactory. {Courtesy of the Taylor Instrument Co., Rochester, N. Y.) In the heart we deal with an aggregation of muscular units which become intermittently active, not as a whole, but in a coordinated sequence which especially sets apart in greater or less degree its different chambers and the threshold formed by the junctional tissues of primary conduction. MEDICAL DIAGNOSIS There is created a recurrent flow and ebb of electric potential from one portion to another, each beat of the heart representing a tidal cycle of "meas- urable action current"' which is described technically as a "diphasic" current. Waller first obtained registrations of such human heart currents in 1887, using a capillar)- electrometer and in 1903 Einthoven devised the string galvanometer which forms the basis of the modern electrocardiograph. Essential Features. — As now made, the electrocardiograph is merely a galvanometer to which a photomicrographic projection apparatus with an arc lamp is attached, which registers the deflection shadows of an inter- ^^^r^ ^^^L. 2 "^^yp- ' M^Bl S ■ ^m. m % 1 9 Fie 2 ;_. — New s:~plined and relatively inexpensive electrocardiograph manufactured by C. F. Hi n die. New York City. This is the instrument used by the author and is most satisfactory. Mr. Hindle now puts out a still simpler and less expensive instrument . ; : sed current-conducting filament, of platinum or of silvered quartz, upon a screen opposed to a photographic film moving at any required rate. Sensitivity and Responsiveness. — To secure sensitivity and quickness of movement the filament which conducts the action currents of the heart must be extremely fine (0.002 to 0.003 trim.) and the strength of the magnetic field in which it lies must be maximal. Any electric current generates a magnetic field acting at right angles to the course of the current and exerting attraction and repulsion upon any second adjacent magnetic field. If. there: ere. a : inducting filament is inter- p : sed as in this instance and made to conduct a current it will move at right angles to itself and to the magnetic field, reversing its direction with reversed now of current. The movements of the conducting filament are directly proportional to THE ELECTRO CARDIOGRAPH 519 the strength of the magnetic field and the current passing through the string itself, and, inversely, to the tension of the latter. Extracardial Sources of Deflection.— One must obtain the heart-action current separate and apart from any others, such as skeletal muscle move- ments and the skin current, generated in the body of the patient who, there- fore, must be absolutely still, muscularly relaxed, and breathing quietly. Fig. 215. — New simplified electrocardiograph. (.4. H. TJwmas Co.. Phila.) The rest "current" representing the difference in potential between the two parts of the body in contact with the electrodes, and quite distinct from the "action current" of the heart, is neutralized by passing through the galvanometer, in an opposite direction, a current derived from an accessory batter>-. Skeletal muscle movements create a slow deflection easily recognized as distinct from that of the heart action and, in the case of mere muscular tension, one meets with a characteristic rapid vibration. : : MEDICAL DI Accidental Vibrations, — Irregular rapid vibrations may arise from the passage of electric cars, defective insulation, improperly applied electrodes, loose connections, wireless waves and the induction due to an imperfect arc lamp, but are easily identified. 7::- Fig. 2i7.^LeadIL Fig = ::_ ;:- ;:: — \ :r~~.' ^~i r~::: Lead II shows largest deflections in all phases. (Some or all R summits touched up with widte for contrast throughout section. AH are oleqnal height in original of "lead Q R R = jR R R m ' 2 L *'■ ' Fig. ::;.—] Metasof All non-muscular vibrations persist even when contact with the patient is absent. The coarse slow waves of active muscle movement are distinctive and the finer ones, though simulating auricular fibrillation, lack the distinctive absence of the "P" wave. The Electrocardiographic Leads. — The action of the heart produces THE ELECTROCARDIOGRAM 521 changes of electric potential throughout the entire body and for convenience one use? the extremities for making the connections necessary to tap the cardiac action currents. touring the records three so-called ''leads" are usually adopted: 1. Right arm and left arm. :. The right arm and left leg, the most important lead, but all three are :ry to accurate differentiation and interpretation. 3. Left arm and left leg. The electrocardiogram obtained varies slightly with the lead, one often yielding information not given by the others (see plates). The second lead is the one most generally useful, but in many instances the other leads are of especial value. Choice of leads. Fig. 220. — A diagram representing the .relationship of the heart to the three Leads. Lead II approximates most closely the long axis of the heart, and is the lead most commonly used. After John Hay. Modified.) The Auricular Complex. — In interpreting the electrocardiogram one must remember that it normally represents practically the current generated by a contraction starting in the auricle at or near the sino-auricular node (junc- tion of right auricle with the superior vena cava). This auricular contraction is registered by the electrocardiogram as the summit " P " representing a base negative effect. This is followed by a short "no-current" (isoelectric) phase which may be represented by a horizontal line, or by a slight (base positive) downward dip. The "P" wave probably represents the phase of sinus activity and the spread of the wave of contraction through the auricle. The Ventricular Complex. — The ventricular complex immediately follows and is characterized: Starting point of contraction. 522 MEDICAL DIAGNOSIS i. By the sharp base-negative upstroke instantly followed by a base-positive downstroke, these together forming "spiked" summit "R," which probably corresponds practically to the contraction of the papillary muscles, as it just precedes the heart sound. 2. By a rapidly succeeding descent ("5") which may dip below the line and finally by a slower phase ("T") which presumably represents the terminal phase of ventricular contraction and ends just before the second sound of the heart. Thus it appears that auricular contraction is represented by the summit "P," and that ventricular contraction is expressed by the phases represented by "R" and "T" or to be more exact by "Q," "R," "S" and "T." Fig. 2 2i. — The normal and typical electrocardiogram. Showing nomenclature of Ein- thoven, in common use. {After Mutter.) VARIOUS INTERPRETATIONS OF THE ELECTROCARDIOGRAM. — Among the many conflicting interpretations of the electrocardiogram that of Hoffman is the simplest and clearest, and best lends itself to the student's memory and comprehension of the complicated and obscure phenomena. His hypothesis assumes that the electrocardiogram represents merely the variations in electric potential accompanying impulse conduction rather than the act of contraction. The "P" wave represents auricular conduction; the "P-R" interval covers the crossing of the auriculo-ventricular bridge ("His bundle"); depression of the intervening ("Q") wave marks the phase at which the papillary muscles first CARDIAC ARRHYTHMIAS 523 a.l!i cl$ cl2_ a,4 (1C. 1L Q,i J'\ \J' L U* j l/* 1 U* J »> *7 M' / *±., :~::;=::;zi::^~::==:=== "7 *" 1 / \ n *■-.- EEEEEE^FEzEE^i^EEEEEEEEEEEEEEEE ^ 2 5 ■ 2 \ « = ^ )ex - kCa= Hiari^^v^is Fig. 222. — Time relationship of the apex and carotid beats, heart sounds, and events of the electrocardiogram. (Miiller, slightly modified.) t fl T' D tt I D -X tt -=.-? ^«- P 4* \ tt -.2 5 t ^=V , ^ v-azt *-,^ 5___2 5 12* T^ ■X U 2 „2„ tt £ n - 3 _J tt M -■■■■■■■■■■■■■*." HE E£ U2 B5 HE" US OX Fig. 223. — Time relationships of the electrocardiographic phases. 1. Electrocardio- gram. 2. Heart tones at apex of heart. 3. Heart tones at base of heart. 4. Ventricular pressure. (Miiller. slightly modified.) 524 MEDICAL DIAGNOSIS receive the excitation; the rise of the " R" peak denotes excitation of the bases of the ventricles; the "T" wave denotes the initiation of muscular relaxation after contraction. Wiggers thus summarizes with admirable brevity the various views now held with respect to the matter.* SUMMARY. — The following summary expresses the different interpre- tations that have been given to the different waves: The "P" wave accompanies (a) contraction of auricle, (b) conduction through auricle, (c) activity of sinus region plus conduction through auricle. The "R" wave (rise) accompanies (a) predominant contraction of right ventricle, (b) contraction of basal portions of both ven- tricles, (c) impulse conduction from base to apex of ventricles. The "R" wave (drop) accompanies (a) predominant contraction of left ventricle, (b) contraction of apical portion, (c) conduction from apex to base. The "S-T" interval results from (a) a balance of potential between left and right hearts, (b) a balance of potential between base and apex, (c) a balance between differ- ent layers of the heart, (d) an absence of further conduction because all muscle is already ex- cited and contracting. The "T" wave is due to (a) a change in the position of the heart (Uskoff), (b) a return of the contraction wave to fibers around the aortfr(Gotch, Nicolai), (c) a continued nega- tivity of base outlasting that of apex (Bayliss and Starling, and Einthoven), (d) the contrac- tion of no particular part but the entire expression of the electrical wave accom- panying the contraction of the ventricle (Samojlojf, Straub, Hoffman), (e) a diminution of the intracardial short-circuiting at the end of systole when the ventricle is empty. The "U" wave (not lettered) is a diastolic event, due to (a) the last relaxation of the fibers of the ventricle (Einthoven), (b) the electrical variation of the arteries (Hering). The Phonocardiograph.— By a relatively simple combination of a second galvanometer, microphone, stethoscope, rheostat, accumulator, and a trans- former, simultaneous electrocardiograms and phonocardiograms are obtain- able which are capable of showing both the volume and pitch of the murmur together with its exact place in the cardiac cycle and relation to the events of the electrocardiogram. * "Modern Aspects of the Circulation in Health and Disease," Carl J. Wiggers, 1915. An admirable exposition of the most recent work in this field. Registers time pitch and vol- ume of murmurs. Fig. 224. — Simple apparatus for registration of heart sounds and murmurs when attached to the electrocardiograph. It consists merely in the bringing of a micro- phone into circuit with the string galvanometer. ELECTROCARDIOGRAPHIC RECORDS 525 MARKING AND INTERPRETATION OF ELECTROCARDIO- GRAPHIC RECORDS Systematic Procedure Indispensable. — The absolute necessity for proceeding in a systematic and orderly manner in the marking and inter- pretation of the polygram was emphasized in that chapter. While it is important there, it is even more important in regard to the marking and interpretation of electrocardiographic records. Time Record. — In all instruments the time is indicated in hundredths of a second. In the Hindle instrument, used by the author, it is indicated by main divisions of 0.20 seconds with sub-divisions of 0.04 seconds. General Description of Waves. — The important deflections in the electro- cardiographic record have been arbitrarily designated as P, Q, R, S, and T, waves as shown on page 522. Usually the P-wave is the first upward deflec- tion of the heart cycle. The Q-wave, which is frequently absent, is the first downward deflection immediately following the P-wave and occurring just before the tall R-wave, which is the second upward and the most promi- nent deflection. The S-wave is the second downward deflection and occurs immediately after the R-wave. The T-wave is the third upward deflection, occurs after the S-wave and indicates the end of the cardiac cycle. Follow- ing this is the diastolic period of rest, indicated on the record by a flat line extending to the P-wave of the next heart cycle. (See pages 522-524 inclusive and accompanying illustrations.) The P-wave normally is a small wave 1.5 to 3.5 mm. in height. The R-wave is the tall narrow peak 5 to 25 mm. high. The width of the R-wave or the Q-R-S- interval is about 0.03 sec. The T-wave is normally a low broad wave 2 to 4 mm. high occurring from 0.30 to 0.40 sec. after the Srwave. The length of the diastolic period of the heart following the T-wave is inversely proportional to the rapidity of the heart beat. Technic of Marking. — The only instrument necessary to the marking is a pair of needle-pointed dividers. 1. Indicate the first lead by the numeral I, and follow this by the date, the patient's name, and any special circumstances surrounding the taking of the record, inasmuch as these are permanent records. Designate also by numerals Leads II and III. 2. Identify and label in capitals the P, R and T waves, and the Q and S waves if they be present. Label the positive waves above the line and the negative waves below. (A positive wave is directed upward and a negative wave downward.) In this manner label three or four heart cycles in each lead. 3. Determine the P-R interval. This observation is made first on Lead II and later, if necessary, on Leads I and III merely to corroborate the first finding. To determine the P-R interval place one point of the dividers on the base line at the first point of rise of the P-wave. The other divider point is placed on the first point of rise of the R-wave. The distance between S26 MEDICAL DIAGNOSIS Fig. 225. — Mr. J. B. Electrocardiographic record showing right branch block and an auricular extrasvstole. The extrasvstole occurs in Lead III. ELECTROCARDIOGRAPHIC RECORDS 527 the two is the P-R interval of that heart cycle. This distance laid off on the time record will give its equivalent in hundredths of a second. The normal P-R interval is 0.12-0. 18 sec. Indicate the time length on the record in the proper heart cycle just below the base line. In a like manner determine the P-R interval of the remaining heart cycles of Lead II and label those showing a variation from the first reading if any be present. It is important to measure many P-R intervals, for a record may show considerable variation in them. This variability of the P-R interval in a record is of distinct clinical significance. 4. Determine the rate of .the record. With the dividers lay off on the time record a distance equal to 3 seconds (15 main divisions on time records. Along the tops of the R-waves lay off a 3-second interval from the exact top of any one and count the R-waves occurring in that period. Then lay off another consecutive distance of ? seconds and continue the count. The result is the number of heart cycles in a 6-second interval as recorded by the time-marker. Multiplying the figure obtained by 10 gives the rate per minute. 5. Determine the rhythm. With the presence of extrasystoles or fibrilla- tion, the arrhythmia is readily apparent. To determine sinus arrhythmia measure the distance between the tops of any two R-waves- and make com- parison with several other similar intervals. The variation in these intervals in a record otherwise normal indicates sinus arrhythmia in its varying degrees. Extrasystoles. — Extrasystoles may be auricular, ventricular, or nodal. 1. Auricular extrasystoles show a premature contraction of the whole heart indicated on the record by a heart cycle occurring abnormally early in diastole, the only abnormality evident in the appearance of this heart cycle being some change in the P-wave, which is usually of the inverted type. On the other hand the P-wave may be upright and show a narrowing or flatten- ing, or may be diphasic; that is. showing both an upward and a downward deflection. The diastolic period of rest following the abnormally early heart cycle is lengthened, but is less than two heart cycles in duration (incomplete com- pensatory pause). 2. The ventricular type of extrasy stole is characterized on the record by an abnormally appearing exaggerated diphasic wave; that is. extending both above and below the base fine. It stands out in striking contrast to the rest of the record. Bearing no relation to the stimulation or contraction of the auricles, the ventricular extrasystole occurs with no relation to the P- wave of auricular contraction. It is a premature heart cycle in which the impulse to contraction originates in the ventricles, not in the auricle. This ectopic impulse causes a contraction of (1st) the ventricle in which it origi- nates, and (2nd) a contraction of the opposite ventricle. This asynchronism of the ventricles, while very slight is sufficient to cause an absolutely character- istic electrocardiographic picture, and determine the ventricle, right or left, in which the aberrant impulse originates. One is able, therefore, by means 528 MEDICAL DIAGNOSIS Fig. 226. — Mr. G. D. Electrocardiographic record showing right ventricular extra- systoles and overaction of the ventricles in a slowly beating heart. Left ventricular pre- ponderance indicated in high R in Lead I and deep S in Lead III. Conduction time nor- mal. Slowing of heart due to digitalis. Exaggeration of T-wave shows overaction of ventricles. ELECTROCARDIOGRAPHIC RECORDS 529 of the electrocardiograph to differentiate the side in which the ventricular extrasystole occurs, by the following characteristics. In Lead II a right ventricular extrasystole is indicated by an initial upward deflection, while the direction of the T-wave following is downward. A left ventricular extrasystole is indicated in Lead II by an initial downward deflection, while the direction of the T-wave following is upward. In other words the one is a mirror image of the other. The direction of all waves of the extrasystole occurring in Lead I may be opposite in direction to those occurring in Leads II and III. For example, a right ventricular extra- systole in Leads II and III would, in Lead I have the appearance of a left ventricular extrasystole and vice versa. The auricular contraction being unaffected as has been said before, the P-wave may be evident after the extrasystole or occur during the extra- systole, malforming its contour. Fig. 227. — Lead III. Three examples of right ventricular extrasystole as shown by the electrocardiograph. The pause following the ventricular extrasystole before the occurrence of the next heart cycle is equivalent to two heart cycles, spoken of as a com- plete compensatory pause. 3. Nodal extr asystoles are premature heart cycles in which the impulse for contraction is supposed to arise in the auriculo-ventricular node instead of in the pacemaker, (sino-auricular node). These are indicated on the record by an abnormally early heart cycle normal in appearance with the exception that the P-wave is absent or merely suggested. The compen- satory pause following is equivalent to two heart cycles. A short run of nodal extrasystoles is spoken of as nodal rhythm. Fibrillation is characterized in the electrocardiographic record by the absence of P-waves, the occurrence of multiple coarse or fine undulations (fibrillatory waves), and an utterly disorderly rhythm in the occurrence of the R-waves. The latter show also considerable variation in height. Fine fibrillation is usually associated with the rapid rates while with coarse fibrillation we have usually a slower rate. The P-wave being absent, of course there is no P-R interval. 34 53° MEDICAL DIAGNOSIS Y ■'UZJHL liL '-IPillllll^ 1 1 i ! A - ! is ! 1 7T (IMZtZ MkJM E*Sj3. f « r "T^--*- -•-— -At ■ riY.rri irr 7/262/2 Fig. 228. — Mr. I. H. Electrocardiograph record showing a right ventricular extra- systole in each Lead. The direction of the deflections of ventricular extrasystoles in Lead I is opposite to that of the deflections in the other two leads. ELECTROCARDIOGRAPHIC RECORDS 531 Block. — Heart block may be either complete or partial. In complete block there is an entire dissociation between the P-waves and the R (or S) waves, together with a slow ventricular rate, as indicated by the number of R- waves occurring in the 6-second interval. In this condition the complete block existing in the conducting fibres compels the ventricles to adopt their own, inherent, slow deliberate rhythm causing an occurrence of correspondingly few R (or S) waves. The con- Fig. 229. — Lead II. A short paroxysm of six beats shown electrocardiographically to be of A-V nodal origin. P-wave is inverted during the progress of the paroxysm, and the P-R intervals are shortened. Time in one-fifth of a second. (After John Parkinson.) duction through the auricles being unimpeded, they respond freely to the stimulation arising in the pacemaker (sino-auricular node). The result is a preponderance of P-waves over R-waves varying in degree with the ventricu- lar rate. An auricular rate of 75 may accompany a ventricular rate of 40 to 20 or much less, for example. tiiitzti mmmm Fig. 230. — Mr. H. F. M. Lead III in a case of auricular fibrillation with a rapid ventricular rate. Left ventricular extrasystole is present. Note absence of P-waves, and inversion of T-wave. In partial block some of the auricular contractions get through and cause corresponding ventricular contractions. There is found a preponderance of the P-waves again but at definite intervals there is found a P-wave which has its normal relation to the R-wave. For example in 2 :i block every other P-wave is in its proper relation to the R-wave with an extra P-wave midway between these two. Here the auricles are beating twice as fast as the ventricles. In 3:1 block there are two extra P-waves between two normally placed P-waves, all of them being the same distance apart. MEDICAL DIAGNOSIS zfife,MfeE if I2.12.J4_ €*_? - ^«/e Fig. 231. — Mr. A. H. Electrocardiographic record of auricular fibrillation under the influence of digitalis. Xote the complete absence of P-waves and the presence of coarse tibrillatory waves (fff). The slow rate of 66 is due to the administration of digitalis. Arborization defect is indicated by the notching and widening of the R-waves. ELECTROCARDIOGRAPHIC RECORDS Block 5 B S55 BS mSS ^RS ■ ■■ ■ ■ SB Bi TBTTTTRI i S?S ma£255 . — M: Electrocardiographic records on a 16 Id bov with mitral and aortic insufficiency and decided decompensation. A Shows a dropped ventricular systole. The conduction time before the period of block is 0.44 and 0.42 sec. and immediately after the rest-period of the Bundle of His is c. and then immediately lengthens to 0.2S sec. This shows the presence of extreme toxemia and the marked fatigability of the bundle. B Taken 6 days later still shows a markedly delayed conduction ('0.40 sec. > and sino- auricular block. This is simply an arrest of the whole heart and comparison with A wtD show "that the "period of rest is not preceded by a "lone " P-wave. as occurs in partial block. C Taken 4 months later after hospital regime, showing absence of all forms of block and reduction of conduction time to 0.22 sec. 5 54 MEDICAL DIAGN In the less severe grades fewer and fewer ventricular contractions are missed until there may be a ventricular beat dropped only rarely. Sino-auricular block is indicated on the record by a temporarily arrested action, that is. the diastolic period is unusually long but the heart cycles preceding and following are both absolutely normal. It is customary to indicate the occurrence of events such as described above on the face of the record in the following manner: Right ventricular extrasystole — R.V.Ex.. left ventricular extrasystole — L.V.Ex., total block — T.B.. partial block— P. B.. fibrillation— f. f. f. sino-auricular block— S. A. B., etc. The reader will recall that the Bundle of His 'Conducting bundle) divides into two main branches, one for each ventricle, and that each of these in turn subdivides into many smaller branches, ending finally in specialized cells, called the Purkinje cells which are situated in the outermost portion of the ventricular musculature. Block may occur in any branch or sub- division, and is determinable by the electrocardiograph alone. In branch block the conduction of the impulse to contraction is inter- fered with in one of the main branches of the bundle of His. The electro- cardiograph indicates this condition by the following findings. i. An accentuation of the first and third leads; that is the deflections are wider here than in the second lead. 2. The R-wave is widened (normally it is 0.03 sec). j. There is a notching of the R or S waves. 4. The T-wave in the first and third leads is opposite in direction to that of the dominant wave of those leads. 5. The general appearance of the second lead is that of a continuous ventricular extrasystole of the side opposite to that on which the block occurs. This has been taken by some as indicative of the side on which the block occurs, but this finding has been found not to be constant. The branch blocked is now more accurately indicated by the following finding In a block of the right branch, the first lead shows a high R-wave. with an inverted T-wave, while the third lead shows a deep S-wave with the follow- ing T-wave upright. In a block of the left branch. Lead I shows a deep S-wave. followed by an upright T-wave. while lead three shows a high R-wave with the T-wave following being inverted. In arborization block, one of the lesser branches is affected. The electro- cardiographic picture has the same essential features as that of branch block, but all are exaggerated. The difference is one of degree only. Arborization defect is a condition in which the terminal fibers of the "His" conduction system are affected. It is a much less important condi- tion than either branch block or arborization block, and is indicated on the records by a notching of the R- waves or the 5-waves. the rest being un- affected. It is usually interpreted as indicative of some impairment of the intrinsic circulation of the heart. Some writers believe it is due to local pathology. Robinson in a recent article assumes that it is due to the ELECTROCARDIOGRAPHIC RECORDS MrJK \ **\jm*m+J\ ^^y^NmuA ^\/^^ui rf^Wvii 1 - * I ? ■ r . ^ i y -a- w** s i Fig. 253. — Mr. J. K. Electrocardiographic record of right branch block. Right branch block is indicated 1 by a vertical accentuation of Leads I and III; (2) by a widen- ing of the V-R-S interval; and 3 by the inversion oi T-i. its direction being opposite to that of the dominant R-i; and T-iii upright in direction and opposite to the dominant S Hi . 536 MEDICAL DIAGNOSIS presence of acid metabolites which are the result of anything that inter- feres with nutrition of these tissues, be it fatigue, over-strain, sclerosed coronaries, or what not. Abnormalities in the P-wave. — Normally the P-wave is a small rounded wave, 1.5 to 3.5 mm. high. A P-wave higher than this is spoken of as an exaggerated P-wave. A wide and exaggerated P-wave is usually interpreted as indicating auricular hypertrophy, while a tall narrow one means usuallv, over-acting auricles. A definite notching of the P-wave is taken to indicate an asynchronism of the action of the auricles, This is a common finding in mitral stenosis. Immediately after the P-wave and before the R-wave, is an isoelectric (no-action) flat line. Frequently there is found here, however, fine oscilla- tions. These may stop just before the R-wave, or they may continue on past the R-wave and be evident up to the T-wave. This condition is spoken of as continued action of the auricle. Auricular disturbance is a term applied to the finding of indefinite undulations in the diastolic period of rest on the electrocardiogram, between the T and the following P-wave. Fig. 234. — Mr. A. M. Lead III of electrocardiographic record showing arborization defect as indicated by the notching and widening of the S-waves. The P-R Interval. — As has been said before, the normal P-R interval is 0.12 to 0.18 sec. A lengthening of the P-R interval is spoken of as delayed conduction and this finding is of great clinical significance. The usual delayed conduction finding is 0.19 to 0.24 sec. The longest conduction period noted by the author is 0.42 sec. without actual block. Frequently there is found variation of the conduction period within the normal limits. This means that the impulse to contraction does not always start from exactly the same point. The T-wave. — This is the last wave of the heart cycle and usually is a positive wave, from 2 to 4 mm. high. The inversion of the T-wave in the first lead, the first and second, or the first second and third leads is very important from the standpoint of prognosis, and is thought to indicate the presence of one of the graver heart conditions, making the prognosis less favorable. Inversion of the T-wave in the third lead alone is of no practical ELECTROCARDIOGRAPHIC RECORDS 537 liB tmzM Fig. 235— Miss L. H. Atypical electrocardiographic record in a 14-year old girl with mitral stenosis. P-ii is exaggerated and wide showing the auricular hypertrophy. The typical notched P-wave of mitral stenosis is flat-topped. Slight notching of the P-wave, indicative of asynchronism of the auricles, can be made out here and there. The conduc- tion time is delayed, being 0.18-0.20 sec. Right ventricular preponderance is indicated by the deep S-i and the high R-iii. The deep S-ii shows the asynchronism of the ven- tricles. 538 MEDICAL DIAGNOSIS t^JUJU^Uy IB kipife •2^ T . PS ill IiiIiiM inn * i iimliiiiihiia^ in i ^titotfiiMI Ass*=Mii^MMiifcA*s&*iilMifc*iiittife^ Q T Mr.T.C Ftg. 236. — Mr. T. C. Electrocardiographic record of over-digitalization. This con-, dition is characterized by an inversion of the T-wave in all Leads together with a delayed conduction. ELECTROCARDIOGRAPHIC RECORDS 539 significance. The inversion of the T-waves due to digitalis must not be lost sight of however, and it is usually readily distinguishable from the other types. It follows the administration of digitalis, and besides the inversion of the T-wave in all leads, there is also a delayed conduction. The sudden development of this picture in an electrocardiogram, should call for immediate cessation of all digitalis administration. Inverted T-waves are of two types, (i) That type which is the mirror image of an upright T-wave, and (2) that type in which there is a negative wave which begins earlier than the rise of the usual upright T-wave. This negative phase then rises, and becomes actually a positive phase, small but definite, ending at the usual time for termination of the T-wave. Ventricular Preponderance. — In ventricular preponderance, there is increased muscle mass, in one or the other ventricle, over that normally found. This increases the conduction time through the affected side, the result being the loss of the normal unison of action of the two ventricles and a characteristic electrocardiographic picture, depending upon the side involved. In preponderance of the right ventricle, there is found a deep S-wave in the first lead, while the third lead shows a dominant R-wave. In preponderance of the left ventricle, the picture is the mirror image of this and shows a dominant R-wave in the first lead with a deep S-wave in the third lead. Asynchronism of the ventricles is indicated by an S-wave in the second lead. Auricular Flutter. — This is a condition of extremely rapid, rhythmic auricular contractions associated with a partial block and occasionally with alternation (alternately higher . and lower R-waves) . An associated block may give rise to a 2:1, 3:1, 4:1, or in rare instances even 6:1 ratio between the recorded auricular and ventricular waves (auricular = P, ventricular = R and T, or S and T-waves). This condition is accurately determinable only by instrumental methods. (See page 555 and 556.) Paroxysmal Tachycardia.— This condition is characterized by a sudden outburst of rapid action of the whole heart and its abrupt termination after a period of minutes, hours or days duration. It is usually, if not always, initiated by extrasystoles of auricular origin. Rarely it is said to be ven- tricular in origin. (See page 559.) Special Conditions. — The infantile type of heart is a centrally placed, low-lying heart. The electrocardiographic record in these cases is said to be characterized by a minute first lead, the other two leads being of the usual height. Hearts having a congenital defect are said to give characteristic electro- cardiographic records, and the unusually wide R-waves, together with evi- dences of hypertrophy in one of the chambers are taken as the indications of this condition. Conditions of hypotonus of the myocardium are indicated on the electro- cardiographic record by unusually low P and T-waves throughout the entire record. Over- digitalization. 54Q MEDICAL DIAGNOSIS I vf ¥ < 1 pMMf /^r. G. 1 . = j^p^ - .|.--|::,:|r.|.:|::; 1 Tc w g^msfil Fig. 237. — Mr. G. Mc. Electrocardiographic record 'showing left ventricular pre- ponderance in a typical "drop" heart of a 36-year old rrale. The preponderance of the left ventrical is indicated by the high R-i and the deep S-iii. ELECTROCARDIOGRAPHIC RECORDS 541 * -r * r * T ' 1 : R R x c SESa Vr.H.l sssw i V i III Q ^t I 3 0* q §| Fig. 238. — Mr. H. L. Electrocardiographic record in a case of typical "soldier's heart" 'exhausted insufficient •"drop" heart) occurring in a 16-year old male. V-wave in Leads II and III shows marked continued action of the auricle. Conduction time is nor- mal (0.15 sec. j. Right ventricular preponderance is indicated by a deep S-i and a high R-iii. 542 MEDICAL DIAGNOSIS An arching of the T-P interval, which is usually flat, is said to indicate a hyperthyroid condition. It is spoken of as the hyperthyroid type of record. Myocarditis is said to be indicated by an abnormally low lead II, the first and third leads being normal in height. £3 liufAi^yik yytai 1 tthfc mm*. mJ ^RUPQ^TFV W V PH yr* P^W *t!W*P^^^^ M^ F i r r FT « 1 1 • ■*• 22.(2 - 8 /? : ; ■I ' «n mmM r riffn il'iiliatWiiH P 1'. t*L I ^n^i--'""f ia y ''"'". ?&Ipn 3TJC I " v !? / 1 * 4 A A k\ k k\ ii fill / ^ii^ir^ir^^ — v Is !«s N IP B Fig. 242. — Extrasystole P. R. originating in left ventricle (lead III). In ventricular extrasystolic "premature." "ectopic." •"heterogenous", contraction, the wave of contrac- tion spreads from the abnormal point of initial stimulus production to the other chambers of the heart, not from the sinus node and auricles. This results in a wide departure from the normal electrocardiographic complex representing the heart cycle or cycles affected. Obviously (.a) the entire diphasic wave will be large and protracted, as compared with the normal and (b) the anticipated, rhythmically recurrent "P" wave of auricular activation is submerged or buried. As between extrasystoles of right and left ventricular origin respectively it is known thai an initial asct>:: :;' the "JR M wave represents initial right ventricular stimulation; an initial descent, left ventricular initial stimulation. In both instances the diphasic "R" wave is of exaggerated dimensions. The characteristic fea- tures then are: 1 The absence of the "P M wave from its normal position. [2 An exag- gerated broad based "R" summit. 5 An " R ward deflection) in right ventric- ular extrasystoles: an -- R" downward deflection in left ventricular extrasystoles. (4) A pause equal to two complete normal heart cycles, by reason of the substitution of the extrasystole for one normal heart cycle and its interruption of the rest period of the preced- ing cycle. There are many variants in the form of double consecutive extras; 5:: very rarely two such successive premature contractions may arise in the right and left ven- tricles respectively as shown in one of the electrocardiograms taken by Dr. R. Edwin Moms (Figure 243). If ventricular extrasystoles are double, or if a premature contraction is auricular in origin, the compensatory pause is less than two full heart cycles. form. It is obvious that the beat following the prolonged pause will be often- times of unusual amplitude because of the prolonged resting period. Underlying Factors. — Aside from experimental stimulation, the extra- systole is a common event in cardiac disease, when the walls are dilated or the heart is working against high pressure. A dilated and usually degenerated ventricle, in the presence of an excess of residual blood (imperfect emptying, overdistention \ failing reserve power, arid, perhaps, a coincident increased peripheral resistance, may become highly excitable and generate its own impulses independent of the pacemaker. * In a case of combined congenital and acquired heart disease examined by the author just before writing this note both the pulmonary and aortic tones were wholly lacking 35 Effect of overload. Toxemia. 546 MEDICAL DIAGNOSIS " So also with an auricle overdistended by reason of an obstructed or insuf- ficient mitral or tricuspid valve. Yet again, toxic influences may similarly affect temporarily even the otherwise normal heart (digitalis, gastrointestinal subinfections, the causa- tive agents of acute infectious disease and their toxins). It is also said to occur in the wholly normal heart, but unless it be due to excessive distention of the stomach or colon or in advanced pregnancy such a statement would seem at least debatable. Clinical Significance of Extrasystoles. — That these not infrequently occur in persons in whom no heart lesion can be demonstrated at the time admits of no doubt, nor can their presence and persistence be considered a grave symptom in the absence of other signs of serious cardiac impairment. They may exist for years PP. f D Pb ! 1 fl 1 ? .R ■1 ^ 1 "R I •I 1 I r 1 k i 11 i T> 1 T I > J T r ► A T "P T 1 1 J 11 l | 1 1 p 7 ~A II r ^ . 1 iir* k ■ ■■r "ir^ .— . ir^ iiiv ir 1 i ' / \r / u I v s 5 *i / %» c h u f Characteristic features. merpolated extrasystoles. Fig. 244. — "Interpolated" right ventricular extrasystole. Compare with left ven- tricular systole (Fig. 242). The "P" of the perverted cycle is submerged in the exaggerated "R" wave in both instances. Note that the extrasystolic contraction of abnormal origin happens to fall in with the rhythm of the normal cycles. Hence, the ab- sence of the usual compensatory pause. {After Thos. Lewis. Lines of original deepened.) unattended by demonstrable gross myocardial disease, but so may the commonest forms of myocardial degeneration. Miniature Murmurs. — If lesions of the valves exist and the strength of the extrasystoles is sufficient, murmurs in miniature may occur with prema- ture contractions, save in the case of mitral stenosis. Extrasystoles of Ventricular Origin. — These are most common and are characterized (a) by a remarkably constant time interval representing the period between the beat just preceding the substituted premature contrac- tion and that regularly following the one which the extrasystole has antici- pated, (b) by a large, single, jerky, venous wave which is the auricular wave of the anticipated systole acting against auriculo-ventricular valves closed by the extrasystolic contraction. This when present sweeps from the jugular fossa over the sterno-mastoid muscle. Exception. — In bradycardia (slow pulse) if the premature contraction is very early the compensatory pause may be absent because the regular beat escapes full elision and takes its proper place in the cycle, time enough having elapsed between the ventricular extrasystole and the period of normal CARDIAC ARRHYTHMIAS 547 auricular excitation of the true contraction to enable the muscle fibers to partially recover from the " refractory stage." Such imperfect normally timed contractions are called ''interpolated" extrasystoles but the term "interpolated ventricular contractions" is preferable as they are not prema- ture but correctly timed. Electrocardiographic Differentiation of Extrasystoles. — The electro- cardiogram is characteristically altered in event of the presence of premature Fig. 245. — Extrasystolic tachycardia. Remarkable occurrence of one right and one left ventricular extrasystole in direct succession. (R. Edwin Morris.) ^^^^^^^^^^^^ Fig. 246. — Right ventricular extrasystoles (ex). "R" summit high; sharp drop down- ward. Giant "peak." Lead II. contractions and shows decided differences not only as to their auricular ! Eiectro- ... . cardiogram _ or ventricular origin, but also as between those originating in the right and and polygram, left ventricle respectively. Thus with lead II right ventricular extrasystoles are indicated by an extremely high "R" summit followed by a deep "S" descent. Left ventricular extrasystoles are indicated by an extreme dip "Q" preceding "R" which is also decidedly higher than normal. In lead I the 548 MEDICAL DI characteristic deflections, with rare exceptions, are reversed, i.e., they are mirror images of the deflections encountered in leads II and III. Electrocardiographic section for further discussk : The Auricular Extrasystoles. — These invariably produce ventricular response in the form of a premature contraction and show usually " shortened bigemini" in the pulse waves if the extrasystoles are carried through to the wrist, inasmuch as the so-called '"compensatory" pause rarely or never is n n n X X Fig. 247. — A beautiful example of ventricular extrasystolic arrhythmia showing pulsus bigeminus (z) and trige m ir.u: g :: aether with the typical corresponding jugular tracing. Right jugular above; right radial belo-v. u n" indicates the normal radial beats. R. Ed:: in Morris.) quite complete.* If they originate in the neighborhood of the great veins or sinus node, the pause is that of the normal rhythm. They are associated with a double jugular wave in the polygraphic tracing and the electrocardio- gram shows an inverted imperfect or superimposed auricular complex "P" wave . the last being due to so premature an impulse as meets and coincides with the B T" of ventricular systole in the electrocardiogram. M MP5 Js Fig. 248. — Inverted K T M in an apparently normal heart. {R. Ed^in Morris.) It is obvious that extrasystoles of shortened pause are of auricular origin and that a pause reduced to that of the normal rhythm indicates the sinus region as the point of origin. Extrasystoles from Bundle of His. — In this type the auricular and ven- tricular systoles may or may not fall absolutely together. These are recog- * Lewis believes that they are in some instances fully compensator)' but he says that "if in the case of any premature contraction the pause fails to be compensatory then such a (premature) beat has arisen in the auricle" adding in a footnote that the interpolation cases are excepted. nize who abs< an typ CARDIAC ARRHYTHMIAS 549 d with difficulty in polygraphic tracings by their prematurity and the lly absent or very short conduction time as shown by the reduced or ait 4 Vc" interval. In the electrocardiogram they show, when typical, undisturbed ventricular complex and a buried auricular complex. The cal electrocardiogram is by no means constant. HiSIH -t 0& S Fig. 249. — Normal electrocardiogram inserted here for contrast and comparison. Clinical Significance of the Auricular and Ventricular Extrasystole. — Premature auricular contractions are most frequently encountered in primary myocardial degeneration and in mitral stenosis. Premature ventricular contractions also occur most frequently in myo- cardial degeneration alone or as associated with aortic and mitral lesions. Ti iR 1? d 1 T ■fr T> , 1 1 re T> II K n. 1 1 1 - 3t A A _!3 A r r , r 1 1 - 41 rx:- 1 > l\ T :> ft 1 Jl L r 1 fj -,*H t ^ 1 1 A 1 1 1| I 1 ji ji 1 Mu 1 11 ir m ■' , imw i\ n 1? i iimr 1 iiiiar m 11 illiri Jkll'.L JLII'.JL Jl A apex but van. actu Ma arte tha crip wit] con ^IG. ich c le cc sun chai carri mt i al el( ny i rios t in pie, 1 ex trac 25 as rr LK a ec >] iC n cl m tr ti 0. e Lb dt :te Is en trc 5t er v as or . the na 3 ris lsc ow )ca an 05 St :t\ ys IS \u ; M tio ft] tic in n i rdi ce- s ns wo to ex ric P n le oj tc IS 02 in U rk e si u n 01 a tl Tc ai LB c 5 la P e br li th le in e [TC c ir 01 at r aa xt 10 fa e s IS s >n BS d k c e: S€ Tc rn il w Dl n e( ei t e - r i ill it i is; 1a St r t -p ?n -a l< X . ra s •s 1( e> s « ro I ] 1. ;1 hi it sys bu tol :yc 05 un P' du n es 111 tol rie< ic c les 's i lm 01 cec m As on 5t I U es 1] Y 5 t: I h EU 1 s a 1 n cl I pi > ni ils -k P P tl ] tl 3S n es vl tr e\ e( 5* ri at ui e tl ei lie al vh 1 r n t t )t «r it le it :h ei cc Is a c d r h 1 t P e >r ri] ui tl ' ( a ic 11 ir 11 tl y a is ir >f ir di t a t ia te a r u ie s the ark lal p alon th( rid i his ry ve nd aea >n L1CC pre( sdi lat e ii i"3 3 be sect scl ntt chi rt ( ft! es :e nc 2 c 1 3 ' ai io er ic ef -h it sive iing reas )fT ±e ) 'sof itifi n. osis le 1 lyt am he pr cy< e ir 10s eye 'th illy ,B iffe enc 1)01 art en :l€ 1 t L es e si ri Cl lii aatu . 1 he 2 ewi of extr 10WI ght :ed, lgt vill f su re Chis mp ith nor asy 1 in 'S( it s be ch cc i li 'J m St s li U tr a P nt s ii tud «« al om ^ea i uc ssc rei rac idi e c y ed rh> e c SO b\ tu )ci na tio cat .ft "i -th Tl ft ai ioi ral ate tu QS ed he >« m, lis he id as iy ;d re Common associations. 55° MEDICAL DIAGNOSIS Proper " viewpoint. Sign of overstrain. Prognostic value. As previously stated, persistent extrasystolic irregularities may occur in persons apparently healthy, but the student should not lose sight of the fact that Thomas Lewis has reported but three such instances out of a group of ninety-seven cases investigated, and furthermore, that of the remainder seventy-one cases were definitely those of cardiovascular disease. Extra-systoles are probably to be regarded precisely as one should view heart lesions in general, viz., as conditions not of themselves and of necessity proving the presence of a dangerous or threatening condition but as morbid phenomena strongly suggesting toxemia or structural deterioration and overload and as such always demanding a thorough and painstaking investigation of conditions.* Certainly premature contractions do not often occur persistently in a heart which is sound, fully competent, and well nourished, and the author Fig. 251. — Auriculo-ventricular (junctional) extra systole; originating in junctional tissues. A long pause follows, then a normal cycle, then a right ventricular extrasystole. Mitral stenosis is indicated by the "P" summits (truncate or split) and the effect of digitalis administration by the constantly inverted T. has rarely encountered it save in decided toxemias and intoxications, frank cardiac or renal disease, or the overstrained, undersized, flabby, and in- sidiously dilating hearts of congenitally asthenic and nutritionally depressed or unstable individuals. Furthermore, the onset of marked extrasystolic irregularity in known cardiopaths, formerly free from it, may be an ominous symptom and its disappearance under treatment a favorable sign. Useful Maneuvers. — It should be remembered that holding the breath, manual or postural increase of intra-abdominal pressure, and the erect posture will often bring out any latent tendency to extrasystolic beats. On the other hand, the abrupt assumption of the erect posture, exercise and even excitement or fear may temporarily abolish such an arrhythmia even if present primarily. A pulsus alternans is occasionally present in connection with them, and irregular extrasystolic beats, or in fact any of the extrasystolic phenomena * The author has seen many cases of long-enduring extrasystolic irregularity, but rarely or never in persons presenting a perfectly clean bill of health. It is quite possible that in Great Britain toxic cases, of gouty origin, are especially frequent, which assumption may account for the optimism of so distinguished an authority as Mackenzie. CARDIAC ARRHYTHMIAS 551 are usually associated with a relatively slow or bigeminal radial pulse by reason of the frustrated beats. Their abrupt disappearance when instrumental recording is attempted is one of the trials often encountered by the medical investigator. AURICULAR FIBRILLATION {Delirium Cordis).— In this important condition there is a veritable riot of abnormal futile and abortive contraction Fig. 252. — An extremely well-marked case of auricular fibrillation. The normal "a" wave of auricular systole is wholly lacking, and replaced by small diastolic undulations (fff). waves in the auricle, the result being a continual fibrillary flickering of the muscle and an entire loss both of effective rhythmic transmission and coor- dinated muscular contraction. Myriad impulses of the most feeble, irregular, hasty, and imperfect sort, crowd upon the ventricles at a rate far exceeding the possibilities of complete transmission, and such as can achieve transmission excite these chambers to ■1? 1 IR fi It j 1 ( 1 . I 1 1 II 1 • 1 1 ■p 1 r lr 1 1 T ■ 1 / 1 n 1 A 1 1 1 T 1 I Fig. 253. — Auricular fibrillation. Note very decided oscillations (f f f) due to fibrilla tion; evidence of absolute irregularity and inequality shown in the varying height of "R' summits and spacing of cycles; absence of "P" in every cycle, indicating lack of efficient auricular impulses to contraction. Pulsus irregularis perpetuus or delirium cordis evident. Record taken over auricles. (After Thos. Lewis.) rapid, irregular and unequal contractions which are nevertheless, in toto, sufficient in many instances to maintain a circulation of some effectiveness over long periods. The auricle itself is meanwhile dilated in the diastolic position and is as utterly unable to maintain an efficient contraction of its own musculature, as it would be in a state of actual paralysis. Fibrillary flickering. Delirium cordis. Blocking and unregulated escape. 552 MEDICAL DIAGNOSIS Polygram and electro- cardiogram. As a result the normal presystolic venous pulse (represented by the "a" wave of the polygram or "P" wave of the normal electrocardiogram) is faint, lacking, or substituted by a systolic wave in the jugulars, the feeble auricular nickering may be revealed as an undulating line in the polygraph] c tracing, and in the electrocardiogram by a complex in which the auricular Fig. 254. — Auricular fibrillation; right ventricular extrasystoles. Auricular fibril- lation (f). Right ventricular extrasystoles (Ex). Pulsus bigeminus was evident in the rhythmic pairing of a normal beat with an extrasystole. Lead I. Time Y^ sec. (R. Edwin Morris.) (presystolic) "P" wave is absent and represented only by this rippling un- dulation and a hurried, irregularly spaced and unequal ventricular complex ("QRS").* If in a case of auricular fibrillation the bundle of His {atrioventricular conduction bundle) be normal, the heart rate is doubled or trebled, though the ventricular contractions are haphazard, the pauses of varying length and s ff$ #**f f f ,:--f Fig. 255. — Auricular fibrillation. (R. Edwin Morris.) the beats unequal. If, however, the conduction bundle is diseased, a block may be evident and the pulse may drop to 40 or less per minute. In- all pulses of less than double the 'normal rate and showing the other characteristics of fibrillation, pronounced digitalis effect being excluded, heart block from other causes may be assumed as a factor. The commoner pulse rate in auricular fibrillation is about 120 to 140, and nearly all markedly irregular pulses of this rate result from this condition. * Unless heart block is present. CARDIAC ARRHYTHMIAS 553 The efficacy of digitalis is peculiarly marked in most but not all such cases in which the pulse rate equals or exceeds 120. A careless observer may overlook fibrillation with slowed pulse; indeed, in some cases its presence cannot be positively affirmed without instru- mental aid. Fig. 256. -Normal electrocardiogram inserted here for purposes of contrast and comparison. Fig. 257. — Lead I. Fig. 258.— Lead III. Figs. 257 and 258. — Auricular fibrillation with left ventricular : extrasystoles. Left ventricular hypertrophy is indicated by large "R" and absent or small "S" in lead I, and small "R" and large "S" in lead III. Fibrillation is evident (f f f); "P" (of auricular contraction) is absent; T is inverted from digitalis effect. It has been said that angina pectoris and fibrillation cannot coexist and the onset of the former condition and its persistence completely removes the tendency to anginal attacks. 554 MEDICAL DIAGNOSIS Importanrfact. Frequency of occurrence. In the light afforded by recently reported cases, one must assume at least this rule is subject to exceptions. Any considerable exertion or even quick change of posture such as so often suffice to temporarily remove or to bring out extrasystolic irregularity represent maneuvers which are not without risk in severe incompensation, and this is especially true of cases showing the delirium cordis* of auricular fibrillation. Fig. 259.— Auricular fibrillation. The absence of all evidence of auricular contraction is manifest. Fibrillary wavelets are shown (f f f +). Cases of auricular fibrillation constitute over 40 per cent, of the total arrhythmias encountered in a general hospital and it is most commonly as- sociated (50 per cent, of cases) with mitral stenosis. It is common in other conditions in which myocardial degeneration, cardiac decompensation and prolonged chronic overstrain are marked features, i.e., advanced myo- cardial degeneration alone (20 per cent.), aortic lesions, chronic diffuse nephritis with arterial hypertension or arteriosclerosis. R.R Fig. 260. — Arrhythmia, pulsus bigeminus of extrasystolic type; fibrillation, n, Nor- mal beat; Ex, l.v. extrasystole producing bigeminal pulse; f, fibrillation waves from auricu- lar fibrillation; RJ, jugular pulse; R, radial. Time % sec. In all of these the myocardial change is doubtless the chief factor and in a public clinic nearly three-fourths of those specifically cardiovascular indoor cases admitted who show severe incompensation and associated arrhythmia will * The secondary slowing of the pulse which follows the primary acceleration induced by exertion is usually lacking in this condition but, if present, decreases fibrillation, though it usually increases other arrhythmias (Lewis). CARDIAC ARRHYTHMIAS 555 show auricular fibrillation. (In the author's clinic at the University Hospitals nearly 90 per cent, were of this type.) * Unquestionably a great number of unrecognized temporary and even fleeting attacks of fibrillation occur and, no doubt, there is a tendency to more frequent recurrence and longer persistence of the individual attacks prior to its appearance in an established form. Once fully developed, it tends to persist throughout the after-lifetime of the victim but this rule also is subject to exceptions. As in the case of auricular flutter, embolic manifestations occasionally follow the resumption of normal rhythm. Fig. 261. — Electrocardiogram. Same case as Fig. 254. R, normal "R" wave; Ex, extrasystole, ventricular type; f, fibrillation; time 3^o sec. showing exact nature of extra- systole in Fig. 254 and absence of "P" wave and presence of fibrillation "f". AURICULAR FLUTTER. — This term is of recent introduction and covers cases of suddenly initiated i excessively rapid auricular contraction exceeding 200 to the minute and reported as high as 420. It may continue for months or years only to cease as abruptly as it came or occur in brief attacks lasting for a few hours. The pulse rate is usually one-half that of the auricular contractions but various degrees of block are ^wl/uJ Fig. 262. — Auricular arrhythmia due to auricular fibrillation. The cause of the greater proportion of cardiac arrhythmias, "f f " indicates auricular waves of fibrillation. Upper line jugular, lower line radial. Time 3^ sec. The "Pulsus irregularis perpetuus" and "delirium cordis" are beautifully shown in the radial. manifest and the ventricle may respond to only the third, fifth or eighth auricular contraction. It not infrequently passes into auricular fibrillation spontaneously or as a result of digitalis administration (Lewis) under which the existing block is *The most responsive cases of fibrillation from the therapeutic standpoint seem to be those in which it is initiated by unusual effort or acute toxemia. (R. E. Morris.) Duration. 556 MEDICAL DIAGNOSIS Digitalis phases. Suggestive resemblances. Relatively un- common. heightened purposely, the ventricular rate falling first with irregularity, then into a regular rhythm of lower rate; then into fibrillation. At this point the drug is discontinued and in "a large proportion of cases" the regular heart action returns and any preexisting cyanosis, engorgement or dropsy "vanish quickly" (Lewis I.* The occasional occurrence of embolic manifestations following the resump- tion of a normal rhythm is a fact of clinical interest and importance. Apparently it is closely allied to paroxysmal tachycardia. It is frequently associated with alternation. It is next neighbor to auricular fibrillation and may pass into that condition spontaneously, but nevertheless is still dealt with as a distinct clinical phenomenon. t> Iff .n R! . P , |K 1 -D n I II J A. -^- a/1 m.' L_ J W~+. f y r r ' 1 r V Mr |i ' P f ' ' W Jr o o M 1 1 1 II 1 q | 1 1 1 i 1 o J . b - Fig. 263. — Case of auricular nutter. Auricular contractions were 310 per minute; ven- tricular rate, 120. Frequency and Causation. — It is a relatively uncommon condition! and its causes are essentially those described under auricular fibrillation save that it more distinctly affects the middle-aged or elderly and seems especially common in cardiosclerotic degeneration. Diagnosis of Auricular Flutter. — The electrocardiograph alone furnishes constant and positive diagnostic results, yet one may in some instances make a correct diagnosis by other means. _. ±l JU J "fc _ i? T, 15 fl A A h n j A T /I T fl T I\ T M T |l rv p f 1 5 tF ln> p n P f p p Irp? #- ■£.- - - ■ ^ _ ii Fig. 264. — Auricular nutter. The ventricle is responding only to alternate auricular stimuli. Auricular rate, 324 per minute. (After Thos. Lewis.) The Venous Pulse in Auricular Flutter. — In some cases the condition is clearly indicated by visible excessive rapidity of the venous pulsations or the multiplicity and rapidity of "a" waves in the polygraph. The auricu- * The frequency of failure of such medication to produce this result would seem to have been somewhat underestimated. Certainly many cases are wholly unaffected. f Thos. Lewis and Mackenize find it common, but in the author's clinic it was encoun- tered very rarely unless one followed Satterthwaite's dictum, which declares all countable auricular contraction rates above 200 to be ,; flutter." CARDIAC ARRHYTHMIAS 557 RJ. ^aaJWjwJV^ /CLajuJ^ J 10 ". 26 5 - — Passa S e fr° m flutter and state of general arterial anemia and venous stasis or fibrillation. Profound cardiac decompensation. (RJ. = right jugular. R.R. = right radial. i. "Running" pulse barely palpable; rate 168 per minute; jugular waves enormous. 2. After 24 hours treatment with digitalis by Eggleston's method. Radial now pre- sents a definite pulse of 156 beats per minute. Jugular less intense but lacking "a" waves. 3. Twenty-four hours later. Radial shows clearly the characteristics of fibrillation (' pulsus irregularis perpetuus")', "a" waves wholly absent from venous tracing. Pulse rate 132. 4. Twenty-four hours later. Pulse rate 108; less arrhythmic; fibrillationclearly shown by minute waves (f f +) in jugular tracing. ^8 :>:> MEDICAL DIAGNOSIS Functional block. lar pulsations are so rapid as to surpass the conduction capacity of the His bundle or the possibilities of recovery and response on the part of the ventri- cles, and, therefore, save in the rarest instances, such cases show a relatively low pulse rate; 240 or even 400 aurciular contractions to but 60 or even 30 ventricular beats being present. If the block, or as one might say, the inadequacy of the conducting bundle, is less marked, the rhythm may be and usually is definitely 2-1, in which case, of course, a rapid radial pulse is present. The polygraphic tracing may show clearly the excessively rapid produc- tion of distinct or even large "a" waves occurring in the various auricular- ventricular ratios common to the "block" usually present in this condition. This statement applies chiefly to cases in which the arterial pulse is distinctly slow, and the veins of the neck are yielding good auricular pulsations. Fig. 266. — Same case three months before. Electrocardiogram shows fibrillation and right ventricular extra.svstoles. Occasional excessive ventricular rapidity. Paroxysmal tachycardia and alter- nation. Distinguished from fibrillation. If, as occasionally happens, the auricular rate is under 300 and the ventricle responds to every auricular contraction, an uncountable, excessively weak radial pulse results, together with symptoms of profound incom- pensation, syncopal attacks, or coma and death. The electrodiagrams show the same characteristics and it is usually clearly distinguished from auricular fibrillation by its lack of the extreme erratic variability both in the pauses and in the heights of the "R" summits characteristic of its congener. The equality in time, large and uniform size and regular occurrence of the '•flutter" waves are points of importance in differentiation. Under such conditions the pulse characteristics of paroxysmal tachycardia are actually present and, very frequently, the excessively rapid beat often slims distinctly an alternating strength and weakness (pulsus alternans) if instrumen- t-ally recorded. Symptoms. — It will be noted that the extreme irregularity of interval so marked in fibrillation is ordinarily absent in these cases, the ventricular response being usually, but by no means always, rhythmic. As in paroxysmal tachycardia these cases may show arterial anemia and venous stasis. Recurring periods of high pulse rate of which the patient is conscious, CARDIAC ARRHYTHMIAS 559 lasting for days or weeks, attended by distinct evidences of cardiac decom- pensation, yet unlike the wholly delirious arrhythmia of fibrillation, vertigo or actual unconsciousness attending the onset and the frequent initiation of the attacks by slight exertion, are among the clinical evidences of the condi- tion given by Thomas Lewis and Mackenzie. It is obvious that they are merely suggestive, and unfortunately true that pulsus alternans and irregularity may render the pulse most puzzling. The cases of regular 2-1 block would be the ones most likely to be guessed correctly, but rational non-instrumental diagnosis would seem to be depend- ent chiefly upon the pulse phases induced by digitalis therapy as previously described. Duration. — Auricular flutter like auricular fibrillation may occur in short paroxysms or endure for months, but during any decided seizure, marked and progressive symptoms of decompensation become manifest. Fig. 267. — Mere febrile tachycardia. Normal cycle throughout in venous tracing. Rapidity only. Physiologic Heart Block. — Inasmuch as the normal conduction time is nearly one-fifth of a second (0.12-0. 18 sec), it is evident, as previously suggested, that a certain degree of functional heart block must occur in this lesion when the auricular flutterings exceed 360 although it has no such sig- nificance as has the heart block due to organically impaired conduction. \ PAROXYSMAL TACHYCARDIA.— This curious speeding up of the whole heart apparently represents the sudden appearance of a few auricular extrasystoles initiating excessively rapid rhythmic, but inefficient heart beats of auricular origin in place of the slower rhythmic stimuli normally arising from the pacemaker (sino-auricular node).* In rare instances the impulse to contraction seems to arise in the ventricles. The rate is usually about double that of the normal heart. Essential Features. — It consists clinically of the abrupt onset of a series of excessively rapid beats, their equally abrupt cessation after a period varying * Paroxysmal trachycardia of ventricular origin is extremely rare. In some instances it would appear unlikely that any extrasystolic phenomena initiate the attacks. Decompensa- tion produced. Excessive rapidity and weakness. Arise in auricles. 5 6 ° MEDICAL DIAGNOSIS Abrupt onset and ending. Vagus inhibi- tion lost. Sometimes beyond counting Electrocardio- gram. from a few seconds to several hours or weeks, a somewhat prolonged pause, and the resumption of a normal rate. The subjective cardiac distress is primarily slight though curiously alarming to the patient. Weakness or oftener a sense of profound exhaustion adds to his apprehension. In a case observed with especial minuteness by the author the attack is not initiated by obtrusive or subjective recognizable extrasystoles although the onset is sudden and definite. An immediate limitation of effort is obligatory. If this cannot be secured anginal pain of moderate or even somewhat severe grade results. This is manifested first in the precordium, then the left arm, and finally by radiation to the left side of the neck and jaw. Until habituated through the frequent recurrence of attacks a "sense of impending death" was experienced in the painful seizures. The patient feels convinced that the heart would dilate rapidly under any decided physical exertion, i.e., he " senses" the extreme overload present as a result of the quickened rate. The tendency to attacks may pass into auricular flutter or fibrillation, wholly cease for long periods or occur persistently several times a day or at any other interval. In many cases an acute cardiac insufficiency is developed in a few days or even hours. The heart dilates widely, general edema appears, orthopnea is present, the liver enlarges and decided passive congestion of the kidneys is manifest. Vagus control is almost or quite removed throughout the period of tachy- cardia. (Vagus pressure slows the ventricular beat in these cases by creating a partial vagus block, but without affecting the abnormal auricular contrac- tions in the slightest degree.) The beats may show decided inequality and the rate varies from 120 to 200, the average rate being somewhat more than double the normal. /1/U- — \%^-\ RR Fig. 268. — Paroxysmal tachycardia. The abrupt onset and cessation of the brief par- oxysm and its equally sudden relapse into extrasystolic irregularity (Ex) and "pulsus bigeminus" are clearly shown. In the full-sized tracing, alternation seems to be present during the paroxysm. (R. Edwin Morris.) The lack of the subjective sense of violent palpitation and the fact that exercise during the attack does not increase the rate (Mackenzie-Lewis) stand in sharp contrast to the symptoms of simple acceleration (palpitation) or a simple tachycardia of exertion or excitement. The electrocardiogram demonstrates clearly in most instances the auricular origin of the aberrant impulses, the "P" wave of the paroxysmal CARDIAC ARRHYTHMIAS 56: „Tic-tac' rhythm. cycles and that of the introductory auricular extrasystoles being identical in form. Rarely it is initiated by a ventricular extrasystole. In cases of excessive rapidity the "P" wave may be merged in the "T" wave or wholly obscured by it. It occurs at any age save the first decade but with significant frequency between the ages of twenty and forty, the selective rheumatic period, and Age groups, even more frequently between forty and sixty, the preferential period of the myocardial degenerations. It is most common in myocardial degeneration, is often present in mitral stenosis, and has a decided pathologic significance though occasionally present without other distinct signs of cardiac disease. In severe cases the rhythm is essentially fetal (the "tic tac" rhythm). To the author it would seem wiser to consider this condition clinically as one standing wholly apart from "flutter and fibrillation." ALTERNATING PULSE.— This represents usually very rapid rhythmic alternation of stronger with weaker beats, the variation and force being often imperceptible to the finger. It is best shown by the radial and carotid tracings, and is sometimes beautifully clear in the electrocardiogram. It will be noted that the beats fall at regular intervals, the abnormality being one of force only. It is especially common in cardiosclerosis, the terminal cardiac insuffi- ciency of interstitial nephritis and coronary sclerosis, and is frequently asso- ciated with paroxysmal tachycardia and with auricular flutter. In practice its immediate seriousness is largely dependent upon the question of attendant pulse rate. Impaired contractility R.J. Fig. 269. ■Pulsus alternans. Rhythmic pulse, a.c.v. waves present in jugular tracing. Upper tracing jugular, lower tracing radial; time }/$ sec. Significance of Associations. — If the alternation occurs in mere rapid heart (simple tachycardia) such as may arise temporarily from trivial causes and subside upon their removal, it may or may not indicate myocardial dis- ease or overstrain. If associated with paroxysmal tachycardia the signifi- cance and associations of that form of pulse acceleration, w T hich is probably a manifestation of "auricular flutter" dominate the clinical picture. // it occurs in a heart beating at, or but slightly above, the normal rate, and especially in persons of middle or advanced age, or in connection with known cardiac disease, it is of serious significance. 36 Prognostic factor. Rapid hearts. Moderate rate. 562 MEDICAL DIAGNOSIS Induced by exercise. A "herald of rfeath." The same is true of cases in which alternation occurs under exercise or sudden changes in position with but moderate resulting acceleration of the heart beat. Fig. 270. — Pulse resembling pulsus alternans, though smaller pulsations are due to extrasystoles. Auricular fibrillation shown by waves ff. Upper tracing jugular, lower tracing radial. Time % sec. (R. Edwin Morris.) It may be confined to but a few cycles, especially in the presence of occasional extrasystoles. Fig. 271. — Auricular fibrillation. Pulse simulates alternans on this half of original tracing, although the spacing is markedly irregular when instrumentally demonstrated. Left one-fifth of tracing, not reproduced here, showed a bigeminal pulse due to extrasystolic arrhythmia. Fibrillation was manifest in both phases, (f f++). (R. Edwin Morris.) Prognostic Significance. — Occurring either under the conditions of moderate rate, on the one hand, or excessive paroxysmal rapidity, on the other, as the Fig. 272. — Sinus arrhythmia. Electrocardiogram and respiratory curve. (After Thos. Lewis.) result of exercise, or in connection with extrasystoles, the alternating pulse is a serious condition representing extreme exhaustion of reserve and impaired effective response, and ranking, as Lewis says, with u risus sardonicus, ,} " sub- sultus tendinum^ and optic neuritis as heralds of a death at best not many CARDIAC ARRHYTHMIAS 563 months distant. In fact it is often actually associated with such urgent and ill-omened conditions as "Cheyne-Stokes breathing," cardiac asthma, and severe angina pectoris, though as in these conditions the possessor may sometimes live many months or even years. SINUS IRREGULARITIES.— The vagus nerve controls the "pacemaker" of the heart (sino- auricular node), normally reduces by over one-half the rate of the unrestrained-heart stimuli, and probably determines their point of departure from the sinus area. Partial inhibition of the vagus influence is evident in the quickened heart (tachycardia) associated with fear, joy, pain and a host of other emotions, no less than from the action of many well-known drugs. The more unstable the nervous system or psyche of the individual, the more readily are trivial sights, sounds, odors, aches and trials magnified and made effective inhibi- tors of vagus control. So also may the inspiratory quickening of rate be exaggerated under conditions or toxemia, poor nutrition or psychasthenia. The known independence and automatic irresponsibility and lawlessness of the heart muscle under certain conditions of overstrain and valvular and myocardial disease largely vitiates the vagus control. Characteristic Features of Sinus Irregularities. — These are characterized by a varying length of cardiac cycle represented by a diastolic variation but unasso- ciated with dropped beats, alternation, delirium cordis or extr asystoles, though peculiarly unstable in rhythm and often responsive to and modified by, the phases of respiration. Merely taking one's pulse during forced inspiration, a long pause and forced expiration demonstrates this common " juvenile type of irregularity." The rate of the beats tends to wax and wane, to speed up and gradually slow down in series. In many the respiratory response is absent but all show the tendency to complete orderly systole, varying diastole, equality of force in the beats, and the serial waxing and waning of the rate. Significance. — Sinus irregularities are usually of slight significance and in the respiratory form constitute the great majority of the arrhythmias of childhood and youth and of neurotic, congenitally asthenic, unstable, undernourished or mildly toxic individuals. Furthermore, if the pulse is sufficiently quickened by exercise, excitement, or more radically, by full doses of atro pin, which usually lifts the vagus influence to a marked degree within an hour, arrhythmia is often modified or wholly set aside. Instrumental methods at once define them clearly for, whatever the rate of any series, the graphic auricular and ventricular complexes are wholly normal and the variable diastolic phases are obvious. It is an arrhythmia of perfect physiological complexes occurring in normal sequence, abnormal only in the spacing of the rest periods. It is obviously a sinus ejfect in every instance for it is space only that is affected save in the dropped beat type of "sinus block" and here the defect lies in the failure of the sinus to release its stimulus. Simple Bradycardia. — If, on the other hand, vagus inhibition be exces- sive, a slow pulse develops (50 to 55 beats per minute) which in itself lacks Vagus influence. A juvenile type. A simple demonstration. Tests of exercise and atropin. Always a sinus effect. Import ant possibilities. 564 MEDICAL DIAGNOSIS serious significance though it may occur in paralysis of the sympathetic, direct vagus pressure from any cause, from poisoning by adrenalin, digitalis, or lead, or in association with intracranial pressure, acute infections, asphyxia, icterus, convalescence from acute infections, profound toxemias, arterial K R p 1 \ u -P 3 - I l>' j|A E fc 1 Is JSl. lu u Fig. 273. — Complete heart block. Note regularity of auricular and ventricular com- plexes and wholly independent rhythm. P 6 has fallen accurately upon a ventricular T. (After Thos. Lewis.) Lead II. Fig. 274.— Digitalis heart block (partial). Inverted "T" and lengthened "P-R" interval (delayed conduction characteristic of digitalis block). "P-R" normally (conduc- tion time) is 0.12-0. 18 sec. In this case 0.32 sec. Split "P" of mitral stenosis was present in lead I. In this case left ventricular hypertrophy was indicated b>- prominent "R" and absent "S" in lead I, contrasted with its opposite, a submerged "R" and relatively prominent "S" in lead III. Only lead II illustrating the block is shown here. (R. Edwin Morris.) "Vagus heart-block. Fig. 275. — Digitalis heart- 2 : 1 block. Pulse 60; auricular contractions 120 per minute. Inverted T throughout all three leads (digitalis). Lead II here shown. Dissociation does not exist here, but one-half of the auricular contractions fail to cross the Bridge of Gaskell' ("Bundle of His") hypertensions and the like, in connection with which heart block is found to be very common if tested by instrumental methods. In sino-auricular heart block the complexes are normal but certain entire beats may be wholly absent or the heart may slow down and beat at CARDIAC ARRHYTHMIAS 565 about one-half the original rate, whether or not this is always a vagus effect is not determined, but it is frequently seen in digitalis toxemia. HEART BLOCK. — As previously stated, true heart block results from an impaired conduction of stimuli to contraction passing from auricle to ventricle through the bundle of His ("GaskelVs bridge"). The normal conduction time is one-fifth of a second and the " block" may represent a mere lengthening of this interval (the a-c interval of the polygram or "P-R" of the electrocardiogram) or there may be complete dis- sociation, in which case the auricle beats independently at about the normal rate while the ventricle originates its own contractions and beats at a rate approximately one-half the normal. Acute Cerebral Anemia. — If the ventricular contractions become too slow and feeble to supply the brain, syncopal attacks, convulsive seizures, vertigo, or headache may occur which with the evidence of auriculo-ventricular block constitute the Adams-Stokes syndrome. Fig. 276. — Heart block. Dissociation of auricle and ventricle is shown. Ventricle has adopted its independent intrinsic rhythm and the auricle is responding faithfully to the impulses from the pace maker. Death may occur in these attacks or recovery may take place despite a complete cessation of ventricular systoles extending over a brief period. The radial pulse may drop to 5 or 6 beats to the minute just before such an attack, and in one such case of the author's in which recovery from the attack occurred the ventricular beat was wholly inaudible for a period of over twenty seconds.* Age Periods. — Heart block is far more frequent in the male (75 per cent.) than in the female, may occur at any age and will fall into two general groups, i.e., those of the younger ages (ten to forty) in which past rheumatism, chorea and acute infections generally play a chief part, and the older group in which the primary cardiovascular degenerations, aortic lesions and syphilis are the main factors. * One of Mackenzie's cases had 50 attacks of syncope and 15 slight epileptiform seizures during a period of ninety minutes, these attacks recurring every few moments for ten days. Odriozola recently reported a case showing shortly before death intervals of from 50 to 58 seconds between the heart beats (practically one to the minute). Partial block. Complete block. Adams-Stokes syndrome. Asystole. Apparent death. Rheumatic. Luetic and degenerative. 5 66 MEDICAL DIAGNOSIS Acute Infections. — The heart block so frequently present in the acute infections though occasionally complete is usually partial and apparently transient, being indicated by a mere increase of the a-c or "P-R" interval, detected by the polygraph or electrocardiograph. Fig. 277. — Heart block and dissociation in child aged twelve years. Auricular waves are marked "a," carotid waves, "c." Auricular rate 38 per minute. Ventricular rate 88 per minute (almost a 2 : 1 block. Fig. 278. — Same case recovering from pneumonia. Auriculo-ventricular dissociation . Upper tracing, jugular. Lower tracing, radial. The auricle beats at the rate of 108 per minute (a.a.a., etc.). The ventricle takes its own rhythm from the junctional tissue and beats at a rate of 41 per minute. Auricular rate has increased one-fifth; ventricular rhythm remains practically unchanged). tftT»tft»»*TtT »»»»»»» R.R. Fig 279. — Carotid and radial tracing of same case. Carotid tracing shows slight emi- nences indirectly due to the auricular contractions. See beats marked+. Heart block of this type is especially common as a sequence of or in direct association with, acute rheumatism, secondary syphilis, influenza, diphtheria, pneumonia, typhoid fever and profound sepsis. As in the case of the extr asystoles, its practical value in this connection lies chiefly in the fact that it emphasizes the importance of myocardial toxemia in the commonest of acute infections, which are doubtless the starting point of chronic degenerative processes far more often than has been believed hitherto. CARDIAC ARRHYTHMIAS ;67 Changes in the Bundle of His. — Aside from the transient acute infectious types of which little is known, these are of the most varied description, viz. — acute myocarditis, ulceration, chronic myocarditis, gummata, fibrosis. [ ::-. ; So. — Lead I. Fig. 281.— Lead II. Fig. 2S2. — Lead III. Figs. 2S0. 2S1 and 2S2. — Intraventricular heart block. Impaired conduction in right branch of "Bundle of His.*' The "R"' "S" >; T' ; complex is characteristically broadened and split. The appearance of the electrocardiogram resembling broadly extrasystolic deflections of the opposite (unaffected j ventricle. If left branch were affected the picture would be reversed. R. Edwin Morris. tumors, etc. Cryptogenetic focal sepsis and syphilis probably play a promi- nent part in the heart block of the older-age group. Recognition of Heart Block by Simple Means. — The lesser grades as- sociated only with a lengthened auriculo-ventricular conduction-interval 568 MEDICAL DIAGNOSIS Suspicious bradycardia. Suggestive conditions. Auricular "ticking." (a-c of the polygram, "P-R" of the electrocardiogram) cannot be detected by mere observation. One should suspect block (a) when the pulse is below 50; (b) whenever the presystolic murmur and, thrill of mitral stenosis is maximal in early or mid- diastole of the ventricles; (c) in cases of fibrillation with a pulse rate less than R Fig. 283. — Lead I. Fig. 284. — Lead II. Xote fibrillation in all leads. Fig. 285.— Lead III. Figs. 283, 284 and 285. — Same case three weeks later. twice the normal; or (d) in cases of any kind associated with clearly redupli- cated first or seconds at the apex. Turning the patient on the right side one rarely may hear over the auricles tiny clicks which resemble the ticking of a watch and represent CARDIAC ARRHYTHMIAS 569 auricular contractions made audible by their distinct separation from the ventricular systole. This, of course, only in cases of complete dissociation or very decided block. Furthermore, the normal visible jugular pulse may be increased and, per- haps, additional undulations single or multiple which are suggestive of a lack of orderly sequence in the auriculo- ventricular events. Single systoles may be dropped even when others pass through the conducting bundle and these elisions may be regular or irregular in occurrence. The silent pause with pulse intermission thus induced is in sharp contrast to ex- trasystolic dropped radial beats in which case the frustrated or abortive ventricular systole is audible either as to one or both its elements. Such silent intermissions if unaffected by deep respiration indicate a blocked impulse. ■ R R 1 k K J J <\ n n " 1 r T /| g± 11 \\w ' ' IP' I A mil MVm.' II III 1 W m " 1 i Ik r A i ■ " a i 1 F h s s ,s r ~ D - i 1 1 Fig. 286. — Nodal rhythm. Auricle and ventricle contract simultaneously. Auricular complex wholly lost. Note absence of " P," normal "R" and " T;" and absolute regularity equality of "R"s. Rate 48 per sec. When the ventricle is wholly dissociated from its auricle it adopts a rhythm of its own representing usually in rate about one-half the normal frequency. ^ If impulses to contraction arising in the sinus are blocked at the junctional tissues ("His bundle") the auricles respond, but the ventricle follows its own steady slow (30-48) rate receiving its impulses to contraction from stimuli arising in the auriculo- ventricular bundle itself. Contrast this Electrocardiogram with the figure showing true heart block complete (Fig. 269). In this present instance both auricle and ventricle are con- tracting from the same junctional center in exact coincidence and the auricular complex is wholly submerged in the normal ventricular phases. The ordinary auriculo-ventricular heart block does not exist, but the sinus node, the normal "pacemaker" is inert. By the pulse it could not be distinguished from simple bradycardia or active auriculo-ventricular complete block (dissociation). (After Thos. Lewis.) Lewis states that in a 2-1 heart block of mitral stenosis, in which ailment block of various degrees is common, one occasionally encounters two distinct murmurs of stenosis each with its thrill to each radial or carotid beat. This because of two distinct auricular contractions, each competent to force blood through the narrowed mitral orifice but only one capable of exciting a ven- tricular response. Such ventricular silences and dropped pulsations are well appreciated if palpation of the carotid and auscultation of the apex of the heart are practised simultaneously. General Rule. — Complete block is almost invariably present if the ventricular rate is under 40 and in such cases the rhythm is usually regular and peculiarly sedate though, as stated previously, faint echo-like ticks or muffled diastolic sounds over the auricles may indicate the blocked auricular contractions. Simultaneous Auricular and Ventricular Systoles. — It must happen at times in heart block with complete dissociation as in ventricular extrasystoles Large positive jugular putee. Dropped systoles. Silent pauses. 570 MEDICAL DIAGNOSIS Alternating jugular pulse, Important distinction. Unmasking heart block. Serious when persistent and severe. May die in an attack. that one auricular contraction accidentally "falls in" exactly with that of the ventricle. In such cases, the first sound is usually loud and an extremely pronounced systolic jugular wave is present of the character described in connection with ventricular extrasy stoles. It is evident that this condition, if regularly repeated, as occasionally happens, would yield alternate large and small jugular waves as timed by the apex, one being ventricular-systolic made up of the accidentally systolic auricular contraction acting against auriculo-ventricular obstruction (from the premature valvular closure), reinforced by ventricular contraction itself; the other due to auricular contraction alone, the lagging, dissociated ven- tricle being at the time of the latter in its prolonged diastole. Adams-Stokes Syndrome. — Any drop in the ventricular rate below 20 renders the patient unconscious precisely as in temporary complete cessation. Temporary attacks, strongly suggesting and often mistaken for the status epilepticus, occur in such cases when actual periods of asystole ensue, though convulsive movements are oftenest limited to twitching of the face and extremities and even severe attacks are unaccompanied by tongue- biting or the involuntary passage of urine. The author has observed but one proven case in which the latter event occurred. Latent Heart Block. — It was believed formerly that a latent block might be unmasked by administration of digitalis to the point of toxic effect. In such cases atropin betters the condition to some extent or even removes it probably because the supposedly latent block is actually an active vagus effect produced by the toxic action of the digitalis itself. The older belief in an actual persistent, pure, "vagus block" is neverthe- less, practically abandoned. Prognosis in Heart Block. — The existence of any pure, primary and severe heart block without involvement of other structures is dubious, or at least very rare, and a genuine and decided block, if persistent, means a serious condition, a shortened after -lifetime and almost invariably indicates an extensive myocardial degeneration of which the changes in the bundle of His constitute but a part. Nevertheless, it is often extremely chronic and, of itself, and in the presence oj an otherwise slightly affected myocardium, need not produce death for long periods. Exitus usually occurs through the same mechanism as in other forms of cardiac disease or through an intercurrent ailment though it may occur during a severe attack of the A dams-Stokes type. HEART ROENTGENOGRAPHY ROENTGEN DIAGNOSIS OF CARDIAC LESIONS 57i Frank S. Bissell, M. D. Minneapolis While an elaborate discussion of technic does, not properly lie within the province of a work of this character, a few points bearing thereon must be emphasized by way of preface to this chapter. 1. To determine approximately the size of the heart one may resort to: (a) teleroentgenography; (b) teleroentgenoscopy ; (c) orthodiagraphy. Procedures (a) and (b) require only that the tube be 2 meters distant from the plate or screen, the patient being closely approximated to the latter. Orthodiagraphy requires a special apparatus to the employment of which attaches considerable danger to the operator. 2. Simple roentgenography, with glass over the screen upon which may be traced various sections of the heart outline, offers much valuable information bearing upon the diagnosis and prognosis of heart lesions. One advantage of this method is that in the right oblique position the posterior mediastinum may be studied. This space may be found markedly encroached upon in pericardial effusion, hypertrophy of the right ventricle, dilatation of the left auricle, or aneurysm of the aorta. The usual measure- ments, however, are made in the postero-anterior position, the patient stand- ing with his back toward the tube and chest against screen or plate. Principle of Orthodiagraphy. — Since the X-rays take a divergent course from the focal point on the antikathode, any shadow resulting from their obstruction must of necessity be larger than the object causing the obstruction. This distortion is greater in proportion to the distance of the object from the screen and the proximity of the object to the antikathode. Since the distance of the heart from the outer chest wall is a variable one, we would obtain variable measurements of hearts of a given size if we employed these divergent rays. Modified Orthodiagraphy. — By means of a very small lead diaphragm, however, one may eliminate all but those rays which pass in a straight line from the antikathode to a given spot on the fluoroscopic screen. If the tube is now carried around the heart so that this spot of light describes its borders, the latter may be traced accurately upon the glass covering the screen, which is disconnected from the tube box and held firmly against the chest wall. Tracings are also made of the lateral chest walls in order to determine the cardio-thoracic ratio, and of the diaphragm in expiration and inspiration. The median line is drawn through the shadows of the dorsal spinous processes. The most distant outer margins of the cardiac silhouette are then indicated upon the orthodiagram and lines are drawn from these points to meet the median line. The sum of these two transverse lines represents the greater transverse diameter and they may be compared to ascertain the relative distance of the right and left cardiac borders. Technic of heart-study. 572 MEDICAL DIAGNOSIS Safer and better. This orthodiagraphic tracing may now be transferred to a transparent sheet of tracing paper laid over the glass. Teleroentgenography. — Alban Kohler (Deutsch. med. Wochenschr., 1908), first described this method by which it is possible to avoid the more distorting effect of the divergent rays. He placed the roentgen tube at a Fig. 287. — "Drop" heart. Extreme type. (Author's series.) distance of 2 meters (about 6 feet 7 inches) from the patient's back; the pro- jected shadow is then only a millimeter or two larger than the heart, and is recorded upon a photographic plate. This method is both safer and more convenient than the orthodiagraphic method and, probably, quite as accurate. Transverse and longitudinal measurements may be traced upon the tele- roentgenogram exactly as on the orthodiagram. The "Drop" or Pendulum Heart. — The typical "drop" heart is long, narrow and on the screen appears to hang suspended from the great vessels above. Its right border, when visible beyond the vertebral shadow, is 1 1 1 ART ROENTGENOGRAPHY 573 formed by the right ventricle rather than the auricle as in the normal. These characteristics are the result of a low position of the diaphragm and a small atonic heart. Such hearts are extremely frequent in those of an asthenic Fig. 288. — A modified form of "drop" heart. Mitral stenosis (Duroziez's type). structural configuration but modified types of the small heart are also occasionally seen in individuals with broad chests. As the author of this book has shown us, such hearts are readily dilatable and easily overstrained when the general nutrition of their possessors is impaired or an acute prostrating infection is present and even when greatly enlarged, from whatever cause, may most misleadingly present what appears to be a normal total transverse measurement. 574 MEDICAL DIAGNOSIS Heart profile. Important divisions. Left border notches. Important exception. Hence it is of great importance for the roentgenologist to be able to recognize the type even when hypertrophy or dilatation has increased the transverse cardiac measurements to normal or above normal. He may find some assistance in the following points of differentiation from the normal. i. The contractions are sharp, the excursions appearing greater than normal as though one could actually see the heart rotate upon its long axis. 2. The right border is seen to contract synchronously with the left, indicating that the former is the right ventricle. This characteristic is observed, however, only in the typical "drop" heart. 3. The distance from the arch of the aorta to the sternoclavicular articu- lation is increased. 4. If one suspects dilated or hypertrophied drop heart, it is of some confirmatory value to examine the stomach when filled, thus perchance to demonstrate another sign of congenital asthenia — the ptosed stomach. THE NORMAL HEART.— The right and left borders of the heart appear sharply outlined in bold contrast to the air-filled lung on either side. The lower border is concealed by the dense shadows of the diaphragm and abdominal organs, unless it is brought into relief by inflation of the stomach with gas. The base is fused with the equally dense shadow of the large blood vessels. The latter should be considered a part of the cardiac silhouette, so closely are they associated both anatomically and pathologically. The Left Border. — A careful study of the left border of the cardiac profile or silhouette makes it possible to separate it into three, sometimes four distinct sections. These sections are convexities separated by slight indentations in the silhouette. The uppermost one, marked and abrupt, represents the transverse and descending portions of the arch of the aorta. Below this, more perpendicular, and only slightly convex, is the section representing the pulmonary artery and the left auricle, frequently indistinguishable from each other in the normal heart. The third section, longer, more diagonal and tending toward the elliptical outline, is the left ventricle. Right Border. — On the right side the shadows of the ascending aorta and the vena cava are usually overridden by that of the spinal column and ster- num. Below, the border of the right auricle appears as a rather sharp con- vexity. The right ventricle is not determinable marginally, for it is the right auricle which forms the right border of the cardiac silhouette, save in the case of u drop " heart in which the right ventricle forms it. Either the aorta or vena cava may be visible above without pathological significance; the former as a convex shadow, the latter as a straight perpendicular line. With this description of the normal heart outline one may proceed logically to a con- sideration of valvular disease. ■ Valvular Disease. — In our present state of knowledge it is more scientific perhaps to speak of a mitral, or aortic heart configuration than to attempt a hear: ROENTGENOGRAPHY 575 more accurate roentgen differentiation of various types. However, each lesion tends to modify the cardiac outline and the orthodiagraphic measure- ments in a somewhat characteristic manner. Fig. 289. — Advanced endocarditic mitral insufficiency. Note prominence of both convexities and elliptic, contour of left ventricle. Lung shadow opposite left ventricle ! probably due to past embolic process. {Dr. Frank S . Bissell.) Mitral Insufficiency. — If the mitral valve becomes freely incompetent a tendency to stasis and overload in the left auricle is at once evident. Both the pulmonary artery and the auricle thus become overdistended and a resultant alteration may be noted in the contour of the left cardiac border. The section intermediate between the aortic convexity above and that of j change in left the left ventricle below becomes rounded out so greatly as to equal or even to 576 MEDICAL DIAGNOSIS exceed the former in prominence, the result being an obliteration of the normal concavity and the formation of a relatively or absolutely straight line from the aortic convexity above, obliquely downward to the apex. As the left ventricle increases in size through dilatation or hypertrophy its silhouette assumes a more rounded or elliptical contour and this, with the alterations noted above, gives the left heart border a semi-circular shape. If the right ventricle enlarges, it tends to force the already prominent right auricle into greater prominence, thus completing the circle. Here we have the typical mitral configuration. A triangle may be constructed around L.Veni orax Fig. 290. — Fluoroscopically demonstrable pulsation of cardiac rhythm in aortic in- sufficiency with hypertrophy and dilatation of the left ventricle, transmitted to surface of gastric contents. (After Holzknecht.) the circle by dropping lines from an interclavicular point (the apex of the triangle) along the right and left cardiac borders to the diaphragm to form the base. The hypertrophied right ventricle may itself become visible as a per- pendicular pulsating border immediately above the diaphragm and to the right of the sternum. The orthodiagraphic measurements are modified by a marked increase in the total transverse diameter and less marked increase in the longitudinal diameter. HEART — ROENTGENOGRAPHY 577 Mitral Stenosis. — In mitral stenosis, the enlargement of the left auricle is the most distinguishing feature, and this is best demonstrated in the left anterior oblique position, the patient being rotated to an angle of 50 degrees. The dilated left auricle is noted as a marked salient into the lower retro-cardial clear space, encroaching upon or merging into the shadow of the vertebral column. The right auricle may also be markedly enlarged while the left ventricle remains small. Since pure mitral stenosis is extremely rare,* the outline usually encoun- tered is that of the double lesion. The enlargement of the right ventricle and the auricles may be so predominant that the left ventricle is completely overshadowed, the entire silhouette being right ventricular and auricular. This is possible only in pure or stenotically dominant cases in which left ventricular hypertrophy is slight, absent or possibly replaced by atrophy. The left ventricle may be wholly forced away from the wall of the chest by its fellow or one may discern sometimes a division of the left ventricular silhouette into upper and lower curves, that above representing the/border of the right ventricle, that below, the left. In both valvular stenosis and regurgitation, but especially in the former, or in the combined lesion; enlarge- ment of the left auricle is inevitable and may assume enormous proportions. Any such increase may be rightly determined by oblique illumination which may reveal an enlargement equal to or much greater than the size of the fist and show clearly and definitely its presystolic pulsations, or its immobility if paralysis or fibrillation is present. The diastolic-presystolic pulsation in cases of very marked stenosis may assume the form of a laborious deliberate vermicular contraction representing the extra effort required to force the blood from the narrowed mitral orifice. In cases of extraordinary dilatation of the auricle, symptoms of pressure upon the left recurrent laryngeal nerve may be present, precisely as in certain cases of aortic aneurysms involving the first or second portions of the arch, or in certain massive pericardial effusions. In like manner decided pressure may be exerted upon the esophagus and the left primary bronchus. The former may be" demonstrated readily by having the patient take and attempt to swallow large capsules of bismuth when these will be found to be checked or actually arrested for considerable periods at the point of esophageal ob- struction. Curiously enough the patient is conscious of little trouble from * According to the author's experience, cases of "pure" stenosis in the light afforded by modern technic are limited almost wholly to those classified under "Duroziez's disease," elsewhere described, and represent a "drop" heart in a congenitally asthenic, visceroptotic individual who has suffered from active tuberculosis in the past or shows, rather more clearly than the average, roentgenographic evidences of past infection. Several of the author's cases had carried for many years an active, but slow-burning and retarded, pul- monary tuberculosis. In mitral stenosis occurring in individuals of robust build, even when no murmur of regurgitation was demonstrable, the author cannot recall any typical of pure stenosis, and but few small hearts. On the contrary, some left ventricular en- largement has been manifest to some degree even in cases in which, doubtless, the regurgitant element was slight, and, in nearly all instances, a systolic bruit has become audible., ultimately, at some time or in some posture. (C. L. G.) 37 "Pure" stenosis rare. Vermicular contraction. Pressure symp- toms possible. 578 MEDICAL DIAGNOSIS this phenomenon. If a bismuth suspension is taken swallow by swallow, transmitted rhythmic undulation of the esophageal content may be observed. Fig. 291. — Aortic insufficiency with wide dilatation of descending aorta. {Dr. Frank S. Bissell.) Aortic Insufficiency. — In this lesion, the predominant feature is left ventricular hypertrophy with little or no dilatation of the auricle. The orthodiagram therefore shows an elongated, elliptical or oval left ventricular border, a marked intermediate concavity, an increased longitudinal diameter and a relatively short horizontal diameter. The right heart border remains unchanged except when there is marked functional disturbance. The HEART — ROENTGENOGRAPHY 579 right cavities may then be dilated. The radiological demonstration of a distended left auricle (previously described) is distinctive evidence of a concomitant mitral stenosis. In the case of such enormous hearts as result from the combined aortic and mitral lesions or from the aortic lesions alone (cor-bovis) the compression of the left lung and the resulting atelectasis may Fig. 292. — Aortic stenosis type of cardiac outline. Note contour of left ventricle "like an egg on its side." Dorso-ventral aspect. (Dr. Frank S. Bissell.) cause so dense a shadow in the left phrenic-costal angle as actually to simulate a pleural exudate or make difficult the delimitation of the true left ventricular border unless the clarifying effect of deep forced inspiration is evoked. In such hearts the diaphragmatic movements are restricted and that struc- A misleading shadow. 5 8o MEDICAL DIAGNOSIS Epigastric oppression. ture itself may be pressed down 2, 3 or even 4 cm. on the left side. Cohn has reported rhythmic transmittent pulsation of the stomach contents in cases of this kind. Jiirgensen believes that the instances of oppression Fig. 293. — Pericarditis with effusion (typical). Note "stubby" neck above. after meals experienced by many sufferers from heart diseases is due to left ventricular enlargement.* * This doutless serves as one means of explanation for the extraordinary frequency of epigastric localization of the pain, distress or discomfort of cardiac origin in connection with heart lesions. In many instances, however, it seems to be due largely to heightened irri- tability of the muscle of an overtaxed or actually overstrained heart or one whose intrinsic HEART — ROENTGENOGRAPHY Arterial Changes in Aortic Insufficiency. — It is important from the stand- point of prognosis, to be able to differentiate an insufficiency of the endo- carditic type from one of arterial origin. In the latter, the aortic shadow appears widened, either from its point of origin to the arch or throughout its visible extent. It usually pulsates more forcibly than normal and shows in the quality and extent of each excursion the water-hammer quali* characteristically manifested in the peripheral arteries. In the endocarditic type (rheumatic type changes are limited to the left ventricle, the aortic arch and right heart border remaining unmodified. The orthodiagram shows an increase in the long diameter and a relative^ decrease in the trans- x diameter. Combined Aortic and Mitral Regurgitation. — When the aortic and mitral valves both are diseased, the heart body appears more diagonally placed, the left border and the right alike are greatly extended and the apex yet more markedly displaced outward and downward, the exaggerated mid-section of the left silhouette border present in pure aortic lesions becoming filled out to approach or meet the widened areas above and below. Aortic Stenosis. — Early in pure stenosis the changes in the cardiac outline are wholly absent or very slight and in the case of a ''drop"'' heart especially or in any of small size, the dimensions of the organ may be less than the normal maximum even in the presence of an established lesion, for the ventricular changes are extremely slow and the hypertrophy induced is to a large degree, though not wholly, concentric. The radiographic picture of aortic stenosis closely resembles that of insufficiency, the enlargement tending to convert the normal parabolic curse of the ventricular border into an ellipse and in contrast to mitral configuration, to intensify the delimiting notches of the mid-curve of the left border. The apex may appear more blunt and rounded than in aortic insufficiency. In aneurysm, especially of the ascending aorta, and in cases of arterial hypertension, as in other conditions which tend to over- load the left ventricle, one may see sometimes the same elliptic type of heart. Pericarditis Exudativa. — .4 large exudate into the pericardial sac forms a very striking and characteristic roentgen picture. The transverse measurements of the cardiac shadow may be extreme, reaching to the left almost to the lateral thoracic wall, and to the right for 8 or even 9 cm. beyond the sternum into the -.eld. Its shape is distinctly that of a squat oval with left lateral predomi- nance surmounted by the short plugAike shadow of the distended sheaths of the greater vessels above, and suggests a similarity to a poorly moulded decant: a stubby broken neck. A point of differential diagnosis between this configuration and that of chronic general cardiac ins 1 with wide dilatation is that the latter inclines to the triangular in outline. In such cases a slight, low-lying, small pericardial accumulation may intensify the triangular configuration and in both the pulsatory excursion of the borders is greatly diminished. blood supply is irregular, unresponsive or inadequate. Jurgensen also made the interesting observation that in pressure cases arterial tension was markedly increased unless the pres- sure of the gastric gas content was relieved. (C. I.. Aortic .-. 1: .1: :-■-. 582 MEDICAL DIAGNOSIS Sagit tal illumination. A reference to the "rationale" of exudative pericarditis, fully set forth under its proper heading, will make evident the difficulty or impossibility of roentgenograph^ detection in the case of many small pericardial exudates. All degrees of variation of the typical picture here depicted may be encountered. Fig. 294. — Large aneurysm of the ascending aorta. (Dr. Frank S. Bissell.) The Normal Aorta. — In the frontal (sagittal) position examination of the left side shows a shadow of semi circular contour above, which represents the projection of the upper descending portion of the aortic arch. Meas- urements are made to determine the total width of the arch at this point, and the distance which separates its point of origin from the sterno-clavicular HEART ROENTGENOGRAPHY 583 articulation. In normal adults of middle age this distance is on the average two or three centimeters. Its length diminishes in the old and tends to shortness in patients with a short thorax. However the upper margin of the aortic semicircle never overlaps the shadow of the left clavicle except in the presence of aneurysm of the arch. The above observations are made in the erect position and during shallow respiration. Fig. 295. -Aneurysm of aortic arch. Enlarged mediastinal glands. Fibrosis pul- monium. {Dr. Frank S. Bissell.) The right anterior oblique position of 45 degrees offers the best view of the ascending aorta, extending with parallel borders toward the clavicle. At an oblique angle of 60 degrees the descending aorta appears as a convex projection into the retro-cardiac space. Aorta largely hidden. J Oblique illumination. 5^4 MEDICAL DIAGNOSIS Source of error ' Middle lung field " or " retrocardial field." In diffuse dilatation of the aortic arch a gently curving, slightly flat- tened convex shadow appears, showing expansile pulsation. To the left the normal degree of projection may be doubled or so enlarged that its outer border intersects that of the heart at the upper part of the left ventricular silhouette or even beyond that point. Such an aortic shadow right and left may strikingly suggest a large aneurysm and frequently is so interpreted. Fig. 296. — Large aneurysm of the transverse and descending aorta. {Dr. Frank S. Bissell.) In such cases the retrocardial light-field is narrowed but not obliterated. In the form of aneurysm which it simulates the illuminated strip is darkened above by the circumscribed projection which represents the aortic aneurysmal sac. HEART ROENTGENOGRAPHY 58; Expansile pulsation is usually present in aneurysm, but if the sac walls are excessively thick and rigid or the dilated portion itself is packed with clot, such pulsation may be absent or slight in that part accessible to view. But one form of malignant new growth shows anything even approaching true aneurysmal expansile pulsation and that is an extremely vascular type of sarcoma rarely encountered. Aneurysm. — Thoracic aneurysm occurs with decreasing frequency in the aortic arch, the ascending aorta and the descending aorta. 77 may attain large proportions before producing characteristic symptoms or physical signs, and may be and often is wholly unsuspected and accidentally or incidentally discovered in the course of routine screen examination. A special search for aneurysm should be made in all cases of middle or advanced age in which complaint is made of pain in the back, pains radiating into the arms and, especially, when the aortic tone is not perfectly normal. Aneurysm of the Ascending Aorta. — The typical appearance of aneurysm of the ascending aorta is that of a sharply rounded prominence of the aortic shadow projecting into the right lung field. * Turning the patient into the first diagonal position with the screen to the right in front and the rays directed between the left scapula and spine, one may observe the same prominence projecting into the posterior mediastinum. If the aneurysm is of a moderate size and the ascending portion alone is affected, there are usually few pressure symptoms. When, however, the arch is also involved, the left bronchus and the esophagus may show early the effect of pressure. The arch appears widened in all directions; the course of a bismuth capsule showing the gullet to be displaced backward and to the right. The upper margin of the semicircle formed by the aorta approaches the clavicle until, as stated above, there is an overlapping of the two shadows. There is also an increase in the length of a line drawn from the sterno- clavicular articulation to the junction of the aortic semicircle with the heart shadow. Aneurysm of the Descending Aorta. — By reason of proximity of the esophagus to the descending aorta, displacement of this organ (with sub- jective difficulty in swallowing), is one of the early signs of aneurysm of this type. The shadow of the widened aorta projects into the left lung field, well beyond the normal heart shadow. The differential diagnosis between aneurysm and mediastinal tumor may be dimcult. A distinctly delimited and defined tumor showing ex- pansile pulsation favors the former, whereas the irregular, less definitely outlined mass speaks for the latter, but the character of the pulsation is the safest guide, though sometimes fallible.! Transmitted pulsation is, of course, relatively common in new growths occupying this region. * In three cases personally observed a massive tumor representing an aneurysm of the ascending portion of the arch extended downward and to the right, the percussion dulness in two of the cases reaching that of the liver. (C. L. G.) f By an extraordinary coincidence, observed some years ago, a malignant growth and a saccular aneurysm co-existed and permitted a tentative diagnosis of the combined lesion based upon the (then very imperfect) roentgenographic procedure. (C. L. G.) Often unsus- pected. Suggestive symptoms. Typical appearance. Dysphagia. Dysphagia. 5 86 MEDICAL DIAGNOSIS The "bob tail" heart. Extremely common. Begins in early stages. Denial of infection the rule. Test treat- ment. "Fatty" Heart. — Fatty overgrowth is characterized roentgenological^ by the appearance, under the use of a soft tube, of a lesser gray shadow filling the cardiophrenic notch at the apex and tailing of! from the pericardium over- lying the left inferior border and apex to the upper surface of the diaphragm It is roughly triangular in most instances. A similar gray shadow may occur at the corresponding angle on the right side. The Heart Silhouette in Nephritis. — The cardiac hypertrophy which occurs as a result of increased blood pressure, arteriosclerotic kidney, etc., offers no characteristic roentgen sign. There may be uniform increase in all the dimensions of the heart, and both pulmonary and aortic shadows may increase in width. With the development of stasis in the pulmonary circu- lation the lung field becomes clouded in appearance. The illustration of "general dilatation and insufficiency " here shown depicts a common late or terminal type. THE DISEASES OF THE HEART AND BLOOD VESSELS The Importance of Prophylaxis and Early Diagnosis Great Advance in Knowledge. — With relation to the causes and preven- tion of cardiovascular diseases much of the recent research work is of great value. Syphilis. — Lesions of the aorta, aortic valves and myocardium are found to be far more commonly associated with syphilitic infection than we have formerly believed, this fact accounting, no doubt, in large measure, for the relative rarity of aortic valvular lesions in childhood and for the effectiveness of the iodides and of fractional doses of salvarsan in many adult cardio paths. It is evident also that in the heart, the luetic process, as related to the stage of the disease, is one of relatively early inception, and slow but pro- gressive development. (See Cardiovascular Syphilis.) Denial of Syphilitic Infection. — In direct opposition to the views of some syphilologists recent reports on cardiac syphilis based upon the specific diagnostic tests and the result of autopsy, emphasize the extraordinary frequency with which luetic infection is denied even in public services. These facts emphasize the diagnostic and protective value of positive Wassermann and luetin tests in obscure cases, the importance of prompt antisyphilitic treatment in proven cases of infection and the propriety of test treatment in resistant aortic and myocardial cases. Space does not permit a general consideration of the entire etiology of arteriosclerosis or of myocardial inflammation and degeneration in general, but a word may be said in relation to acute rheumatism and certain other infections producing endocarditis and myocarditis. * Dr. Thos. B. Hartzell, Dr. Henrici, and Dr. Gray working in the medical clinic of the University of Minnesota, have demonstrated the extraordinary frequency of occurrence of the streptococcus viridans in pure culture in the peridental abscesses so commonly associated with chronic joint lesions. HEART DISEASE — EARLY DIAGNOSIS 587 Rheumatism. — The onset and course of acute rheumatism have always suggested an infection of a modified septic type, and the relatively recent work of Poynton and Payne, Beattie, Beatson, Longcope, E. C. Rosenow and many other observers has shown that a mildly virulent microorganism assuming any of three forms (a diplococcus, micrococcus or streptococcus) in its different strains, may be quite constantly recovered from the subsynovial areolar tissue of the inflamed joints of the rheumatic patients {Poynton) . Grown in pure culture and passed through a series of susceptible young animals these organisms are said to produce consistently an acute arthritis. Being extremely susceptible to phagocytosis, they are quickly destroyed, are recovered somewhat rarely from the blood, in which they do not multiply, and with difficulty from the joint exudate (Poynton). Foci of Infection. — The intimate relationship between acute and chronic non-suppurative arthritis, and chronic streptococcus infections of the tonsil, and, frequently, of the accessory nasal sinuses, jaw or prostate, seems to be definitely established not alone by the extraordinary frequency with which pure or nearly pure cultures of various strains of the pathogenic streptococci occur in the depths of the tonsils of rheumatic patients or in dental abscesses, but also by the astonishing immunity to or relief from the disease following the complete painstaking removal of all tonsillar tissue or the radical cure of other foci of infection. Rosenow's work, in clinical collaboration with Frank Billings, later indi- cates that the organisms above described, together with the streptococcus viridans, are strains of the hemolytic streptococcus, modified by the varia- tions of oxygen pressure attending their growth, and that the different varieties show more or less well-defined selective affinities for the endo- cardium, synovial membrane, myocardium and skeletal muscles respectively. Radical Treatment of the Chief Etiologic Factor. — Guerich advocates the removal of suspected tonsils at any stage of active rheumatism,* and though we may consider this a too radical rule of action, we must admit that, if diseased, or if past attacks of tonsillitis have occurred, their complete extirpation is indicated in all persons able to bear the operation who show a rheumatic tendency or who have passed through an attack of the disease. Indeed, bearing in mind the early or primary involvement of these struc- tures in diphtheria, influenza, scarlatina and other acute infections in which endocarditis and myocarditis frequently occur together, with their etiologic potency in relation to chronic arthritis, anemia, and probably in many other chronic ailments, it would seem that with respect to the urgency of surgical procedure we are justified in placing tonsils in the same category and at the head of the list which comprises adenoids, chronically infected accessory sinuses, chronic appendicitis, cholecystitis, prostatitis and the peridental infections. The author finds that many cases carrying curiously unstable intermittently toxic hearts, quite apart from actual valvular disease, and often with no history * In the relapsing form of rheumatism this procedure may be quite justifiable and ini- tiate permanent recovery after one or two days of post-operative exacerbation. Modified sepsis. Recovery of organisms. Portals of infection. Streptococcus strains. Radical suggestion. Justifiable procedure. Relation to other infec- tions. Tonsils head the list. 5 88 MEDICAL DIAGNOSIS Chronic inter- mittent myo- cardial toxemia. May appear normal. Prostrating infections. Myocardial toxemia. A striking contrast. of rheumatism or any related acute infection, recover myocardial tonus only after such foci are discovered and removed. Diseased tonsils, especially, are natural incubators, transmutators and com- missaries for invading organisms, and may appear misleadingly normal on in- spection even while breeding successive generations of pathogenic germs or con- taining actual pus in considerable quantity. Partial removal is a poor and usually a wholly ineffective substitute for complete enucleation. Again and again the Author has seen acute rheumatism develop after a tonsillitis affecting the tonsillar remnants persisting after a partial extirpation. Misleading Delayed Onset. — In seeking to establish the etiologic factors in a given case of acute rheumatism or endocarditis, one may readily overlook acute tonsillar inflammation. An acute tonsillitis though rarely absent in a carefully taken history, seldom accompanies the actual onset of arthritis, but more frequently precedes it by a period varying from a few days to three weeks, and may be very mild. Physical Debility and Cardiac Weakness. — Yet another point of practical value in relation to etiology, diagnosis and therapy is to be found in the consideration of acute rheumatism, diphtheria, scarlatina, influenza and indeed any acute infection associated with marked physical prostration. To the author it seems probable that in such cases the excessive, genuine weakness so often encountered is ordinarily not one primarily or chiefly resident in or directly affecting the skeletal musculature, though this and the nervous system must be important factors, but, in a large degree, repre- sents the relative inadequacy of a more or less poisoned myocardium. In the fatal cases of acute infections the cardiac muscle invariably shows at autopsy, greater or lesser local effects of circulating toxins even though a grossly demonstrable endocarditis or actual myocarditis be absent. The as- sumption that in all acute prostrating infections the myocardium suffers at least temporary damage is justified apparently by our present better knowledge of the symptomatology of minor cardiac insufficiencies and, of late, is generally accepted. The vasomotor control is also greatly disturbed. Heart Muscle vs. Skeletal Muscle. — The heart's intrinsic circulatory capacity is ten times that of skeletal muscles. It is an extraordinarily delicate and highly specialized tissue, and must maintain constant activity under conditions of direct and disproportionate exposure of its naked fibers to the toxins of disease.* The less delicate and highly organized skeletal muscles, on the other hand, are at rest during an illness, receive relatively a far less abundant supply of toxic blood and, in most instances of brief prostrating infections, fail to show under dynamometric tests any such degree of weakness as accords with the subjective and objective manifestations of exhaustion which may be present. Instrumental methods, moreover, have shown that auricular fibrillation, the * Heart-muscle fibres are unsheathed. HEART DISEASE — EARLY DIAGNOSIS 589 lesser degree of heart block and extrasystolic irregularities occur with suggestive frequency in various acute infections followed by recovery. Percussion Outlines. — In many of these cases, during such periods of weakness, carefully conducted percussion by modern methods, especially after slight exertion, reveals an abnormally increased cardiac outline, most frequent and most marked in such persons as structurally fall under the head of "chronic congenital asthenia," but by no means limited to that group. Abnormal Heart Sounds and Bruits. — Furthermore, one will often find, under like conditions, and even in the absence of profound anemia or actual endocarditis, not only transitory or inconstant murmurs, but also a weakness, undue sharpness, muffling, or abnormal accentuation of the cardiac tones, indi- cative of distinct though usually transient myocardial damage. Rest after Acute Prostrating Infections. — Many a case of persisting cardiac weakness and ultimate chronic degeneration of the myocardium dates its inception from the onset of such an attack, unrecognized and unsus- pected, and its persistence to a premature resumption of customary activities. Prolonged cardiac rest, rational heart stimulation, and a gradual and guarded resumption of normal activity, after diphtheria, acute rheumatism, scarlet fever, typhoid, severe influenza, and in fact, all acute infections attended by profound physical prostration, is a matter of vital prophylactic importance too little regarded at the present time. The almost universal failure to examine such cases thoroughly and critically after the resumption of full activity, results in the loss of many golden oppor- tunities to detect chronic cardiac and cardiorenal lesions in their early stages. The Viewpoint. — Obviously, a mere detailed study of individual lesions is by no means sufficient to prepare one to meet and deal with a branch of medicine characterized alike by the diversity and complexity of its problems and the interdependence and logical sequence of its morbid phenomena. Therefore, we must understand the genesis of such lesions and acquire a thorough knowledge of the symptomatic expressions of cardiovascular in- adequacy, more or less common to every organic lesion. THE VITAL POINT. — Heart-muscle is the paramount clinical factor in cardiovascular problems even though primary, associated, or consecutive valvular lesions, arteriosclerosis or pericardial inflammation are the most obvious and obtrusive elements in the given case. Diagnostic Limitations. — An impeccable antemortem differentiation of the many forms of pathologic change which may enter into myocardial degenera- tion and resulting cardiac insufficiency is an absolute impossibility. We cannot clinically differentiate the clinically indivisible, but we can and should recognize the resulting cardiovascidar insufficiency. Xor is it vitally necessary that we should finically differentiate the myo- cardial degenerative processes, if, relatively early, we are able to detect their presence and to retard their damaging effects upon the circulation and the body tissues which this nourishes and purifies. That which, even upon the autopsy table, leaves much for the microscope to determine does not lend itself to hair-splitting clinical diagnosis, and Toxic arrhythmias. Minor dilatations common. Significant signs. A neglected precaution. Always the myocardium. 59° MEDICAL DIAGNOSIS No clean-cuf divisions. Shifts and changes. Subjective vs. objective symptoms. Loose use of term. Suggested limitation. A probability not a certainty. though one may definitely place an arrhythmia or a specific valvular lesion, the exact anatomic alterations of the heart muscle or of its coronary ar- teries cannot be determined antemortem. The Problem is Always Myocardial. — One properly may reiterate the fact that valvular lesions and the arrhythmias alone offer an opportunity for specific diagnosis and indeed their separate recognition is of great value and may strongly influence our management of the case. At bottom, neverthe- less, practically all problems are those of heart muscle and even our patholo- gists give few clean-cut differentiations of that composite of myocardial degenerations, invariably encountered post-mortem in the diseased heart. The question ever is that of predominance of one of the many pathologic processes present. Many Possibilities. — -A heart muscle may be congenitally unstable in strength and tonus, as in congenital asthenia; weakened by severe infections, by mitogenetic sepsis, or by the damage wrought by the physical handi- caps and associated myocardial damage, inseparable from valvular defects. To either condition, fatty overgrowth, fatty degeneration, cardiosclerosis, acute or chronic toxemias, actual bacillary invasion, coronary sclerosis, fresh endocarditis, or a pericarditis, may be superadded. Phasic Changes in Co-existent Lesions. — Several important lesions, valvular, vascular, or myocardial, may co-exist in the same heart, and, with the passage of time, the primary dominance of one may be submerged in that of another, and, ultimately, the combined, cumulative effect of all may be exerted. It is with relation to the myocardium especially, quite apart from manifest dilatation, that subjective manifestations are more important than objective symptoms as aids to early diagnosis and, as in the case of a positive Wasser- mann or the recovery of the streptococcus viridans or streptococcus rheu- maticus from a blood culture, may outweigh in therapeutic importance all the murmurs and thrills in the category. The basic symptoms are ever those of cardiovascular weakness, and im- paired "reserve" manifested in all varieties by much the same general symptoms and permitting no finely spun conclusions of a clinical sort as to the dominance of this or that form of degenerative process. "Chronic Myocarditis." — Myocardial degeneration or even "myocardial insufficiency 1 ' is a far better clinical term than the much employed " chronic myocarditis" until we shall have been told what actual chronic myocarditis really means in clinical terms. The author prefers to limit the latter term to cover, at most, the earlier periods in cases of chronic insufriciency distinctly following the acute infec- tions, in which severe acute myocardial processes, recognizable or not, have left residual nutritive deficiencies and degenerative processes which latter result in a dominance of fibrosis, fatty degeneration, brown atrophy or what not. We can no more than assume as probable the presence of a true chronic myocardial inflammation, from any antecedent history of a recent acute infection during which clinical signs and symptoms of myocardial insufficiency, still in part or whole existent, were clearly in evidence. HEART DISEASE — EARLY DIAGNOSIS 591 Recognition of Insufficiency Imperative. — Inasmuch as cardiac insuffi- ciency arising from any one of its many causes is so often exactly like that of the ott: :ust strive to recognize " insufficiency" itself, and as such. Upon thai foundation, we may build as stable a diagnostic structure as the ascertain- able, additional data permit and by this determine our therapeutic initiative. Cardiovascular Reserve. — A knowledge of these signs and symptoms peculiar to individual valvular lesions and those of gross myocardial insuffi- ciency together with the technical training necessary to their recognition are alike indispensable, but the therapeutically productive, life-extending field is that of conservation of cardiovascular reserve, and, as previously emphasized, the chief duty of the physician lies in the careful study of the signs and symptoms of the earlier and lesser compensatory defects. The Lesser Symptom -producing Insufficiencies. — These lesser cardiac insufficiencies and minor dilatations merit a far greater amount of study and therapeutic attention than they have hitherto received, for modern experience and investigation shows that damaging, acute and chronic, per* sistent, or temporary, but recurrent, toxemic overstrains with or without myocardial degeneration or underlying valvular disease, are relatively com- mon sources of many misinterpreted subjective or even objective symptoms.* CARDIOVASCULAR "SUFFICIENCY" AND "INSUFFICIENCY".— What Constitutes Compensation. — Although the so-called "compensatory" cardiac changes associated with and necessitated by actual diseases of the heart are usually adaptive rather than truly compensatory, they are never- theless wonderful in their efficiency and may remain effective as to the indi- vidual for decades in the case of certain lesions. Yet nothing can compensate more than partially or temporarily for the loss of a normal cardiovascular mechanism, and in certain forms of cardiac disease and in certain individuals compensatory changes are extremely imperfect. Even now we overestimate greatly the efficacy of those remarkable but imperfect retarding processes, which we term '•compensation."" Those of us who were privileged to serve in the Great War saw compensatory changes in the juvenile heart at their best, and it was difficult to realize the fact that if these young cardiopathic cases were as a body to be taken over by an insurance company the loss would run anywhere from 250 to 500 per cent. above that of an equal number of normal men. Nine hundred and ninety-nine out of one thousand confirmed cardiopaths today owe the major part of their protection from gross decompensation to symptoms, recognized or not by them, which automatically enforce a s' down of their activities, and most cardiopaths, with boaderline reserve, are constantly forcing their diseased hearts. The primary necessity. Early recognition imperative. Unrecognized inadequacies. Adaptation to conditions. Obligatory Dilatation. -In valvular lesions dilatation of some degree is * Homing's report upon a radiographic series of 1100 apparently normal hearts among which he found a considerable number of acute transient heart strains has served to show that the condition is more frequent than is generally supposed. Had his observations been directed especially to the "drop" heart and the remediable minor dilatations of the diseased heart his figures would have been yet more illuminating. 592 MEDICAL DIAGNOSIS primary and, ultimately, a certain increase in the cubic capacity of the heart chambers must be permanent. Secondary hypertrophy, responsive to the need of increased energy, limits dilatation and maintains reserve. Never strictly concentric, it is often a source of vascular degeneration from the associated in- crease of initial pressure involved. Almost invariably, it is soon in gradual process of being insidiously undermined by progressive myocardial degener- ation and an impaired coronary blood supply. The existence of aclinic ally and pathologically recognizable pure work-hypertrophy has never been demonstrated. Theoretically, hypertrophy may overcome completely any primary dilatation or be gradually induced without it as in the case of gradually de- veloped arterial hypertension or aortic stenosis, and adequately maintain the circulation for years by simple increase of ventricular force. Few, if any, cases justifying this assumption appear upon the autopsy table whatever the cause of death, nor can one understand the continued and stable effectiveness of such force increase, associated with normal rhythm, whether in the presence of free mitral or aortic regurgitation, aortic stenosis, or chronic hypertension, unless there is combined with hypertrophy an increase in the cubic content of the ventricular cavity. A certain amount of fixed dilata- tion is a necessary ultimate accompaniment of all such conditions, and with that the physician need not and cannot interfere. It is when tonicity and contractility begin to fail that aeticn is demanded. Morbid Dilatation. — Hypertrophy by limiting dilatation prevents over long peiiods that "overdistension" which represents the dominance of acute or chronic overstrain and excessive stimulus to contraction due to residual blood overload, venous stasis or both conditions in the presence of a diminished myocardial tonus. Such morbid dilatation produces symptoms, subjective and objective, in varying degree; narrows cardiac reserve; accelerrates ex- isting degenerative processes; and may properly be called morbid dilatation. An Apparent Fallacy. — One of the apparent fallacies of cardiac pathology is the theoretic assumption that inasmuch as the heart possesses the power to exert a thirteen-fold increase of strength to cover the field of response repre- sented by minimal and maximal demands, absolute rest on the one hand and severe physical strain on the other, it is quite capable of tiding over unaided and without additional damage, the period between the onset of a valvular lesion and the occurrence of established and adequate hyper- trophy, or even the increased dilatation which may result from infection, shock, or physical overstrain in established lesions. The normal heart of the individual who is reasonably "fit" may, and almost always does recover from temporary overstrain and dilatation provided that relative rest is secured. Otherwise, many, rather than a small minority, of college athletes would carry damaged or even crippled hearts."* * The heart of the perfectly trained robustly built athlete will actually diminish in size with quickened rhythm under strenuous exercise even if sustained during considerable periods, but the author has seen many congenitally asthenic or badly trained young ath- letes retired with badly dilated and extremely irritable hearts. Permanent damage is not uncommon. HEART DISEASE-EARLY DIAGNOSIS 593 It cannot be true of the heart which had weakened and dilated under an acute toxemia of the sort associated with acute endocarditis or myocarditis or one which is more or less continuously subjected to chronic toxemia or sepsis and recurrent or persistent overstrain. Fortunately, however, from its large primary reserve fund enough usually is left available to keep even these hearts safe from actual disaster to their Fig. 297. — Normal heart, taken in inspiratory phase. Transverse measurement 13 cm. possessors until the necessary relief occurs, and some further self-protection is afforded the patient by the subjective sense of weakness, or an actual physical disability, which limits his activity during this period, but which he, unwatched and uninstructed, all too frequently disregards. brake That no damage is done in such cases is hardly conceivable nor is it in accord either with clinical experience or experimental work. 35 The automatic 594 MEDICAL DIAGNOSIS Big normal hearts rare or non-existent. Exaggerated Estimate of the Normal Dimensions of the Heart. — No radiographic examples of a normal heart of excessive size (exceeding 13.5 cm. in total transverse diameter) have come under the author's observation. (See Cohn's Table under " Heart. "p. 429.) Damaging error. A common type. Fig. 298. — Beautiful example of the "hanging" ("drop") heart. The same quality is more or less well marked in all, if viewed fLuoroscopically during full inspiration. Total transverse, 9 . 5 cm. Many abnormally dilated hearts are accepted as normal in size because of a faulty conception of what constitutes a normal outline, together with a disre- gard of the law of proportionate weights and of individual peculiarities of body structure and conformation. THE "DROP" HEART OF THE CONGENITALLY ASTHENIC IN- DIVIDUAL. — During the past ten years the author has been deeply interested THE DROP-HEART 595 in the study of a host of cardiopaths showing predominant subjective mani- festations, together with clearly denned evidences of impairment of tonicity with or without either persistent cardiac dilatation or extreme dilatability, though the heart diameter, radio graphically, and by percussion, falls within the maximum "normal" The underlying condition corresponds apparently to what Mackenzie called the "X disease." His description is precisely that of a common type of Fig. 299. — An extreme instance of the "drop" heart (dorso- ventral aspect). Dimensions: Mr., 2 cm.; Ml., 5.5 cm.; total transverse, 7.5 cm. (Same heart shown in Fig. 158.) so-called "passive neurasthenia," and the physical and mental characteristics of these patients, as described by him, would seem to justify one in replacing his "sign of the unknown quantity" by the term " chronic congenital asthenia ." This, the constitutional defect of structure and function of which Berthold Stiller, of Budapest, has drawn so clear and vivid a picture as to secure What it represents. 596 MEDICAL DIAGNOSIS Fig. 300. — Dilated "drop" heart. (Outlines drawn from original roentgenograms (by E. Brill) and superimposed.) Dotted vertical white lines indicate outline after treatment. Case of premature resumption of activity after a very severe attack of lobar pneumonia. Note that in the case of this ambulant patient carrying a decidedly dilated heart the total transverse measurement is but 12 cm. Original measurements: Mr., 4.0; Ml., 8.0; total, 12 cm. Final: Mr. 4.0; ML, 5.3; total, 9.3 cm. Fig. 301. — Dilated "drop" heart. (Original outline determined by orthopercussion; final profile, by roentgenogram.) Acute toxic dilatation associated with premature resump- tion of activity, following a severe attack of articular rheumatism. Syncopal attacks. Dotted vertical white line represents border after return to normal " drop." Original measurements: Mr., 4.3; ML, n. 5; total, 15.8 cm. Final: Mr., 4; ML, 6.5; total, 10.3 cm. THE DROP-HEART : " Fig. zo2. — Dilated "drop" heart. (Outlines drawn from original roentgenograms by Note small transverse area (12.2 cm.) of the heart even when dilated. Vertical white dotted^line shows left border after treatment. Cause of dilatation unknown in this case. Right border of •'drop' 1 heart is ventricular not auricular as in normal heart. No objective symptoms of incompensation. Exertion dyspnea. Original measurements: _ : W ' : 2; total, ::.: cm. Final: Mr.. 4.; ML, 5. 7; total, :.- cm. — Dilated "drop" heart. (Drawn from original roentgenograms by E. Brill.) Perhaps the commoner acute type, showing decided involvement of the right ventricle. Case of influenza with marked prostration. Premature resumption of activity. Vertical dotted white lines show right and left borders after subsidence of dilatation. No objective ive a soft apical systolic bruit and exertion dyspnea. Complained of persistent sense of fatigue drowsiness during the day. Insomnia at night. Original measurements: Mr.. : 5. Ml., 8.0; total. 14.5 cm. Final: Mr 4.81; ML, 5.8; total, 10.6 cm. Clarifies obscure complexes. 59S MEDICAL DIAGNOSIS its wide recognition by his European colleagues, nnd sits expression in a protean and kaleidoscopic symptomatology which satisfies a large portion of the terminology of several hitherto obscure syndromes, of which it con- stitutes apparently the basic factor. Fig. 504. — Re:ess:onof borders of a dilated ""drop " heart. Figures ;c^ and 505 sriowthe remarkable retraction attending the treatment of a dilated "drop"' heart. The case one of influenzal bronchopneumonia of long duration. Patient was ambulant when first seen by the author on February 17. Heart sounds short and sharp. Systolic bruits at apex and m pulmonary area. Apex beat diffuse. Systolic retractions over right ventricle. Pulse extremely labile but regular. Radiography showed a heart 16 cm. in total transverse diameter. On March 20 a second radiograph showed a reduction to- 13 cm. and a third taken on June 2, a further reduction to 0.5 err:. Fig. 305). The Heart of Congenital Asthenia. — If dilatation and hypertrophy are The "hanging" absent, these patients show usually a misleading!)' narrow, attenuated, extremely motile." mobile, more or less low-lying, ''hanging," heart {tropenform Herz), often asso- THE DROP-HEART 599 dated with a low diaphragm, arterial hypoplasia and marked vasomotor ar.c general circulatory instability and lability. During periods of impaired nutrition or toxemia the heart muscle is singularly deficient in sustained tonus or in any tendency to undergo decided Fi: - — rLesumption 01 ai laaon of the "drop" hear: th ::-rtr.::i'_;- ~ri--: - i:~. : zr:j ir. line of massive pericardial enusi< id and full hypertrophy even when the seat of recurrent or more or less persistent minor ".rains, but the readiness with which minor insufficiency or even dilata- tion occurs, under physical or emotional overstrain and, especially in acute infection, with or without associated murmurs of a peculiarly transitory DOatabiLty 6oo MEDICAL DIAGNOSIS and evanescent character, is a striking clinical phenomenon which hitherto seems to have escaped specific recognition.* Fig. 306. — "Drop" heart of a man six feet two inches in height and of the asthenic type. He attends to business daily, but has so marked an exertion dyspnea as to make the ascent of a half dozen steps a cause of breathlessness. Reading aloud is difficult. Dimensions: Mr., 6.8 cm.; Ml., 2.8 cm.; total transverse diameter, 9.6 cm. There is no evidence of any attempt on the part of nature to repair the congenital defect. The signs of insufficiency are seldom strikingly objective even in decided dilatation and the change in the cardiac profile may be either very great, as in * So far as the author is aware attention to the direct clinical importance of this form of heart in the relationships here discussed dates from his delivery of the "Oration in Med- icine," read before the American Medical Association in 191 2. There is a wealth of liter- ature bearing upon the "drop " heart under its many variants of title. But the significance of its obviously defective musculature, misleadingly common clinical occurrence, tendency to obscure its own dilatations even when decided, and direct and constant relationship to visceroptosis seem to have been disregarded. See "Prognosis in Chronic Heart Disease as Adversely Affected by Certain Medical Traditions.'' Jour. A.M. A. vol. 59, p. 685-690, 1912. THE DROP-HEART 60 1 the case of severe acute dilatation in a prostrating acute infection or so slight as to make its recognition a matter of difficulty. In the latter cases, the quick response to rest and digitalis is illuminating. Effect of Environment and of Sex. — The series of illustrations offered show clearly the variations in form that these hearts may assume and suggest strongly the basic unity of the so-called " small heart" and the. "drop" heart. Fig. 307.— Stomach of patient whose heart is shown in Fig. 302. They also serve to explain the puzzling orthodiagraphic contours which have been presented, for example, by Adler and Krehbiel.* A dilated or a dilated and hypertrophied ''drop" heart may produce such outlines; a fundamentally normal heart, never. The so-called u small-heart" will be found almost invariably in suggestive association with the visceroptosis of congenitally asthenic individuals and in most instances represents a dilated or hypertrophied "drop" heart. * Archiv. Int. Med., Chicago, vol. ix, p. 346-361, 191 2. 6o2 MEDICAL DIAGNOSIS The "drop" heart is extremely common in the female; common in the male, and, probably, the effect of environment and mode of life in childhood has a great effect in determining its strict adherence or relative nonadherence to the type in development. In many if not most instances these individuals attain a degree of myo- cardial adequacy which enables them to lead an active life. Fig. 308. — Modified "drop" heart. Case showing distinct impairment of cardiac reserve, although heart measures but 9 cm. in total transverse diameter: Mr., 3 cm.; ML, 6 cm. A soft localized systolic murmur was present at the apex. Right ventricle is enlarged, left also probably. To what extent the almost universally present roentgenographic signs of obsolete, latent or, more rarely, active tuberculous infection, affects the devel- opment of this type of heart is a question of interest. Such infections almost wholly, no doubt, date from childhood; for the " asthenic" tissues afford a favorable locus for the tubercle bacillus. Misleading Bruits. — Murmurs when present over these hearts are systolic and may be maximal in the mitral, tricuspid or pulmonic auscultation areas. THE DROP-HEART 603 The last are usually ascribed to anemia alone, but in such cases they may and often do occur in its absence or tend to persist or recur after any existing initial anemia is relieved. (See "Anemic" and "Accidental ^lurmurs.") Therapeutic Test. — In such cases the administration of full test doses of digitalis with, or oftentimes without, enforced rest, usually causes distinct amel- ioration or disappearance of some or even all subjective symptoms and, not Fig. 309. — "Drop" heart. It will be noted that the right border is hidden by the sternum- Ml. in this case is 5 cm. infrequently, a more or less decided but demonstrable shrinkage in the cardiac area of what may have seemed originally to be a heart of normal dimensions, but which proves to have been a dilated "drop." As previously stated, a "normal" transverse diameter, as usually defined, The cardinal represents in the heart of the congenital asthenic an enlargement, or, in 604 MEDICAL DIAGNOSIS Deceptive measurements. Such hearts Qf ten adequate. other words, the heart that is normal for the congenital asthenic is abnormally narrow for the individual of good physique. The undilated and non-hypertrophied asthenic heart may measure no more than 7.5 cm. in total transverse diameter in thin subjects and 9.5 to 10.5 cm. constitute the usual normal. Fig. 310. — A modified "drop" heart associated with a soft mitral murmur and distinct signs of minor incompensation. A common form. Heart dimensions: Ml., 6 cm.; Mr., 4 cm.; total transverse, 10 cm. Occurrence of Symptoms. — Possessors of "drop" hearts even of the nar- rowest type need yield no subjective symptoms or physical signs abnormal for the (abnormal) individual unless an acute infection, emotional shock, or actual and unusual physical overexertion initiates it. Furthermore, their resistance to such influences seems to depend to an amazing degree upon the state of nutrition of the individual, all well-marked and physically unre- generate asthenics being nutritional barometers. THE DROP-HEART 605 nutiitiun. /;; addition to subjective symptoms due to cardiac inadequacy these individ- uals, as patients, show a wealth of obscurant subjective symptoms resulting from their general structural deficiencies, and their chronic tendency to subnutrition Unstable and psychasthenic. A congenital muscular weakness and relaxation is present, which, as manifested by uterine displacements, loose kidneys, gastroptosis, intes- tinal kinks and the like, have afforded a large, though usually a thankless field for surgery. Fig. 311. — Stomach of same patient showing high grade gastroptosis. These cardiac and gastric types are apparently well nigh, if not wholly, inseparable. Constancy of Concurrence of "Drop" Heart and Visceroptosis. — So con- stant is the concurrence of this cardioptosis with abdominal visceroptosis that, finding a decided "drop" heart, one may assume with certainty a demonstrable gastroptosis and enteroptosis, and vice versa. Within slightly varying limits the degree of ptosis in the one is reflected in that of the other. Frequency of Occurrence. — One who is constantly using roentgenography Extremely as a part of the routine examination of patients, will find the "drop" heart in 6o6 MEDICAL DIAGNOSIS A bastard syndrome. some of its various forms just as common as is the abdominal visceroptosis with which it has run parallel in the author's experience. ''Neurasthenia." — In this connection the author ventures the hope that the term " neurasthenia. '" which, though professedly a descriptive name for a supposedly concrete ailment, at present serves to obscure the true nature of so many of these cases, will either drop out of medical literature or be con- Fig. :::. — Modified •''drop* 5 heart. Periods of decided incompensation marked by syncopal attacks, exertion dyspnea, and precordial and epigastric distress. Total trans- trie diameter, 9.5 cm. hned to the extremely few cases left without a more definite assignment under the application of modern diagnostic methods. i,See '"Neurasthenia.'"' Psychasthenia.* — Recurrent or long-persisting subjective mental fatigue and excessive psychic irritability are the logical symptomatic results of a basic condition in which a constant tendency toward poor circulation, chronic * The term is used in its literal sense. THE DROP-HEART 607 subnutrition, toxemia, anemia, and secretory anomalies of the digestive tract and ductless glands, play the important part, and an hereditary struc- tural and constitutional disposition to psychic instability furnishes a fertile soil for the ready production of diverse and often bizarre symptoms. The Rest Cure. — Fortunately the u n so widely and effectively employed under the diagnosis oi "'neurasthenia." exactly suits the needs oi Fig. 313.— Same of "drop" heart. Usui: Lent the asthenic cardiopath from the standpoint of both nutrition and cardiac muscle tone, as indeed it fits the therapeutic needs of a vast number of other chronic diseases. SOLDIER'S HEART. — For the past ten years the author has been try- ing to emphasize the great clinical importance of the structural peculiarities prediction. of these people with relation to the heart itself. In 1915, in making a revision 6o8 MEDICAL DIAGNOSIS "Heart ex- haustion." Heart diseas may be lacking. of his "Medical Diagnosis" he predicted that a vast number of such cases would arise in army service and prove an embarrassment to the carrying on of military operations and also outlined the clinical picture which such individuals would present.* "Civil War" Cases. — These congenitally underpowered^ functionally unstable persons are born with defective or potentially inadequate {not diseased) myocardia and furnish the most typical examples in army service of that condition described originally by the elder DaCosta during our Civil War as the "irritable heart of the soldier," and better and much more aptly by Dr. Hartshorn, also of Philadelphia, as "heart exhaustion." Basic Factors. — During the war just past great numbers of cases of profound myocardial exhaustion were denominated "soldier's heart," "neuro- circulatory asthenia" "neurocirculatory myasthenia " or "effort syndrome" but fundamentally the larger and more interesting group was composed of victims of universal congenital asthenia wholly free from any actual disease of the heart yet showing abundant evidence of myocardial exhaustion. The condition of the heart in these soldiers differed in no essential feature from that encountered by the author in civil practice during the past decade, save that the degree of decompensation present was much greater on the Myocardial exhaustion. The Commoner Symptoms. — The cardiovascular symptoms present in these "soldier's hearts" are simply those of myocardial exhaustion or impairment of various degrees accompanied no doubt in many instances by those of an acute dilatation which in all probability was recognized as such only in the rarest instances because of the initial narrow diameters of the "drop" heart and its modification. These maybe summarized as follows : (a) Persisting sense of fatigue or an unusual fatigability. * ' ' The elements of shock, emotional crises and physical exertion which enter so greatly into modern warfare must produce acute heart strain in vast numbers of young soldiers of the slender congenitally asthenic type. One may venture to predict that the condition will prove to be extremely common in the European war and that it will fall upon this type of individual in a large proportion of the cases. This being the case the clinical picture presented will be one of profound physical exhaustion, a high pulse rate, without any marked constancy of arrhythmias save of the juvenile type, except there be a history of antecedent ''trench fever," "rheumatism," " tonsillitis " or antecedent organic heart disease. Arrhythmias should occur chiefly in the older groups in whom antecedent degenera- tive myocardial processes might be anticipated. In young asthenics high grades of functional nervous disturbances might be expected. The heart outline in the older or previously tainted individuals might be abnormally large. In members of the asthenic group it should seldom exceed greatly the normal maximum diameter (13 cm.), by reason of the fundamentally small size of the "drop" hearts which constitute their normal. Both subjective and exertion dyspnea should be present initially and vertigo, faint- ness or actual syncopal seizures would be noted at the onset of the attack in many instances. The symptoms of more or less profound psychasthenia might be assumed as inevitable in a large number of cases." THE DROP HEART 609 (b) Dyspnea on exertion or, in the severer cases, more or less persistent even when at rest. (c) Vertigo in the more extreme cases. (d) Discomfort and, in the more acute cases, actual precordial pain. This sensation varied from a mere sense of substernal fulness, crowding or pressure, dull aching, to actual angina of the severest type. (e) Syncope. Syncopal attacks seem to have occurred with far greater frequency than would be the case in civil practice, no doubt because of the more complete and acute exhaustion sustained by the myocardium under service conditions. (/) Tachycardia. As might be expected, tachycardia was a symptom very generally encountered and this sometimes persisted over long periods or even after treatment had been abandoned. On the other hand, persistent arrhythmias seem to have been relatively infrequent. Heart murmurs, if present, were slight, often transient, systolic, and of the type usually termed functional or accidental. Failures in Primary Selection. — In 191 7, when acting on a Cardiovascular Board, the author found and reported that we were passing large numbers of these congenital asthenics into all branches of army service who could not prove otherwise than a burden to any command, but practically no recognition had been given to this clinical group and consequently there were no rules of selection in effect adequate to protect the army from their undesirable presence. As is now known, to an astonishing degree they proved an element of embarrassment in the conduct of military operations, many breaking, at the outset and during training, others going on and yielding only under the stress of actual front-line service. Vital Points. — Surprisingly, one finds even in the recent literature little understanding of the fundamental structural and functional inferiority which pertains to this most interesting body of men and women. The author would especially lay stress upon the fact that, although in them as in other individuals, any and all kinds and degrees of organic myo- cardial or valvular defects may occur, yet the interesting and outstanding feature is the relative ease with which varying degrees of myocardial insuffi- ciency, from slight to grave, may be produced in the absence of actual disease of the heart muscle, its valves, or its blood vessels, by causes insufficient to affect adversely the hearts of sthenic individuals. Adaptation and Self -protection. — Furthermore, a large proportion of these congenital asthenics, though born under a handicap, achieve through favorable environment an amount of myocardial reserve and a degree of functional sufficiency which does not permit us to distinguish them from the more favored individuals of our general population except by the detec- tion and assessment of certain stigmata to be referred to later. In civil life the congenitally asthenic individual in many instances consciously or unconsciously acquires the habitude of self-limitation of effort and self-protection from adverse influences which threaten his 39 Non-recogni- ion. Its result Self- protection. 6io MEDICAL DIAGNOSIS inadequate myocardial reserve. In the Army such self -protection was impossible. Period of Breakdown. — The cases which figure so largely in the medical reports of all armies engaged in the "Great War" fall naturally into two groups. Fig. 314. — (E 72). So-called "soldier's heart" in civilian patient. A typical ex- ample of what is so frequently described as the "small" heart. ■ Is actually an enlarged drop heart. The electrocardiogram shows marked right ventricular preponderance. i. The particularly unstable group which broke down at the outset. 2. Those who "carried on" until their greater yet fundamentally less- ened reserve yielded to the tremendous strains imposed upon them in actual service or in combat warfare. THK DROP HEART 6ll It may be added that this same group of individuals furnished a large proportion of the persisting psychoneuroses which were returned to our country and to others for treatment. Leading Characteristics. — The chief characteristics of this group, aside from the presence of the "drop heart" or its modifications (usually described as the "small" heart), are: Fig. 315. — ''Drop" heart in patient suffering at intervals from definite but not extreme decompensation. All through life there has been conscious self protection from overexertion. Xo murmurs were present even during periods of decompensation. Elec- trocardiogram shows right heart preponderance. (a) A slender build, in general representing what used to be called the pre-phthisical habitus." with slender bones, slender and oftentimes poorly- 6l2 MEDICAL DIAGNOSIS developed muscles, an especial flabbiness being present in many cases in the abdominal musculature. (b) Most of them are possessed of a long and narrow or flattened thorax with a sharp or relatively sharp intercostal angle. Fig. 316. — Enlarged and insufficient "drop" heart. Total transverse diameter n. 1 cm. The type of heart frequently miscalled the " small" heart. Skeletal musculature in this young woman unusually developed. Abdominal muscles relatively flabby. Marked gastroptosis present with atony. Dyspnea on exertion pronounced; fatigability decided. Patient has been very strong with respect to individual and brief physical effort but has lacked endurance all her life. Such hearts at present are almost invariably passed as normal by the physician or life insurance examiner. This does not mean that such individuals are necessarily meagre, emaciated, or underweight. Indeed many are "heavyweights" and some carry an amount of adipose tissue which tends to obscure their structural peculiarities. THE DROP HEART 6l 3 (c) All are predisposed to the curious instability of function which is universal, and to another peculiarity of the utmost importance in connection with war, namely, a remarkable dependence upon nutritional reserve and a peculiar instability of this reserve. Furthermore, they are especially vulner- Two vital factors in causation. Fig. 317. — Markedly dilated "drop" heart the seat of myocardial degeneration. Symptoms of decompensation marked during preceding six years. No murmurs present. Gastric disturbance a prominent feature. Dyspnea on exertion, constant fatigue, slight edema of lower extremities, marked tenderness over left heart border. Gastroptosis decided. Patient a woman, weighs 200 pounds. Under treatment the diameter of this heart (i6.4.cm.) was reduced to 13.8 cm. as shown in Fig. 318. It will be noted that the original "drop" heart contour has been measurably resumed although both right and left ventricles are hypertrophied. Such silent degenerated "drop" heart are especially decep- tive and misleading. able with respect to infections, and well-defined cases convalesce slowly and oftentimes imperfectly from such infections. 614 MEDICAL DIAGNOSIS Visceroptosis. (d) The great majority of them go on without any symptoms so long as they are well-fed, well-nourished, and well-environed. Reverse this and they become subjectively, or, less often, frankly ill. (e) More vital, from a diagnostic standpoint, than these traits just named is the presence of universal visceroptosis in varying degrees. Fig. 318. — Same heart as shown i-n Fig. 317 showing shrinkage of outline under treatment and the approach to the original "drop" heart outline, which has been obscured by the dilatation existing over a long period of time. Many years ago the author pointed out that, with rare exceptions, in fluoro- scopic examinations one might make an immediate diagnosis of "drop-heart" in examining the abdomen and finding a gastro ptosis or decidedly movable kidney. So on the other hand, finding the heart of congenital asthenia, one could accurately affirm the presence of a ptotic stomach. THE DROP HEART 615 One must not understand that all cases of so-called ''effort syndrome," or ''soldier's heart" are congenital asthenics. The symptoms characteristic of this syndrome are merely those of profound myocardial exhaustion. extreme narrowing of reserve, and may be produced most readily in these individuals congenitally unfit or potentially so. Fig. 319. — (E 86). "Soldier's heart" in civilian male. Type of individual who in the Army broke down under the severer stress and strain of actual campaigning. This man had lead an active out-of-door life as a ranchman but following severe overstrain com- plained of syncopal attacks, precordial pain on or following exertion, marked fatigability, recurrent edema of ankles and feet, and intervals of arrhythmia apparently due to recurrent fibrillation. Note that total transverse diameter of heart at this time was but 11.7 cm. The gastro- ptosis present in this case is shown in Fig. 320. (See also Fig. 321.) On the other hand any and every cause operating upon any heart and adequate to produce a marked diminution of tonus may produce exactly the 6i6 MEDICAL DIAGNOSIS same symptoms, for these are identical with those shown by individuals carrying normal hearts but subjected to intense exhausting myocardial overstrain. Indeed, the recognition of the "soldier's heart" rested largely upon the ease with which these symptoms were produced under physical effort, mental strain, or both combined in individuals lacking the signs of frank organic heart disease. Fig. 320. — Gastroptosis associated with insufficient drop heart shown in Fig. 319. Obligatory Exposure to Adverse Influences. — The adverse influences operating upon the victim of universal congenital asthenia who had been inducted into army service varied greatly with the type of service demanded of him but embraced on the whole everv factor calculated to break down THE DROP HEART 617 the reserve of a considerable proportion of the young adults carrying this constitutional defect. As has been stated, the element of self-protection often unconsciously plays a large part in the ability of large numbers of the congenital asthenics to endure such stress and strain of life as falls upon them, but when brought Fig. 321. — Same heart as shown in Fig. 319 showing increase of diameter to 12.7 cm. following the undertaking of heavy work against physician's orders. This enlargement was associated with a renewal of the old symptoms which had disappeared under treatment. Note that even when thus dilated the heart falls well within the so-called "normal'' transverse cardiac diameter. into army service these safeguards, consciously or unconsciously established bv them, were of necessity abolished. As a result large numbers could not withstand the "hikes" and drills even of the opening days or weeks of their period of military training. Others with greater reserve weathered the 6i8 MEDICAL DIAGNOSIS training period only to become unfitted for service under conditions of actual campaigning across the water or the yet more strenuous demands, psychic and physical alike, of actual fighting at the front. Fig. 322. — "Soldier's heart" in civilian. Another example of the "drop" heart which played so important a part in the cardiac disabilities of our troops in Army service. This individual was able to do heavy farm work up to the age of 18. Collapsed while working in hayfield during very hot weather. At the time this exposure was made, showing a heart only n. 7 cm. in total transverse diameter, decompensation symptoms were pronounced, there being marked dyspnea on exertion, subjective persisting dyspnea and precordial discomfort. Patient's recovery was reasonably prompt under treatment and all active symptoms disappeared. Nevertheless his reserve is per- manently impaired and heavy work cannot how be undertaken. Myocardial Toxemia. — Aside from this, it should be remembered that a very large proportion of these individuals carried concealed septic foci or I larval tuberculous infection such as might be, and often were, relighted under I conditions of army service. nn: drop in: \u r 619 Furthermore, many were subjected to primary acute infections such as infections, mumps, measles, pneumonia, and influenza and were not giveii that pro- longed period of convalescence necessary to individuals of this type. 6 A.V Fig. 323. — "Soldier's heart'' in civilian. A type frequently encountered in Army service. Reserve capacity good but failing under great physical and mental stress, or both of these elements combined. This individual was seen first in an attack of acute dilatation associated with fibrillation; both of which conditions endured only sixteen hours as nearly as could be determined at the time. Young active man. The outline is that of a "drop" heart. There still exists (after treatment covering about three weeks) mani- fest enlargement of the left ventricle which probably is permanent and represents hyper- trophy. This finding is confirmed by the electrocardiogram. Condition Common to Civilian and Soldier. — The author would repeat that "soldier's heart," "effort syndrome," "neurocirculatory asthenia," 620 MEDICAL DIAGNOSIS Non-recogni- tion of dilatations. "neurocirculatory myasthenia' ' not only are one and the same thing but represent conditions in no way peculiar to army service. As stated previously, the cardiovascular symptoms presented by these cases differed in no way from thoseeencounyered every day in cival practice though in a larger proportion the evidence of exhausted myocardial reserve were more extreme and the difficulties attending its rehabilitation and restoration were correspondingly greater. Undoubtedly, owing to the adoption of faulty standards with relation to heart measurements, a great number of cases of actual dilatation were overlooked and, furthermore, the treatment which these men received in general was not such as would in the highest degree promote their permanent recovery. One is not surprised, therefore, to find that a large percentage of such cases were discharged unbenefited, or but partially restored to health. Unstable Reserve. — In the heart of the congenital asthenic there is a degree of instability with relation to reserve which makes the rebuilding of the myocardial strength a matter of the utmost difficulty. This is peculiarly true of such cases as arose in a multitude of instances during army service where, because of unavoidable and obligatory exposure to adverse influences, the exhaustion of the myocardium was unusually profound. Fundamentals in Treatment. — In treating profoundly exhausted cases the utmost care should be observed throughout with respect to the resump- tion of physical activity. One must be satisfied with slow, tedious, incre- mental renewal of reserve power through primary rest followed by a most carefully regulated resumption of walking exercise. Under no circum- stances should such individuals be " tested out" from time to time to a point of fatigue or the revival of any of those symptoms characterizing their condition. According to the author's experience in civil practice, it is as easy to empty such hearts of newly acquired reserve in the earlier stages of their improvement as it is to pour water out of a glass, and the utmost care is necessary to prevent the patient from putting his newly acquired strength to tests long before he has reached a degree of restoration which makes this safe. He must not only be kept within the limits of his reserve during his slow progression but always well within the safety zone. Another curious factor in relation to such cases with marked degrees of reserve impairment has been the deleterious effect of upper-arm exercises or marked body flexion, and in the author's private practice these are carefully avoided. It is to be hoped that in the deplorable event of another war the rules and the means of selection may be such as will better protect the army and its various services from those members of the congenitally asthenic class who are likely to break down under the stress of war, and, on the other hand, secure to selected members of this grouo opportunity for patriotic service suited to their physical ability. THE DROP-HEART 621 MINOR INSUFFICIENCIES.— The symptoms of cardiac origin as mani- fest oftentimes in such cases as fall under the ailment just described, namely, those of chronic congenital asthenia with weakened hearts, throw much light on the Fig. 324. — Modified '"drop" heart often encountered. Young man of nineteen Never robust, yet six feet tall and inclined to athletics, in which he is fairly proficient Inherits the powerful build of his mother's family and the "drop" heart of his small-boned father (radiographically demonstrated). Boys may attain a good heart despite congenital handicaps, but frequently pass through phases of partial inadequacy. Many break down on the athletic field, but only temporarily in most instances. A young man of this type with exactly the same inheritance and heart outline, stroked one of the greatest crews in this country for a year, only to break down in his second year with wide dilatation. subjective manifestations of cardiac insufficiency of minor grades arising from more serious causes. The peculiar clinical features of the ptotic heart and its chief relationships mav be thus summarized. 622 MEDICAL DIAGNOSIS The "drop" heart is merely one manifestation of what is usually a general visceroptosis, slight or decided, and may or may not consti- tute its dominant feature clinically and anatomically. The author is convinced that the parallel between the "drop" heart and the "'drop" stomach especially is a relatively exact one. v 1 I - Fig. 325. — (E 66). Interesting example of enlarged "drop" heart in a female of Amazonian type, representing probably a case of crossed inheritance. General build and skeletal musculature was extraordinarily good. The symptoms were almost wholly gastric. There was slight edema of the lower extremities which had gone unnoticed by the patient. Slight exertion dyspnea also was present. Gastroptosis decided. (See Fig. 259 for com- parison.) Both are evidences of constitutional defect in great measure. Both are extremely common but may show all gradations from the typi- cal to that which closely approximates the normal. Both tend to show THK DROP-UK \R I ()2 . 2 > symptoms only under conditions of impaired nutrition and in each these take the form of atony, functional instability and the production of trouble- some subjective symptoms often of a most misleading character. Both are peculiarly responsive to functional rest and other measures cal- culated to restore their labile nutritional balance and increase their tonus. Fig. 326. — (E 66'). Outline of heart shown in Fig. 325 following treatment. Total transverse diameter has been reduced 1 cm. All symptoms have disappeared and the heart is shown to be of the modified "drop" type with enlargement of both right and left ven- tricles. This is the type of heart so often described misleadingly as the "small" heart. Neither, of itself, is a fatal or even serious ailment and under favorable environment both conditions may be carried throughout a lifetime replete with good health and characterized by what is essentially normal activity, both mental and physical. 624 MEDICAL DIAGNOSIS On the other hand, both may make their possessor trouble from child- hood to the day of his or her death from some other cause. The heart by reason of the peculiarly insistent and persistent demand upon its musculature and its abnormal sensitivity to acute and chronic Fig. 32; -Modified insufficient "drop" heart in a heavy woman carrying beneath her fat the basic asthenic stigmata. Transverse measurement 8.5 cm. toxemias is especially Uable,remittently or persistently, to show a diminution of reserve and consequent limitation of the field of symptomless forced response. In the heart both periods of impaired tonicity and even of actual minor THE DROP-HEART 625 but pathologic dilatation are extremely common. See Figs. 329 and 330 and, especially, Figs. 356 and 357. Finally, that these periods have, in the past, almost wholly been over- looked and disregarded. Fundamental Assumption. — It is obvious that one would not await the onset of pulmonary or renal congestion, hepatic engorgement, marked dyspnea, ascending edema and flagrant and obtrusive dilatation, before feeling justified in active therapeutic interference in heart disease if he pos* sessed the means of recognizing with some degree of certainty the minor grades of actual insufficiency. These major symptoms represent the expression of serious or extreme cardiac Fig. 328. — Heart of a fat male asthenic with poor resisting power and endurance. "Hanging-drop" heart typical save that it gives evidence by its contour of a musculature far above the normal for that type. Total transverse measurement only 9 . 2 cm. weakness, a dangerously narrowed field of myocardial response, and, fortunately for the patient, often serve him both as danger signals and emergency brakes, but they should not constitute the sole criteria of therapeutic initiative. Unavoidable Effects of Cardiovascular Lesions. — However chronic and slowly progressive the condition, crippling valvular lesions, progressive myo- cardial degenerations, sclerosis of the coronary arteries or of the entire vascular system, high arterial tension and the like, once established, after a variable but usually greatly prolonged period of adequate balance inevit- ably embarrass and hamper the intricate, exquisitely responsive and deli- cately balanced mechanism of the circulation and tend constantly or inter- mittently to overwork the heart and blood vessels, narrow the field of pre- viously effortless response and reduce the legitimate life expectancy of the patient. COMPENSATION AND DECOMPENSATION.— Sequence of Events in Decompensation. — This varies somewhat with the nature and site of the 40 Avoidable delay. 626 MEDICAL DIAGNOSIS Over- distention Dilatation primary or dominant lesion. If one assumes as an example the sudden production of aortic leakage, his mind's eye at once sees the diastolic back- rush of the blood from the aorta to the left ventricle, the overdistention of that elastic pumping chamber by the opposing currents represented by Fig. 329. — (E 80). Same heart as shown in Fig. 330. showing the reduced diameter following a short period of ambulatory treatment. The heart was originally a "drop" heart, marked associated gastroptosis being present. The outer white line shows the passing out of the left border by renewed dilatations after the patient had broken treatment and disregarded all instructions, the result being the recurrence of pulmonary congestion and other signs of minor decompensation. that pouring through the open mitral valve from the auricular reservoir above and the abnormal inrush from the aorta below. One finds primarily a dilatation of the left ventricle, limited and con- stantly resisted by muscle tonus and contractility, and usually, by an in- Ill ART- COMPENSATION 627 creased frequency, evidently adapted to lessen the load per heart beat, and yet supply the vitally necessary nutriment to the body tissues and burn their waste products. It is evident that the intermittent shock and overaction now experienced by the aorta and to a less degree by the blood vessel Arteries. throughout the body cannot but tend gradually to produce degenerative Fig. 330. — E 80'). Readily dilatable "drop" heart in obese young woman. Decom- pensation when present manifested chiefly by pulmonary congestion. Exposure shown was made during such a decompensate ry period. The total transverse diameter is 14.7 cm. See Fig. 329 for comparison. arterial changes and a slowly progressive increasing deficiency of the peripheral circulation and of the heart itself. Men do not often die of chronic valvular disease, per se, but of its inevitable accompaniment, myocardial degeneration. 628 MEDICAL DIAGNOSIS Acquired equilibrium. Hypertrophy is gradually superadded to dilatation and after a variable period, in young hearts at least, the increase of muscle and the dilatation limiting tonus establish a circulatory equilibrium backed by a variable amount of "reserve," often wholly adequate to hard labor, and a normal pulse Fig. 331. — A type of cardiac outline frequently observed in high blood-pressure cases. Note underlying "hanging drop" type and extremely small transverse diameter despite the increase of left heart area. rate. There remains, however, perhaps only in slight and unnoticeable degree, a constant slowly progressing damage in the vascular field. In such cases we inaccurately but conveniently say that " the lesion is compensated." HEART-COMPENSATION 629 A Cardiovascular Paradox. — So wonderful is this adaptive change that for years a man may pursue a laborious occupation without any serious break in this circulatory equilibrium, yet he may and often does break down suddenly under some unusual physical strain, no greater, less perhaps, than May endure for years. Fig. 332. — A "drop" heart, once typical roentgenographically, which has assumed a modified aortic profile during the past ten years by reason of the development of an inter- stitial nephritis and sclerotic changes in the aortic valve, associated with systolic and dias- tolic bruits, persistent arterial hypertension and a sustained high diastolic level. Viscer- optosis and other stigmata of congenital asthenia typical; patient during many years was typical "neurasthenic" and "nervous dyspeptic;" and bears scars of several futile abdominal operations. Cardiac compensation never more than "fair." Best for several years at the time this exposure was made. Dotted line shows approximate form and position of left border before the period of change. Under author's observation twenty years. Despite the great relative change in size, the heart measures but 14 cm., total trans- verse diameter. (Died of cerebral hemorrhage since the legend was written.) that of his daily labor, to the peculiar strains and vicissitudes of which cardiac and skeletal muscles alike have become trained and habituated. 6.SO MEDICAL DIAGNOSIS Progressive Diminution of Cardiac Reserve. — Year by year the margin of relative safety for such patients diminishes under the effects of more or less Potent causes, constant myocardial overstrain, the abnormal arterial and venous pressure, the toxins of fatigue, disturbed metabolism j the constantly impaired and ever diminishing coronary blood supply, and the invariably progressive cardio- vascular degeneration. Fig. 7)33' — -^ n interesting example of the dilated and hypertrophied imperfectly com- pensating "drop" heart. The patient's heart formerly measured about 10 cm. For the past eight years she has carried arterial hypertension 170 to 220 + and passed through a cerebral apoplexy. Weight of patient was 185 lb. but the structure was typically asthenic. The diseased and greatly enlarged heart shows a "normal" (13.5 cm.) measurement. An impure mitral first sound or an actual apical bruit has persisted. Slight edema is present usually, but patient is ambulant. Direct factors. To t k e5e constant f ac t rs one must usually add the effects of recurrent infection or toxemia from primary cryptogenetic sources or from without. HEART COMPENSAT: 63 1 The Laboring Heart, — Certain direct decompensatory factors are com- mon to all valvular and myocardial lesions and the chief of these are muscle strain, gradually oUininishing tonus with progressive or recurrent in both of dilatation and dilatabilitv, and progr .isceptibilitv to fatigue. Fig. 554- — Widely dilated heart of the ''drop'* type. Ambulant patient extremely weak and dyspneic. Case of pernicious anemia, erythrocyte count 1,325.000. Heart undoubt- edly the seat of fatty degeneration and shows evidence of fatty infiltration in the shape of an illy-denned "tail" at the apex. Heart measurements — _: _ ML, 11.5 cm.; total transverse. 16 cm. Typical stigmata of congenital asthenia. Death six weeks later. representing a slow but constant contraction of the field of cardiac response. The wonderful cardiovascular mechanism can and does overcome unaided its more or Jess frequently recurring periods of minor insufficiency, though at a con- stantly increasing cost f but not without flying distress signals other and earlier than the classic symptoms of the later stages of decompensation. 632 MEDICAL DIAGNOSIS Permits effect- ive therapy. Early Diagnosis. — We are just learning the importance and value of the early diagnosis of heart disease and of prompt recognition of myocardial insufficiency of lesser grades as prerequisite to timely and effective treat- ment. The aim and end of diagnosis is effective therapy and no department Fig. 355. — Interstitial nephritis with progressive increase of arterial hypertension Effect upon a "drop*' heart. Patient under observation twenty years. Change in outline associated with periods of transient dilatation and increased arterial tension nve years ago. At present systolic pressure varies from 185 to 200 -p and incompensation is manifest in slight diurnal leg edema, slight dyspnea on exertion and persistent subjective fatigue. Heart only 13.8 cm. in total transverse diameter. (Death from acute dilatation and pulmonary edema since legend was written.) of medicine offers a broader, better, or more fruitful field than that of cardio- vascular disease. A suggestive parallel is to be found between the present neglect of the early evidences of decompensation in the cardiopath and the like failure to recogjiize HEART — COMPENSATION (>33 and direct or treat the victim of incipient and early phases of tuberculosis but a few decades ago. Results may be obtained in heart disease through early recognition, wise supervision and direction in minor grades of insufficiency, which will compare most favorably in respect to bestowal of added comfort and Fig. 336. — Aortic regurgitation and mitral insufficiency superimposed upon a "drop" heart. After several years the heart has attained a transverse diameter of 11.5 cm. Ml. 8.5; Mr., 3 cm; total. 11.5 cm. The "hanging" quality is shown even better in the original negative. The patient's reserve was distinctly impaired. increase of longevity, with those now obtained in tuberculosis. One cannot but surmise that, if the cardiopath were infective in proportion to the presence or increase of decompensatory signs, he would fare better. 634 MEDICAL DIAGNOSIS Retardation and Rehabilitation the Primary Need. — As in the case of tuberculosis, so also in heart disease, the effectiveness of its management depends upon the earliest possible recognition of the lesion itself and of its decompensations. Such management involves intelligent oversight, sane counsel and, when any insufficiency is discovered, rational and timely thera- Ftg. 337. — Despite obvious enlargement of the left ventricle the total transverse measurement is but 10.5 cm. i^See Fig. 338). peutic aid directed especially to the relief of those lesser decompensatory phases which are inevitable sooner or later, once the lesion is definitely established, though often almost unbelievably slow in. reaching a recogniz- able stage, once the primary insufficiency has been compensated. HEART — JNCOMPENSA TM\ 635 MEANS OF EARLY RECOGNITION OF FAILING RESERVE.— It is evident that the means of such prompt recognition of cardiovascular insufficiency deserves first consideration and discussion. Direct Tests of Cardiac Sufficiency. — We have sought long, but never yet found a direct, single, simple test of cardiac sufficiency of moderate grades. Even the wonder-working modern instruments of precision fail to supply Unreliable tests. Fig. 338. — Stomach of patient whose heart is shown in Fig. 2i gastroptosis. Note decided this need in any degree at all commensurate with the time and training neces- sary to their intelligent and critical use. The muscle antagonism test of Herz* the pulse rate recovery test of Mendel- * Flexion of the forearm at the elbow if firmly maintained is supposed to slow the pulse if the heart be weak. ::: MZDICAL DIAGNOSIS 3ohn and Graupmer* or thai of KaktnsUinJ ore alike uncertain and Varioos other tests based upon the variations in blood pressure attend- ing changes in posture or stated exercise, and even resort to the deter* ±zz: :- - ; :zs: iere-d :i;i:::; ::":: :e *Tnnerec " Iz-Ztn: ± ::: Ilrr I Z hear: DECOMPENSATION 657 Many other similar tests are alike indeterminate, but fortunately we may in most instances detect existent cardiac insufficiency bx the response of anx sub- Valuable , . . /•', ,. ■ simple w symptoms present, and. m many instances, oj the cardiac percussion area method. Fig. 54c. — Same heart as shown in Fig. 2 So. showing remarkable change in outline under treatment and full recovery of compensation. Mr.. 5 .5 cm.; ML, 10.5 cm.; total M., 16 cm. A reduction of 3 cm. in transverse diameter is evident, a remarkable figure for a hypertrophied and dilated heart of this type. One has to think of the circumferential reduction obtained to appreciate the full measure of change. Another patient under treat- ment at the same time (transverse measurement 17 cm., and showing initially the same conditions less the Cheyne-Stokes breathing, left the hospital rehabilitated, yet showed a shrinkage of but 0.5 cm., an amount too small to be exactly determinable. The cases emphasize the fact that impaired tonus rather than mere relief of dilatation is the funda- mental factor. of the suspect, to a few full and adequate but physiologic doses o T ' a direct cardiac stimulant with or without absolute rest, as the individual case demands. y either the normal heart nor the efficiently compensating hypertrophied Heiphii fact heart should show a decided change [Frankel and Schwartz, Cloetta;. 6;S MEDICAL DIAGNOSIS Una voki able errors. Know and demand the normal. The readiness with which decided dyspnea is produced under exertion doubtless remains the mcst useful direct rough test of myocardial inadequacy. Great Value of Skilful Percussion. — As may readily be shown by X-ray control, serious error in skillfuly applied percussion by modern methods, though occasionally unavoidable, and sometimes gross, is far less frequent than is generally believed if one adheres to like conditions on different occa- sions, outlines both borders, and substitutes the modern rectilinear ortho- percussion method, with or without threshold percussion, for the heavy flat-finger technic of former days.* In the case of acutely or subacutely dilated hearts even though preexisting hypertrophy is present, the shrinkage of outline is usually marked and the lessened area is often so well maintained under and following the therapeutic: test as to be most illuminating, but the most important and constant factor is the rapid amelioration or disappearance of troublesome symptoms oftentimes pri- marily obscure and remote. The most dramatic relief of symptoms may result in cases showing a roentgenographs or roentgenoscopic change of cardiac outline so slight as to be useless for purposes of routine clinical comparison and this is especially true of many symptom-producing "drop" hearts and of old lesions with well-established enlargement of the ventricular cavity and hypertrophy of its walls. This statement applies both to those cases presenting subjective symptoms only, and to such as carry objective signs of the grossest and most obvious type. One has but to recall the ratio of circumference to the diameter to realize that a very definite and decided shrinkage may fail to diminish the cardiac profile by even one centimeter. It is evident also that a symptom-producing diminution of tonus may be unaccompanied by a dearly demonstrable extension of the cardiac silhouette. Auscultation. — With respect to auscultation our great need is of an accur- ate knowledge of normal sounds and the range of permissible variations, together with a concentration of our attention primarily upon the question of their presence or absence in the given case.T One may suggest the need of more careful attention to weak and impure sounds and abnormalities of accent, and * Treupel found in 97 per cent, of the cases examined by the method of threshold per- cussion a variation of less than 1 cm. in the position of the right border as compared with the orthodiagraph^: outline. In 95 per cent, the left border- was established with the same accuracy. Such remarkable figures are not applicable of course to the ordinary routine of a busy practitioner. inasmuch as they represent doubtiess examinations made under ideal conditions of time and place. The author finds accurate determination of both the left and right borders sometimes impossible, for him, by any method, when working under ordinary office condition s-which embody noise and interruptions. In general he finds that an error by one careful man is shared by those who follow him. Roentgenography and roentgenoscopy long since were adopted therefore as an unvarying part of the routine of his consulting-room work. f In the section dealing with the exa min ation of the heart the author has referred to the common mistake of seeking primarily the abnormal; rather than the proving of the pres- ence of the normal. The difference is a email v vital. HEART DECOMPENSATION 639 a less exclusive concentration on actual murmurs which are the most obvious of the phenomena of cardiac disease. Cardinal Factors in Timely Diagnosis. — Five decided steps in advance make this possible, viz.-' (1) A fuller realization of the importance of the anamnesis and of the cardinal value of the sensations of the patient together with a knowledge of the number and diversity of subjective symptoms of cardiac origin. For this we must thank chiefly James Mackenzie and Henry Head. . 2. A more accurate standard of "normal" heart measurements. 3. .1 proper valuation of alterations in subjective and objective symptoms and, oftentimes, in the heart outline under tentative therapeutic measures. 4. The knowledge that both the wholly normal and the fully compensating 'though crippled heart fail to show material response to doses of digitalis * which are clinically effective in decompensation. 5. The substantial increase in accuracy afforded by modern percussion methods and the use of the x-ray. 6. The use of instruments of precision yielding graphic records of the heart action. It is to be hoped that before long one may be able to add — The abandonment of the flat-finger method in heart percussion. Proper Valuation of Subjective Symptoms. — The early recognition of cardiac incompensation demands a better understanding and truer valuation of the subjective manifestations of cardiovascular disease, until recently submerged and concealed by our ignorance of their genesis, nature and peculiarities of localization and by a natural but most unfortunate tendency to attribute them nearly always to sources other than the heart. THE RECOGNITION OF SUBJECTIVE SYMPTOMS.— The subjective symptoms of heart disease are many, varied, and invaluable, though few are peculiar to cardiac insufficiency and none are pathognomonic. The fundamental factors in interpretation are: 1. The relation of their occurrence to concurrent or precedent physical exertion, especially if this be of an unusual nature. 2. Their occasional association with the lesser demonstrable dilatations. 3. Especially in the case of the middle-aged patients and to a less degree in. younger persons, their relation to excitement or emotional strain. 4. But chiefly their favorable response, and oftentimes that of the cardiac outline, when increased, to cardiac stimulation, with or without physical rest or regulated exercise, as may be found necessary. Subjective Dyspnea. — A subjective sensation of dyspnea, diurnal or nocturnal, even of the milder types, is a striking symptom of value, too readily ascribed to hysteria or "neurasthenia." Even a persistently increased respiratory frequency or an inability to hold the breath is frequently over- * Frankel: Ueber Digitaliswirkung auf gesunden Menschen, Miinchener med. Woch- enschr., Hi, p. 1537, 1905. Cloetta: Einfluss der chronischen Digitalis behandlung auf das normale and patholo- gische Herz, Therapic der Gegenwart, vol. xlix, p. 437, 1908. Why formerly unrecognized. Fundamental factors. Very im- portant. 640 MEDICAL DIAGNOSIS Of corrobor- ative value. Hypertension. Muscle cramp. looked in the absence of any complaint of dyspnea or too hastily credited to the same diagnostic " catch all."* Another cardinal early symptom of failing reserve is subjective dyspnea initiated by relatively slight, but unusual effort. Purely Subjective Symptoms. — A sense of lassitude, of easily induced physical fatigue, vertigo, unexplained drowsiness during the day time and unrelated to heavy meals, f or insomnia, wakefulness, lack of concentration and sustained application, mental confusion, faintness, actual syncope, heaviness of the legs or the sensa- tion of wading through water, together with disturbed sleep, bad dreams and subjective gastric dis- turbances of the most varied kinds, are extremely common, helpful and suggestive, though by no means dis- tinctive, symptoms. One of the most important of all symptoms is an inability to per- form without conscious added effort and fatigue everyday tasks formerly easily dispatched. This represents in most in- stances the first evidence of a nar- rowing of the cardiovascular reserve and may be associated with any one or several of the other symptoms mentioned. In cases of insufficiency asso- ciated with high arterial tension, numbness and prickling of the lower extremities frequently occur, often being manifested only under a coincident increase of cardiac dilatation and increased arterial pressure and subsiding as these are relieved. Pain or Discomfort Due to Muscle Fatigue and Overstrain. — Any muscle in the body may give rise to manifestations varying from mere subjective discom- fort to agonizing cramp-like pain when forced to continue maximal effort under conditions of excessive strain and fatigue. We have the report of forced marches, the records of various long-dis- tance contests, as well as the histories of acute heart strain in patients to * In a number of instances observed by the author the recurrent or paroxysmal dyspnea attending excitement or emotional strain has had all the earmarks of the hysterical form, which doubtless can occur, yet was found to be associated with cardiac insufficiency and arterial hypertension. In such cases not only the emotions, but even slight gastric or intes- tinal overdistention, or mere corset pressure, may precipitate an attack. t A very common symptom in the author's experience and one of the most responsive to the therapeutic test if due to circulatory insufficiency. Fig. 341. — Case of mitral leakage and moderate dilatation. Pain during preced- ing year. Illustrates curious distribution of pain and tenderness, occasionally ob- served in cardiac insufficiency. Dark areas indicate maximal points of chronically recurring pain; shaded area — its distribu- tion. Patient was to undergo exploratory operation. Entirely free after four days of partial rest and full doses of digipuratum. Has remained free for past two years. (Another case showing this pain reference has been observed since this legend was originally written.) HEART DECOMPENSATION <>4 attest this fact ami to explain one of the chief manifestations of chronic cardiac overstrain. Multiple Factors. — In most heart cases many factors other than actual overexertion diminish the tonus and contractile power of a diseased heart, and in varying degree the other functions of the heart muscle, until accus- tomed use, and later mere existence, involves serious overstrain. Sclerosis of the coronary arteries not only may produce a persistent I intrinsic deficit in the intrinsic blood supply of the heart and render its response to increased demand distressing or actually impossible, but may also cause attacks of angina pectoris under conditions of physical rest (see "Angina Pectoris"). Fig. 342. Fig. 343. Figs. 342 and 343. — Interesting areas of pain and residual tenderness associated with certain cases of cardiac decompensation, induced by over-exertion or acute infections. Dull pain or discomfort and more or less marked hyperesthesia over the region of the left heart border are extremely common. Occasionally it is bilateral and in such a case is almost invariably referred to hysteria or "neurasthenia." Minor Crises. — From time to time, long before the terminal period is reached, the struggling heart cries out for relief. Our clinical interest must, therefore, be directed primarily to the lesser painful or distressing expressions of cardiac fatigue and overstrain and the regions to which these may be referred. Extracardial Factors in Diagnosis. — Both subjective and objective symptoms of chronic myocardial insufficiency arise in considerable measure, in both the minor and the grosser insufficiencies, from districts lying outside the precordial area and the heart itself, and this is strikingly true of certain types of pain. Referred Pain and Discomfort. — The work of Henry Head, Sherrington, Mackenzie and others shows that despite the relative insensitiveness of the heart parenchyma itself, painful sensations, with or without hyperesthesia, Referred pains. blood supply. Deceptive localization. 642 MEDICAL DIAGNOSIS Many types. Often epigastric arise from cardiac embarrassment, follow the direct embryonic distribution of the primitive cardiac tube and, because of the distortion attending fetal development, may be referred to the chest wall, axilla, neck, shoulders, inner aspect of arm, epigastrium and even the right and left hypochondrium.* With such a wide area of distribution for cardiac pain and granting the logical assumption that various sensations of discomfort may substitute pain in cardiac overstrain, toxemia and fatigue, as in like conditions affecting any other muscle, we see the possible relationships not alone of precordial dis- tress, but of the many axillary, neck, shoulder, thoracic and upper ab- dominal pains or uncomfortable sen- sations, such as are usually, and rightly given the more obvious in- terpretation suggested by their sur- face relation to underlying tissues. Epigastric, Substernal and Pre- cordial Discomfort. — This usually takes the form . of precordial or epigastric discomfort and, fre- quently, both combined; a sense of weight or pressure; a subjective sense of "crowding" distention, sub- sternal gripping or constriction, usually mild, but sometimes de- scribed as "vise-like," even when unassociated with true angina pectoris. f These sensations are referred to the stomach more frequently than to Fig. 344. — Darker shading indicates pain maxima. Lighter shading, its distri- bution. Recurrent acute major angina. Widely dilated heart. History of acute overstrain ( electric-car accident). Opera- tion for gall-stones advised. Prompt relief from rest and digitalis. No recurrence until return of dilatation and signs of major insufficiency several months later. the precordium and by the physician are interpreted usually as of gastric original or, not infrequently, in nervous women, as hysteria ("globus hystericus," etc.). The irritable overstrained or degenerated heart is affected greatly by an over- distended stomach or an overloaded portal system. An Old Rule Reversed. — So frequent is the occurrence of gastric symp- toms even in the minor decompensations that it would seem that in the case * The auricles may refer their pain to the lower axilla and shoulders; the ventricles to the chest wall, epigastrium, inner aspect of the upper arm, ulnar surface of the forearm and wrist or to the little and ring fingers. Pain from the ascending aorta may be referred to the entire neck, including the occiput. Cases of major angina, to which all portions may con- tribute, are reported in which even the gums were painful and others produce pain and residual hyperesthesia over the entire thorax, neck and upper abdomen. t Many patients report voluntarily, after successful treatment, even though no marked shrinkage of the cardiac outline is demonstrable, that for the first time in many months or years they feel that their heart is not "crowded" or "too large for the chest." % The number of so-called "dyspepsias" relieved promptly by digitalis, with or without rest, is surprising. HEART — 1) ECOMPENSATION 643 of the elderly patient, especially, we should reverse the traditional rule, "indigestion' and instead of considering first the stomach when he complains of his heart, complaint, look rather to the arteries, blood pressure and kidneys primarily and the stomach secondarily when he complains of either the heart or stomach. Fig. 345. — (Ej;77). Decompensated and dilated heart of the " drop " type associated with dyspeptic symptoms which dominate the clinical picture. The most pronounced dys- peptic symptoms appear during the latter part of the day or following, either directly or after a short period, unusual physical exertion. Vertigo and fatigability were also present. Exertion dyspnea was slight and there was no edema of the extremities. This is of the type commonly miscalled the "small" heart. (See Fig. 346. : — (E 77'). for com- parison.) Simulation of Urgent Abdominal Lesions. — Occasionally a patient with chronic myocarditis or coronary sclerosis and a dilated laboring heart is. con- fidently but vainly explored for gall-stones or gastric ulcer under a not 644 MEDICAL DIAGNOSIS unnatural misinterpretation of referred cardiac pain and hyperesthesia. Such errors may be avoided usually if the radiation of the pain with reference to the precordium, upper thorax, neck and arms is studied. Though such pain may be maximal over the upper abdomen, it usually Fig. 346. — (E 77'). Same heart as shown in Fig. 345 showing the reduced diameter following a short period of ambulatory treatment. The heart was originally a " drop " heart, marked associated gastroptosis being present. The outer white line shows the passing out of the left border by renewed dilatations after the patient had broken treatment and disregarded all instructions, the result being the recurrence of pulmonary congestion and other signs of minor decompensation. shows a tendency to involve the other regions in part at least. Careful examination of the heart, and blood-pressure estimations, usually reveal an adequate cause. A Word of Warning. — It must be remembered that gastric, duodenal, H1AK r DECOMPENS \ HON 645 Fig. 347. — Toxic heart. Patient had suffered from gall-stones 10 years previously and temporary relief had been afforded by the passage of a large number of small biliary calculi. Previous to, and from that time, recurrent severe precordial and epigastric pain and increas- ing disability had been present, all being charged against the gall bladder, though no opera- tion was attempted. When seen by the author in 1914 she carried decided edema of the legs, some hepatic engorgement, and marked enlargement of the heart, with auricular fibril- lation. A history of recurrent typical attacks of cardiac angina combined with epigastric distress was obtained and the nature of some of the abdominal pain distinctly suggested the participation of the diseased gall-bladder, although no local tenderness or fever was present. The heart measured 15.5 cm. in total transverse diameter a-nd decided diffuse enlargement of the transverse and descending portion of the aortic arch was evident in the original negative. The patient was placed at rest and under digitalis with the result that all symptoms were relieved promptly and the heart rhythm became extrasystolic. The outline of the heart at the end of this period is shown in Fig. 348. Aside from a slight inconstant and untransmitted mitral bruit or "murmurishness" the heart was silent. She had been told repeatedly that her heart was wholly normal. 6 4 6 MEDICAL DIAGNOSIS Fig. 348. — Toxic heart after treatment. The total transverse measurement is reduced from 15.5 cm. to 13.5 cm., a normal area, apparently, for so large a woman (weight 185+) but actually a greatly enlarged heart primarily of the "drop" or modified "drop" type, in a very small-boned individual. It will be noted that with the subsidence of the fibrillation the right border is lost behind the sternum and the left has lost its mitral configuration above, though in this printed reproduction the prominence of the left hilus shadow obscures the true outline obtained. Despite all warnings the patient so imposed upon the immunity from suffering obtained as to create from time to time through rash overactivity a recur- rence of fibrillation and intervals of diurnal edema of the extremities. Finally, while on a visit certain purely abdominal seizures arose which were apparently due to gall-stones alone. Upon her return it was evident that definite fibrillation and other decompensatory signs were present. The patient was put to bed, but after a brief period of improvement a definite attack of cholecystitis occurred. The evident hazard involved in an operation upon one with so slight a margin of reserve led the surgeons to decline interference, but after 48 hours, at the patient's urgent request and by reason of the threatening nature of the symp- toms, an operation was attempted and expeditiously performed. The patient never reacted. The heart dilated acutely and she died 12 hours after removal from the table. It will be noted that the existence of a highly toxic, greatly enlarged silent heart had been wholly unsuspected up to 1914. Yet so far had the process advanced as to render periods of fibrillation frequent and maintain a decided edema for many years. HEART — DECOMPENSATION appendiceal, and choice ystic conditions may be coexistent with and sometimes the basic cause of a toxic heart (see Figs ad ;44 . Moderate or trivial pain oi a slight, vague character or in the form of sharp '\ may occur over the heart itself, often extending upward to the left or behind the sternum. Tenderness. — Not infrequently one encounters tenderness just within the apex and for a few centimeters up the left border of the heart. This commonly curious hyperesthesia is often mistaken for the hysterical breast stigma mi * mt when occurring in nervous women, but is common in the chronic tonus de- derate dilatation and chronic overstrain of myocardial degeneration or mere asthenia, as well as in acute toxic dilatation and mitral stenosis* It sometimes shifts its maximal point with the recession of the left border as a toxic widely dilated heart contracts. Major Anginal Pain. — Intense pain of the severe paroxysmal type may occu - iated with fear of impending death, pallor and cya :ld perspiration, orthopnea and tense immobility on the part of the patient, shallow breathing, weak, rapid or unduly slow pulse and high arterial tension. Pain may extend to the left arm, wrist, and ringers up into the neck, or involve the arm and neck of both sides. In rare instances such paroxysmal pain of cardiovascular origin may be maximal over the epigastrium and gall- bladder area and be preceded or followed by nausea or vomiting, f Miniature replicas of such attacks have been I and reported by Rqikas ia the author, oftener fragmentary clinical pictures, and a marked and wide- spread hyperesthesia may follow the severe attacks. Paroxysmal Pain of the Sciatic Type. — Sciatic pain, lameness, quickly induced leg-fatisrue or sudden temporarv loss of power, in the lower extrem- Art* i i i er i spasm. lties or even the arm. may attend attempts to put the aire :te 1 extremities to accustomed use (" inter mitt ierende kinken"), and in many such cases the pulse of the affected member will be weak or absent, the accessible arteri— rotic. and the heart degenerated. When the sciatic pain is marked, an erroneous primary diagnosis is common. OBJECTIVE SYMPTOMS OF DECIDED CARDIOVASCULAR IN- SUFFICIENCY. — Subjective dyspnea has ed elsewhere. Ob- jective dyspnea may be present only on exertion or in one position of : body, or be constant, paroxysmal, of the type of '"air hunger." Cheyne- Stokes. or a replica of spasmodic asthma. Occasionally it is no more than an evident inability to hold the breath but in some cases it will abruptly en- force the sitting posture or even force the patient to stand suddenly erect see "Dyspnea"' . * "Stitch in the side" is, of course, common and unimportant in the absence of other signs, but occurring in the precordium, and especially in middle-aged individuals, often represents a minor angina. e author has seen a number of such cases in one of which a very large aneurysm of the transverse portion of the arch was present and ruptured during the early period of general anesthesia incident to an attempted operation for gall-stones. MEDICAL DIAGNOSIS Stasis and edema. Portal conges- tion. Engorgement. Variations. Pulsation. Ominous if persistent. Important sign. Varying output. Laboratory findings. Obscures existing nephritis. The Lungs. — Recurrent acute or subacute bronchitis, chronic bronchitis, blood-stained sputum, with the pigmented ("heart") cells, actual hemoptysis, or pulmonary edema, may occur as the result of passive congestion of the lungs or pulmonary infarct, in the failing heart of certain valvular lesions or primary myocardial degenerations. Crepitations at the lung bases, persisting after the first deep inspiration indicate right heart weakness and become of importance in the diagnosis of myocardial insufficiency and its treatment. They may be more marked on one side or present only as persistent rales. In such instances one finds usually that the patient lies upon that side by preference or has so lain for a considerable period. Gastrointestinal Tract. — Misleading referred cardiac pain or discom- fort and gastric disturbances more or less directly attributable to passive congestion occur frequently together with constipation, diarrhea, anorexia, excessive flatulence or nausea and vomiting. Usually all these symptoms are significantly relieved or ameliorated by rest aftd cardiac stimulation if they are of cardiac origin. The Liver. — The liver is frequently enlarged in the myocardial degenera- tions attended by gross decompensation, especially when these are associated with valvular lesions involving right heart stasis (mitral or tricuspid lesions especially . Its variations in size may roughly reflect the degree of decided incompensa- tion present at a given time. Systolic venous pulsation, palpable or shown by instrumental registration is not uncommon and the liver may become permanently indurated ("nutmeg liver" ] . though in many instances that which may have seemed a permanent change wholly or almost wholly disappears under proper, prolonged treatment. Jaundice of slight or even marked degree is not uncommonly seen in advanced tricuspid lesions, whether primary or secondary, in association with long-established passive hepatic congestion. Kidneys. — Chronic passive congestion is one of the manifestations of advanced incompensation in primary myocardial degenerations and mitral or tricuspid lesions. The amount of urine is more or less reduced and diurnal variations in the amount roughly measure the variations of severe incompensation if tfe fluid intake is maintained at a uniform level and no sweating or purging occurs. The color and specific gravity are high. Albumin is present in small amount and hyaline with occasional granular casts may be found. If other forms of nephritis co-exist, their typical urinary signs will be obscured, intensified, or modified by any existing passive renal congestion and uncovered or rendered clearer by an improvement in the heart strength. EDEMA. — This, when pronounced, is the most strikingly objective of the commoner gross symptoms and the most marked of any save pronounced dyspnea or the profound cyanosis of right heart stasis. In its slighter and localized forms it is very likely to be overlooked, espe- HEART DECOMPI 649 dally if it occurs only in unusual locations. In a number of cases the author has found it present over the calf of the leg and absent at the ankle. x :ht. equal, bilateral edema is almost invariably overlooked in xaminations an,: ■erally. in the ordinary office or hospital procedure. its presence or thinks so Usually seeks dependent parts. /*//; The patient carr v of it as to jail to report it. rs before : ptoms of decompensation mani- and is a symptom of cardinal imports Cardiac edema appears as the right heart fails.* seeks primarily the de- pendent portions of the body, is markedly affected by decubitus, and, in advanced cases with primary or secondary right heart weakness, is pro- nounced, slowly progressive in the absence of effective treatment, and tends to superadd to the already obstructed blood flow and the laboring heart behind it (see "'Edema"'., the adverse pressure effects of effusion into the peritoneal, pleural, or even the pericardial cavities. Rationale of Cardiac Edema. — Under conditions of rapidly induced or persistent venous congestion and consequent increased pressure and slowing of the blood stream in the capillaries, a great excess of fluid, poor in albumin, is poured out and distends the connective-tissue spaces. The general circu- lation is thus further slowed, the distension and loss of tonus of the con- nective-tissue spaces invites further invasion, and the pressure of collected fluid tends further to block the flow of blood and establish a vicious circle. The loss of tonus in the connective tissue is sufficiently proven by the persistent indentations left by finger-pressure. Weigh Cardiac and Renal Cases. — In both renal and cardiac cases show- ing a tendency to edema it is of great importance to weigh the patient from time to time. Any sudden increase in weight should suggest the possibility of an exudate either into the connective tissue or the enclosed cavities of the body and the pleurae should be watched with especial care. Cyanosis. — Any and every type of cyanosis may be encountered in cardiac insufficiency according to the anatomic seat and chief effect of the dominant lesion, the degrt Element and the grade of incompensation present. All cardiac incompensations or pulmonary diseases weakening the right heart, directly or indirectly, and hindering or preventing free oxygen and CO2 exchanges, produce cyanosis In most forms of congenital heart disease it is so obtrusive and extreme and so evidently related to infancy in its inception as to be an almost pathognomonic sign. In the least rare type of congenital insufficiency (pulmonary stenosis or atresia; the patient is almost invariably blue and, on exertion or in paroxysmal seizures, deep purple or even black. EmDarras5.z£ transudates. .•Another -5 circh Weight often varies with edema. Diminished oxygen and CO : exchanges. Blue babies. * Edema may be absent throughout the entire course of an aortic stenosis or even a regurgitant lesion, for the patient may and often does die before the right heart is rendered markedly insufficient, the burden in either instance being carried wholly or m large measure by the left ventricle until the terminal stages are reached. 650 MEDICAL DIAGNOSIS Absent in pure aortic cases. Relative insufficiencies. Therapeutic test Invaluable. Factors deter- mining severity of symptoms. Age. Congenital asthenia. Avoid mere meddling. In aortic stenosis or regurgitation it may never be present to any marked degree until the mitral yields or becomes involved structurally in the disease process, and throws back its burden in part upon the pulmonary circuit and the right heart. Cyanosis is decided in incompensated mitral lesions and still more so if secondary tricuspid insufficiency or the far rarer pulmonary leakage ensues. Heart Sounds. — Absolutely normal heart sounds are always absent in primary or secondary valvular disease and murmurs are usually present or more or less readily elicited under exertion, change of posture, properly regu- lated stethoscopic pressure, rest, or direct cardiac stimulation. In myocarditis, acute or chronic, or in the myocardial degenerations of marked degree, there is a tendency for murmurs to develop, especially in the mitral area, as the disease advances, the valvular deficiency being due either to an extension of the disease to the valve itself or to weakening of the valvular ring. Abnormalities of accent, sharpness, undue brevity, and heightened pitch of heart sounds, no less than impurity, " ' murmurishness ," or "muffled" tones, are also to be noted. Arrhythmias. — Any and every variety of abnormal rhythm may be encountered (see "Arrhythmias"). CARDIAC OUTLINE. — As previously stated, the cardiac outline as de- termined by the more modern percussion methods with or without the reenforce- ment of the fiuoroscope is one of the chief means of detecting otherwise dubious or indefinite lesions. Almost invariably an enlarged profile due to coincident increase of dilatation is present in the case of a grossly incompensating heart and this yields oftentimes a significant recession in response to full doses of digitalis and rest, both of which measures are without effect upon a normal heart or one fully compensating any existing lesion. The cardinal sign is, however, a decided and demonstrable amelioration or relief of symptoms under such therapeutic procedures. Summary. — (a) The severity or degree of all symptoms of cardiac insuffi- ciency depends upon the nature and location of the lesion and the stage and duration of the incompensatory period. (b) The frequency of damagingly reduced tonus, lacking the coarser and more obtrusive incompensatory signs, is as striking as is the relief of its vague and ojten misleading symptoms under a brief period of treatment and proper instruction. (c) Such hearts occur with especial frequency in patients who have entered the fifth or sixth decennium and in younger patients as well, if they are under- nourished and carry the stigmata of chronic congenital asthenia and its movable, pendant, low-lying, unstable and, oftentimes, readily dilatable heart. Truly Effective Therapy. — The larger, most effective and most permanent part of an effective therapy lies in the regulation of occupation, habits, physical and mental exertion, diet, and above all an intelligent appreciation hear: = 651 t that neither cardiac murmurs nor cardiac arrhythmia, in and of ike selves, demand active treat n: Neither Drugs nor Rest, Whether Alcne or Combined, are Adequate.— One of the most important factors in the therapy of cardiac disorders cons:- - in the use 0: . and definitely graduated and conservatively increased Vmiue of regn- exercise, following the correction of any acute or chronic insufficiency re- quiring primary limitation of activity or an insistence upon a sufficiently prolonged period of absolute re- Reiteration. — The student should carefully consider the following p<: in revie 1. An early diagnosis of myocardial insufficiency is essential to the best re and maximal longevity of the cardiopath. :. Such early diagnosis necessitates an acquaintance with symptomatic expressions of the subjective type, and the determination of the presence and symptomatic relationships of any existing cardiac dilatation. A large group of structurally deficient individuals many of whom are commonly classed as "neurasthenics." while, possibly, comparatively free The heart* from organic heart disease of the valvular or luetic type or that taking asthenia, the form of primary myocardial or vascular degenerations, are peculiarly lacking in resistance and prone to undernutrition, to acute infections, and recurrent or persisting deficiencies in heart muscle tonus, and possess ptotic, readily dilatable, symptom-producing hearts as a part of their fundamental and usually congenital defects in general body structure and function.* The author's more recent experience has convinced him that such hearts are in no sense immune to infection whether of the juvenile degenerative or luetic type, but that in the past we have failed to recognize the i% drop" heart when transformed by valvular or primary degenerative disease. If, as the author hopes, he has found the key in associated gasiroptosis and more or less definite peculiarities of outline, much more light upon this subject may be anticipated. 4. Such hearts, in individuals of this type, are narrow when undilated, mobile, and even when pathologically enlarged show a transverse measure- ment which is usually less than that of the undilated heart of the non-asthenic individual. 5. In many patients of this type a relative cardiac ^sufficiency may play a large part in their disability and be accountable for many symptor usuallv referred to such svndromes as "neurasthenia*" and '"nervous dvspep- Periods of • i» 1 - 1 r 1 11 1 - ••• " minor instif- sia, which, tor the greater part, represent, m all probabih: symptom- fideacy. groupings of various maxima of localization, of the same general, congenital, constitutional and structural defect (see "Congenital Astheni * In opposition to the views of Prof. Stiller relative to the asserted immunity of this type of individual to organic heart disease, the author believes that the females of the asthenic group furnish the greater number at least of those cases of the pure funnel type, mitral stenosis, of the youthful non-rheumatic and non-infectious form described by Duro- 15 a special form of that ailment. Every example of these peculiarly long-enduring cases seen by the author during the last decade have shown distinctively the stigma of congenital asthenia. 6>2 MEDICAL DIAGNOSIS Responsive to treatment. Lost oppor- tunities. 6. Adaptation vs. "Perfect Compensation." — Though patients with organic heart lesions may go for years without serious symptoms after adapt- ive hypertrophy is established, the pathologic events in such cases make it evident that there is a constant, more or less gradual but progressive limita- tion of the field of cardiac response. Long before the onset of gross or emergent symptoms, periods of more or less decided minor insufficiency appear and recur from time to .time with increasing frequency. Appropriate therapeutic measures will then support and aid the embarrassed and labor- ing heart and prolong the life of its possessor. 7. Causative Agents and Portals of Infection. — The recent studies of the causative agents and portals of infection in acute rheumatism, a better knowledge of the effects of prostrating acute infection, and chronic or recur- rent cryptogenetic sepsis upon the heart, the better understanding of the nature and means of detection of syphilitic infection and the introduction of new agencies and better methods for the early and efficient treatment of lues, indicate the possibility of limiting considerably the large group of myo- cardial, pericardial and valvular lesions of which they are the causative factors. 8. The mere existence of a heart lesion is no justification for active treatment by the exhibition of drugs, though a fully compensating heart neither is damaged nor influenced by test doses of digitalis properly administered and controlled. Active treatment of any considerable duration is necessary and justifiable only when symptoms of cardio vascular insufficiency are clearly established and the use of heart stimulants should be limited if possible, (a) to test doses, which should be freely used,* (b) prophylactic small doses during con- valescence from acute prostrating ailments, (c) to the more or less prolonged periods or recurrent intervals of actual stress or genuine emergency. 9. The importance of early diagnosis is emphasized by the fact that chronic heart disease, though incurable, is on the whole, wonderfully responsive to in- telligent and properly timed treatment, and always benefited by such proper supervision and control as may be indicated in the individual case and obtain- able only through early diagnosis, tactful disclosure and a judiciously tempered optimism. The "Abandoned" Heart Case. — An unfortunate tendency exists to the practical or actual abandonment of advanced or apparently hopeless cases of heart disease. Practical abandonment may take the form of a failure to establish such control of the patient's activities and such therapy as will, on the one hand, give the greatest possible amount of rest to the laboring heart muscle and, on the other, assist it directly, to regain in some important degree its waning tonus. Total abandonment is usually represented by an attitude of utter hope- * If one were to try the experiment of substituting them initially for the "tonic" or digestant," so universally used in obscure cases of "nervous debility" and "dyspepsia," he might be greatly surprised by the frequency of decided favorable effects. MYOCARDIAL OVERSTRAIN 653 lessness and a disinclination to do more than smooth the victim's pathway to the grave. In mitral cases, especially and, to a lesser degree, in other common cardio- vascular lesions, the patient may go to an apparent utter cardiac break- down with renal congestion, hepatic and pulmonary engorgement and general anasarca and still respond to treatment and live for years. Absolute rest is but too seldom enforced and rationally maintained. The patient is up and down, even though mostly down, and if improvement occurs is not held to a schedule demanding a gradual increase of activity, such as is needed in the generality of cases if improvement is to be had. In far too many instances in which absolute rest is enforced it is maintained for too long a period and almost immediately thereafter the patient is permitted to resume his or her activity. Too abrupt a transition from absolute rest to physical activity is often- times less effective and more dangerous than ambulant treatment. Above everything in cardiac therapy must be placed the element of time when one deals with its severer types or the cases of the nutritionally depressed asthenic type. These latter demand treatment which, as elsewhere stated, is practically identical with that of so-called "neurasthenia." The After Lifetime of the Cardiopath. — Cardiovascular disease greatly reduces the life expectancy of its "group" but the duration of life, in the case of any individual, involves a host of factors among which are the nature of the lesion, its cause, the constitutional peculiarities of the individual, his environment, habits, occupation and, above all, his own intelligence and common sense, and the same qualities in his physician. Futile Forecasts. — Despite adverse conditions and oftentimes despite the demands of an active, useful and even laborious life, certain individuals may and do carry the cardiac lesions of youth into a ripe old age and nothing can be more elusive and uncertain than prognosis in cardiovascular disease or more futile than the attempt on the part of the physician to set a date for the exitus of any patient not patently moribund at the time. With early recognition and prompt medical intervention in cases of actual insufficiencies, not only the life expectancy of the individual but that of cardio- paths as a group will be greatly extended. MYOCARDIAL OVERSTRAIN Acute Cardiac Overstrain Fundamental Factors. — Physical overstrain may affect the heart in different degrees dependent upon: (a) the congenital structural peculiarities or deficiencies of the individual; (b) his age, general physical condition and the actual state of his heart and blood vessels at the time of exposure; (c) the severity, abruptness and duration of the strain imposed; (d) the habituation or non- habituation of the individual both to physical exertion of the degree attempted, and to such specific coordination of certain neuro-muscular units as is involved Keep fighting. Abundant time indispensable. Greatly shortens life. Individualiza- tion of cases imperative. Wonderful individual resistance. Futility of prophecy. Promise of added days. Basic factors. ^54 MEDICAL DIACN M.;1t i Z.Zl : i i ■ s in the partic. >ut forth, and, finally and chiefly, the question of toxemia 7 proximate, actually present, or recurrent. Physical Fitness and Habituation. — Physical fitness is an important factor, one of the commonest causes of acute overstrain being the attempted performance of tasks suited only to the trained athlete or the frontiersman by individuals who are distinctly out of condition, actually convalescing from an illness, or congenitally unfit.* The author has encountered it repeatedly in well-fed men, outwardly appearing to possess a powerful build, but proving to be of asthenic stock and to carry inherited deficiencies, especially such as involve the heart, blood vessels and lungs. Also in individuals possessing a past replete with athletic prowess, but at the time distinctly out of condition and unfit. In the well-conditioned athlete the heart is actually slightly smaller after or during some endurance test than at its beginning, being fully able to meet the demand by a combination of increased rate and driving power, this being in direct contrast to the condition of dilatation produced in untrained or structurally deficient individuals.! : riei summary of a typical case oat of the great number encountered by the author would read thus: Male. Sedentary occupation and habit, aet. forty-seven, weight 200, complains of indigestion (as most of them do) chiefly manifested by dull pain over pit of stomach. Pain usually late in day {after day's activities), sometimes seems to follow I exertion. Can't do his work as easily as he did formerly. Gets tired quickly when out Is often drowsy during the latter part of the day. This often passes off after X: definite relation of pain to meal hours, but is always worse when he is con- stipated or has "gas on the stomach." This patient's heart was found to measure 16 cm. in total transverse diameter and a soft systolic murmur was present, limited to the apex; pulmonary second sound about equal to the aortic tone. All findings negative save as to --.iz~.. His pain had begun three years previously while duck hunting, but he had not related to us the events because of the misleading epigastric localization. On that day he had shot both morning and evening standing in the water and deep mud of a shallow North Dakota slough lake. Shooting was good and when darkness fell and he waded about ---Q-.:r"- :jie iter zli-ring ~.:l :: richer — = - :^ — e :^:::.:::: .: :: :: iirry rl : e : :■- long wade to shore he felt " all in." Had a great deal of pain in the chest, struggled to shore, felt faint, vomited, and lost consciousness. Finally struggled to his feet and went to camp to lie down, leaving ducks, shells and game behind him. "Felt pretty well" next day but now recalled the fact that his "indigestion" had dated from that day. (Judex treatment the pain iisappeared iofly in three or four days. He remained under for four — eeks The cardiac outline shrank to 13 cm. and the murmur wholly ::e: -5: He has now remained pexfectb ell during five years. This represented an acute dilatation occurring in a particularly well-built robust but middle-aged man, leading a sedentary life and wholly out of tr aining . Anyone who has -::::::-: \i-z: : .z.z exzeriez.-r k-:~ s —ell :he e~::e~e ef ::: rezuirei. _- ie: :he ;:.:::: _li: conditions present. His not at all unlikely that some transient antecedent infection may have played a part. The "drop" hearts or those of individuals in poor health dilate far more easily and with less dran 1 :: c ~y~z : : ms in ma st instances J The author has been struck by the frequency with which he has encountered cases of distinct physical impairment in men of athletic records who have suddenly been translated to sedentary pursuits but still seek to pursue sporadically and fitfully athletic pursuits of an extremelv strenuous sort. DIAL OVERS TRAIN 655 The Commonest Cause of Minor Heart Strain. — The placid state of physicaPunpreparedness'' represented by middle age. a sedentary occupation, Middle age. and a daily life in which the accustomed exercise is represented at best by a round of golf and a walk to the orhce. is often disturbed by an abrupt autumnal indUn summer overstrains. Fig. 349. — Plate made nineteen days after acute dilatation of a supposedly norma heart. Fibrillation was present during eighteen hours after attack. Some precordial distress still present when exposure was made. Total transverse diameter of heart 12.5 cm. (See also Figs. 350 and 351.) rejuvenescence taking the form of a tendency to play tennis with mistaken strenuosity and perseverance; to climb mountains; take an oar or a paddle '"to show them."' or hunt the deer over heavy going; all these plunges being taken without sensible moderation or previous preparation. Such unwisdom results in a host of cardiac overstrains, for the most part, spontaneously 6 5 6 MEDICAL DIAGNOSIS readjusted, but in some instances working great damage if undetected and unaided. The Asthenic Heart. — Considerable attention has already been paid to the peculiar heart of the congenital asthenic ("drop" heart) and one need only Fig. 350. — Same case of acute dilatation as is shown in Fig. 349. Patient, when apparently fully recovered, slipped and fell on the ice severely wrenching himself. A second attack of acute dilatation followed. Heart is still dilated from second seizure. [ Total transverse diameter 14. 1 cm. Both right and left borders are extended outward. (See Fig. 351.) repeat in this connection, that such hearts are among the commonest of clinical findings. They are peculiarly prone to transient or persistent loss of tonus or actual minor dilatation, and, to the production of subjective expressions of insufficiency, often remote from the heart itself. As stated previously, such hearts, even when both overstrained and decidedly MYOCARDIAL OVERSTRAIN 657 overlooked. dilated are, at present, almost universally disregarded, because of the fact that even when greatly enlarged (hey need not equal in transverse diameter the area constantly of the normal heart of a non-asthenic individual and further because of their unfortunate tendency to present the clinical features of so-called ''neurasthenia" or the equally dubious syndrome "nervous dyspepsia." w mmw^ ^ Ei^B| 1 - pi jgfr ifl j ■ » IP i ■ W ! w ,-«-... w 1*1 '+ o.i-W .ct\« XlW **n Fig. 351. — Same case. Acute dilatation of the heart. Plate taken nine days later, showing shrinkage of the heart after second attack of dilatation. Heart is still dilated as compared with Fig. 349. toxemia. A Common Cause of Overstrain. — One of the commonest sources of acute or sustained cardiac overstrain lies in the too early resumption of exercise alter Myocardial an exhausting surgical operation or prostrating illness, or even in hasty uncon- sidered exertion during the actual illness. We too often forget that for one case of recognized acute myocardial disease there must be a multitude in which a similar though less pronounced and advanced process is present, but undiscovered and undiscoverable save 6 5 8 MEDICAL DIAGNOSIS Hurried convalescence. during periods of impaired tonicity and overstrain. In all severe acute pros- trating infections, even though of short duration, the heart is peculiarly liable to suffer from myocardial toxemia of varying degrees and in acute rheumatism affecting the already damaged heart, as also in true influenza, we are pecul- iarly likely to have larval and obscure or definite and recognizable insuffi- ciency. The former type is almost universally overlooked at the present time during and following such an illness. Mr. M.fl fl&ZI Rr IOO BMW! it> Mr.M.A. Ufa /* , "Wl *X^ s ^v^«~^^ U^kN>WvKKk^NNJVAv LR B Fig. 352. — Mr. M. A. (A) 11-6-21. Temporary fibrillation of the auricles following acute overstrain, and a readily demonstrable dilatation in a supposedly normal "drop" heart. (B) 11-10-21. Record taken four days later showing a normal sinus rhythm. Clinically the normal sinus rhythm was reestablished in 24 hours. LR = Left radial. RJ = right jugular. Subjective Weakness. — In the absence of frankly objective cardiac symptoms the best guide often proves to be the therapeutic test, which unmasks a slight dilatation or loss of tonus, and the evident or merely sub- jective weakness of the patient. It may be demonstrated easily in many in- stances that despite a striking loss in endurance and in the capacity for symptomless performance of the day's work or ordinary physical activities the strength of the skeletal muscles is well preserved. Many patients themselves date a persistent myocardial weakness and dilatation from an illness during which neither myocarditis nor endocarditis was recognized, but following which there was a forced resumption of activity in the face of a persistent bodily weakness. MYOCARDIAL OVERSTR \1\ ^59 Patients should be guarded with special care during and after prostrating tonsillitis, acute rheumatism, influenza, diphtheria, scarlet fever and typhoid; important and their own sensations, properly interpreted, as a rule constitute the best v * w » 9 » ■ » r » ^ » V » » » » T »r»» ■ r 9 7,621 Radial R*te ' 4& Joflu'or f ~N/V J ./ — - »»»»» wm 9 9 Mrs. WH BtdZl 'Radial Fig. 353. — Airs. W. H. Variability in myocardial strength as indicated by polygraphic records. {A) 7-6-21. Record taken before operation showing high radial thrust and indicative of good myocardial strength and tone. (B) 7-26-21. Record taken 6 days after laparotomy under local anesthesia for supravaginal hysterectomy with removal of both appendages. Xote marked flattening of radial as compared with that in (A), indi- cating a decided loss of myocardial tone and strength after operation. (C) 8-13-2 1. Record taken 24 days after operation. Compare radial with that of (^4) and (B) and note that even then the record indicates that myocardial tone and strength have not yet been completely regained. Patient in hospital under ideal conditions. general guide for the physician, but do not replace a physical examination. Nor should they be allowed to drop out of sight wholly for months afterward, May initiate for both primary myocardial damage and actual endocarditis may delay tion. 66o MEDICAL DIAGNOSIS Mr w FT (ftZt M«> n Gftzi fl.R 21 C Rate > >S( Mr. Pi bZOZI RoJ*ot Juguhr D V Fig. 354. — Mr. Fi. Series of four polygraphic records in a case of fibrillation during hospital regime, showing marked variation in myocardial strength and tone as indicated by the radial record. (A) Note the high radial thrust indicating good myocardial strength and tone. (B) and (C) show a progressive diminution of myocardial strength and tone, while (D) shows that myocardial strength is only partially regained. The myocardial weakening was due to a very slight cardiac overstrain as a result of a breach of instruction as to graduated exercise. RR = right radial. RJ = right jugular. MYOCARDIAL OVERSTRAIN 66l Mr.H.F. IbaZi r'-^->- 1 w «5 IOZT-t-1 Mr. H-F Rata -~ BS B Mr. H.F. Ra+e = i.8 -\ >S